The Pearl at Kruse Way

The facilityGÇÖs 3/2021 Transfer or Discharge Notice Policy indicated the following:- The resident and his or her representative are given a thirty day advance written notice of an impending transfer or discharge from this facility.- A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.-á1. Resident 7 was admitted to the facility in 9/2025 with diagnoses including hypo-osmolality and hyponatremia (retention of water by loss of sodium or both). Resident 7 was discharged home on 9/24/25.A review of Resident 7GÇÖs clinical record revealed no indication the LTCO was notified when the resident discharged from the facility.On 10/1/25 at 11:28 AM, Staff 10 (Social Services Director) stated she did not send notice of transfers to the LTCO.-áOn 10/1/25 at 11:33 AM, Staff 4 (Former DNS) acknowledged the requirement to notify the LTCO and stated the facility did not have a system in place to implement the requirement.-á2. Resident 46 was admitted to the facility in 9/2025 with diagnoses including fracture of left femur.-áResident 46 was hospitalized on 9/8/25.A review of Resident 46GÇÖs clinical record revealed no indication the LTCO was notified when the resident was transferred to the hospital.-áOn 10/1/25 at 11:28 AM, Staff 10 (Social Services Director) stated she did not send notice of transfers to the Ombudsman.On 10/1/25 at 11:33 AM, Staff 4 (Former DNS) acknowledged the requirement to notify the LTCO and stated the facility did not have a system in place to implement the requirement.-á

On 9/30/25 at 10:35 AM a review of the OTC (over the counter) medication storage room revealed four bottles of Milk of Magnesia (laxative) expired on 6/2025, two bottles of TUMS (antacid for heartburn) expired on 3/2025, and two bottles of Renovite (multivitamin for kidney disease) expired on 7/2025.On 9/30/25 at 10:40 AM Staff 9 (CMA) acknowledged the medications were expired.On 9/30/25 at 10:42 AM Staff 4 (Former DNS) acknowledged the medications were expired and stated it was her expectation nurses and CMAs checked for expired medications at least weekly. Staff 4 further stated Central Supply staff were to check expiration dates before placing medications in the OTC room and medication carts-á-á-á-á

Based on interview and record review it was determined the facility failed to follow physician orders and implement bowel care for 1 of 3 sampled residents (#4) reviewed for constipation. This placed residents at risk for medical complications from constipation including bowel impaction. Findings include:

The facility's 10/2020 Bowel Care Protocol indicated the following:
-If a resident did not have a bowel movement for three consecutive days then evening shift was to run a report and administer Milk of Magnesia (MOM). If no results, then day shift was to administer a suppository and if no results then a Fleets enema was to be administered.

Resident 4 admitted to the facility on 1/6/24 with diagnoses including femur fracture.

The 1/6/24 physician order indicated Resident 4 was to receive the following:
-Milk of Magnesia 30 ml every 24 hours PRN for bowel care and constipation.
-Dulcolax suppository 10 mg insert rectally PRN for constipation, give for no bowel movement for four days for constipation if MOM was ineffective.
-Fleet enema insert 1 application rectally as needed for constipation.

Resident 4's 1/2024 bowel records revealed the following:
-1/14/24-1/19/24 no bowel movement (six days).
-1/21/24-1/25/24 no bowel movement (five days).

There was no indication Resident 4 received or refused the ordered bowel medications on the identified dates.

Interviews on 1/22/25 and 1/23/25 with Staff 10 (LPN Resident Care Manager), Staff 3 (Therapy Director), Staff 8 (LPN), Staff 7 (RNCM), Staff 11 (RN), Staff 12 (RN) and Staff 5 (SSD) revealed the staff did not remember Resident 4. Two unsuccessful attempts were made to contact Staff 9 (CNA) who was noted in the clinical record to often work with Resident 4.

On 1/23/25 at 2:30 PM Staff 2 (DNS) acknowledged Resident 4 did not have bowel movements on the identified dates. Staff 2 further acknowledged there was no evidence to indicate the resident was offered bowel medications on the identified dates.

Based on interview and record review it was determined the facility failed to assess and monitor pressure ulcers for 1 of 3 sampled residents (#4) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include:

Resident 4 admitted to the facility on 1/6/24 with diagnoses including femur fracture. Resident 4 discharged from the facility on 1/29/24.

The 1/6/24 Admission Nursing Database indicated Resident 4 did not have skin issues.

The 1/2024 TAR indicated weekly skin audits were completed on 1/13/24 and 1/20/24 and no new skin issues were identified.

The 1/22/24 physician progress note indicated the following:
-Bilateral pressure injuries on heels with no open areas or drainage. The heels were floated and in cushion boots.
-Pressure ulcer of the left buttock Stage 2 (Partial thickness skin loss).

There was no evidence in Resident 4's clinical record to indicate the pressure ulcers were assessed including staging and measuring the wounds.

The 1/2024 care plan did not include information or interventions regarding the bilateral heel pressure ulcers and the left buttock Stage 2 pressure ulcer.

The 1/2024 TAR indicated Resident 4 received treatments to the bilateral heels and buttocks pressure ulcers as ordered.

There was no indication the pressure ulcers were investigated to determine the cause or interventions needed to avoid further skin decline until 4/19/24 (81 days after the residents discharged).

Interviews on 1/22/25 and 1/23/25 with Staff 10 (LPN Resident Care Manager), Staff 3 (Therapy Director), Staff 8 (LPN), Staff 7 (RNCM), Staff 11 (RN), Staff 12 (RN) and Staff 5 (SSD) revealed the staff did not remember Resident 4. Two unsuccessful attempts were made to contact Staff 9 (CNA) who was noted in the clinical record to often work with Resident 4.

On 1/22/25 at 11:46 AM and 1/23/25 at 2:30 PM Staff 2 (DNS) stated the expectation was for nursing staff to take pictures of pressure ulcers when they were identified and then weekly. Staff 2 stated staff were to also stage the wounds and update the care plan to reflect appropriate interventions. Staff 2 acknowledged no pictures were taken of the bilateral heel pressure ulcers or the Stage 2 pressure ulcer to the buttocks, no measurements were completed upon identification of the pressure ulcers on 1/22/24, the care plan was not updated with interventions and the investigation was not completed until 4/19/24 after the resident discharged.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 6 of 61 sampled days reviewed for sufficient staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

A review of the facility Direct Care Staff Daily Reports from 9/1/24 through 10/31/24 revealed the facility did not meet mandatory minimum CNA ratios for one or more shifts on the following dates:

-10/11/24: day shift.
-10/13/24: day shift.
-10/16/24: day shift.
-10/26/24: night shift.
-10/27/24: day shift.
-10/30/24: evening shift.

On 1/23/25 at 1:50 PM Staff 30 (Staffing Coordinator) and at 2:41 PM Staff 2 (DNS) stated CNA staffing was based on the census, resident acuity, and by the CNA mandatory minimum staffing ratios. Staff 30 reviewed the Direct Care Staff Daily Reports and confirmed the facility did not meet CNA staffing ratios on the dates identified.

On 1/23/25 at 2:55 PM Staff 1 (Administrator) acknowledged the facility did not maintain adequate staffing levels on the dates identified.

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411-086-0110 Nursing Services: Resident Care

Refer to F684
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411-086-0140 Nursing Services: Problem Resolution & Preventative Care

Refer to F686
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Based on interview and record review it was determined the facility failed to notify a resident of a medication change for 1 of 5 sampled residents (#19) reviewed for unnecessary medications. This placed residents at risk for lack of participation in treatment decisions. Findings include:

Resident 19 admitted to the facility in 7/2024 with diagnoses including depression.

The Admission MDS dated 7/19/24 indicated Resident 19 was cognitively intact.

The 7/2024 MAR indicated 40 mg of Citalopram was administered at bedtime from 7/7/24 through 7/19/24.

Pharmacy recommendations dated 7/17/24 included a request to decrease Resident 19's Citalopram (anti-depressant medication) from 40 mg to 20 mg with a provider agreement and signature dated 7/18/24.

A nursing note dated 7/19/24 indicated a gradual dosage decrease of Citalopram from 40 mg to 30 mg and then 20 mg per provider order.

The 7/2024 MAR indicated 30 mg of Citalopram was administered from 7/20/24 through 7/22/24.

Progress notes from 7/21/24 to 7/22/24 indicated the change to Resident 19's dosage of Citalopram was not discussed with the resident until 7/22/24 after the resident requested to speak with the provider. After that discussion, the dosage was changed back to 40 mg.

On 8/1/24 at 10:21 AM Resident 19 stated, "They treated me like I was brain dead," and she/he was "outraged, incensed, and disgusted" about the lack of communication regarding changes to the resident's Citalopram dose. Resident 19 stated she/he experienced no adverse reactions from changes to the Citalopram dosage.

On 8/1/24 at 2:43 PM Staff 2 (DNS) indicated she usually followed up on pharmacy recommendations with residents prior to any changes to medications. Staff 2 reviewed the progress notes and verified the first communication with Resident 19 regarding changes to the resident's Citalopram dosage was on 7/22/24, four days after the dose was reduced.

2. Resident 124 admitted 7/2024 with diagnoses including bone fractures and hearing loss.

A 7/26/24 cognition assessment indicated Resident 124 was cognitively intact.

A review of Resident 124's clinical record revealed no indication Resident 124 received a copy of the baseline care plan.

On 8/1/24 at 11:24 AM Staff 2 (DNS) confirmed a copy of the resident's baseline care plan was not provided to Resident 124.

3. Resident 125 admitted to the facility in 7/2024 with diagnoses including cognitive impairment and hypertension.

A 7/25/24 cognition assessment indicated Resident 125 was cognitively intact.

A review of Resident 125's clinical record revealed no indication Resident 125 received a copy of the baseline care plan.

On 8/1/24 at 11:24 AM Staff 2 (DNS) confirmed a copy of the resident's baseline care plan was not provided to Resident 125.

4. Resident 130 admitted to the facility in 7/2024 with diagnoses including diabetes and seizures.

A 7/22/24 cognition assessment indicated Resident 130 had moderate cognitive impairment.

A review of Resident 130's clinical record revealed no indication Resident 130 received a copy of the baseline care plan.

On 8/1/24 at 11:24 AM Staff 2 (DNS) confirmed a copy of the resident's baseline care plan was not provided to Resident 130.

5. Resident 133 admitted to the facility in 7/2024 with diagnoses including hypertension and bone fractures.

A 7/29/24 cognition assessment indicated Resident 133 was cognitively intact.

A review of Resident 133's clinical record revealed no indication Resident 133 received a copy of the baseline care plan.

On 8/1/24 at 11:24 AM Staff 2 (DNS) confirmed a copy of the resident's baseline care plan was not provided to Resident 133.






, Based on interview and record review it was determined the facility failed to provide a summary of the baseline care plan to 5 of 5 sampled residents (#s 19, 124, 125, 130, and 133) reviewed for pain, rehab services and unnecessary medication. This placed residents at risk for being uninformed of their plan of care. Findings include:

1. Resident 19 admitted in 7/2024 with diagnoses including aftercare following joint replacement surgery and depression.

The Admission MDS dated 7/19/24 indicated Resident 19 was cognitively intact.

No information was found in the resident's clinical record to indicate a baseline care plan or summary was provided to the resident.

On 7/29/24 at 11:26 AM Resident 19 stated she/he did not receive any care plan paperwork.

On 8/1/24 at 11:24 AM Staff 2 (DNS) confirmed a copy of the resident's baseline care plan was not provided to Resident 19.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 8 sampled residents (#s 125, 135, 181, and 228) reviewed for medications. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include:

1. Resident 228 admitted to the facility in 7/2024 with diagnoses including hypertension and prostate cancer.

An 8/2/24 facility audit of Resident 228's medication administrations from 7/27/24 through 8/1/24 revealed the following:

- On 7/31/24 seven medications were administered one hour and 38 minutes to two hours and 49 minutes late.
- On 8/1/24 four medications were administered one hour and 30 minutes late.

On 8/2/24 Staff 2 (DNS) confirmed the medications were not administered timely.

2. Resident 135 admitted to the facility in 7/2024 with diagnoses including paralysis and depression.

An 8/2/24 facility audit of Resident 135's medication administrations from 7/27/24 through 8/1/24 revealed the following:

- On 7/31/24 four medications were administered 47 minutes to two hours and 47 minutes late.
- On 8/1/24 five medications were administered two hours and 30 minutes late.

On 8/2/24 Staff 2 (DNS) confirmed the medications were not administered timely.

3. Resident 125 admitted to the facility in 7/2024 with diagnoses including cognitive impairment and hypertension.

An 8/2/24 facility audit of Resident 125's medication administrations from 7/27/24 through 8/1/24 revealed the following:

- On 7/31/24 six medications were administered 48 minutes to three hours late.
- On 8/1/24 four medications were administered two hours and 30 minutes late.

On 8/2/24 Staff 2 (DNS) confirmed the medications were not administered timely.

4. Resident 181 admitted to the facility in 7/2024 with diagnoses including diabetes and heart failure.

An 8/2/24 facility audit of Resident 181's medication administrations from 7/27/24 through 8/1/24 revealed the following:

- On 7/27/24 one medication was administered one hour and 21 minutes late
- On 7/28/24 three medications were administered 30-55 minutes late
- On 7/29/24 seven medications were administered one hour and 45 minutes to 3 hours and 46 minutes late
- On 7/30/24 three medications were administered one hour and 25 minutes late
- On 8/1/24 four medications were administered one hour and 9 to one hour and 16 minutes late.

On 8/2/24 Staff 2 (DNS) confirmed the medications were not administered timely.

Based on observation and interview it was determined the facility failed to ensure medications were secured and only accessible to authorized persons for 1 of 2 sampled medication carts and 1 of 1 treatment cart reviewed for medication storage. This placed residents at risk for drug diversion. Findings include:

1. On 8/1/24 at 7:53 AM a medication cart on West Hall was observed to be unlocked and unattended outside of room 14.

On 8/1/24 at 7:55 AM Staff 10 (LPN) confirmed the medication cart was left unlocked and unattended.
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2. On 7/31/24 between 3:40 PM and 3:53 PM a treatment cart was observed in the East Hall unattended and unlocked. During the continuous observations both staff and visitors were seen walking past the cart.

On 7/31/24 at 3:53 PM Staff 3 (RN) confirmed the cart contained insulin and other treatment supplies and was supposed to be locked when not in use.

On 8/2/24 at 9:55 AM Staff 2 (DNS) confirmed treatment carts were to be locked when unattended.

Based on observation and interview it was determined the facility failed to ensure food was labeled and stored in a manner to prevent food spoilage, expired food was discarded, staff used appropriate hand hygiene, and staff used hair restraints properly for 1 of 1 kitchen and 1 of 2 unit refrigerators reviewed for food storage and handling. This placed residents at risk for food contamination and food-borne illnesses. Findings include:

The facility's Food Safety and Sanitation Policy, revised 1/2024, indicated food was to be labeled and dated. The policy also indicated hair restraints were required to cover all head hair.

1. On 7/29/24 at 9:48 AM during an initial tour of the facility's walk-in refrigerator and freezer the following were observed:

Refrigerator:
- dark liquid in a clear dispenser with a spigot had no label or date
- bagged grapes sitting in brown liquid in a cardboard tray
- three plastic clamshell packs of strawberries were mushy and had white fuzz
- small metal container labeled, "Ham," with a use by date of 7/24/24
- to go container with a use by date of 7/26/24
- an undated to go container with no name
- cooked bacon in a metal pan with a plastic lid and no label or date
- clear bag of shredded fresh purple vegetable with no label
- partially consumed carton of ricotta with no date

Freezer:
- open inner bag and outer box of frozen hamburger patties with ice crystals
- partially open bag of chicken tenders with ice crystals
- metal container labeled "casserole" with a tin foil lid with holes in it and visible ice crystals

On 7/30/24 at 2:00 PM Staff 4 (Executive Chef) stated the food storage process required a label and date for all food items, all expired items were to be thrown away, and all storage containers were to be kept closed. Staff 4 acknowledged the identified items in the refrigerator and freezer were not labeled, stored, and discarded correctly.

2. Observation of the facility's unit refrigerators on 7/30/24 at 2:14 PM revealed the West Hall resident refrigerator contained:
- wrapped sandwich with a use by date of 7/29/24
- partially consumed jug of 1% milk with no date

On 7/30/24 at 2:18 PM Staff 8 (CNA) verified the identified items in the refrigerator and freezer were not stored and labeled properly.

3. During a kitchen observation on 7/31/24 at 12:14 PM Staff 6 (Prep Cook) was noted wearing the same pair of gloves to touch the refrigerator door, food cart, food containers, utensils, bread slices, tomato slices, lettuce slices, portions of meat and chips. Staff 5 (Chef), Staff 7 (Dietary Aide), and Staff 6 (Prep Cook) were noted to have hair not completely covered by hair restraints.

On 7/31/24 at 12:24 PM Staff 3 (Dietary Manager) verified staff were not using gloves and hair restraints properly.

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OAR 411-085-0310 Residents' Rights: General

Refer to F552
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OAR 411-086-0040 Admission of Residents

Refer to F655
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
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OAR 411-086-0260 Pharmaceutical Services

Refer to F761
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OAR 411-086-0250 Dietary Services

Refer to F812
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Based on interview and record review it was determined the facility failed to administer medications at the prescribed dose for 1 of 3 sampled residents (#3) reviewed for physician orders. This placed residents at risk to receive a sub-therapeutic dose of medication. Findings include:

Resident 3 was admitted to the facility in 12/2023, with diagnoses including high blood pressure.

Resident 3's 12/15/23 Physician Orders included an order for metoprolol (a high blood pressure medication) 50 mg every evening.

Review of Resident 3's 12/2023 and 1/2024 MARs revealed the resident received 25 mg of metoprolol instead of 50 mg from 12/15/23 through 1/8/24.

On 6/27/24 at 8:39 AM, Staff 4 (Regional RN) verified Resident 3 was administered 25 mg of metoprolol instead of the 50 mg as ordered from 12/15/23 through 1/8/24.

Based on interview and record review it was determined the facility failed to follow the resident's plan of care for 1 of 3 sampled residents (#5) reviewed for accidents. This placed residents at risk for falls and injury. Findings include:

Resident 5 was admitted to the facility in 12/2023, with diagnoses including stroke and attention and concentration deficit.

Resident 5's 12/21/23 ADL Care Plan instructed staff to not leave the resident alone when she/he was up in the wheelchair.

Resident 5's 1/31/23 Progress Note indicated Resident 5 was left alone in her/his room while in a wheelchair. The resident attempted to self-transfer and fell to the floor.

On 6/25/24 at 12:20 PM, Staff 4 (Regional RN) verified Resident 5 was left alone in her/his wheelchair, the resident attempted to self-transfer and fell. Staff 4 acknowledged Resident 5's care plan was not followed.

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

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

Refer to F689
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1. Based on interview and record review it was determined the facility failed to implement a system which addressed missing personal items in a timely manner for 1 of 1 sampled resident (#6) reviewed for personal property. This placed the resident at risk for loss of personal property. Findings include:

Resident 6 was admitted in 6/2023 with diagnoses including end stage renal disease.

In a 7/11/23 interview at 8:47 AM, Resident 6 reported she/he was missing a red nightgown for over a month. Resident 6 reported it missing but could not state to whom.

The 6/5/23 Personal Possessions Record did not identify a red nightgown as part of the possessions brought with the resident on admission.

In a 7/12/23 interview at 5:06 PM, Staff 21 (CNA) stated there was a current list of missing items for Resident 6. Staff 21 referred to a log (a sheet of paper visible on the counter of the common area) and stated if the CNAs were unable to find the missing items, someone followed up. Staff 21 could not state who the missing item list was referred to.

In a 7/13/23 interview at 11:58 AM, Staff 24 (Social Service) stated if a resident, family or staff told her there were missing items, a missing item form was given to them to complete and returned to her. She then sent that form to the manager to search for the item. If the item was not found, Staff 24 checked the resident's inventory list, checked cognition and talked with family if the resident was deemed confused. If Staff 24's investigation showed the item was likely in the facility, the cost of the item was reimbursed. According to Staff 24, Resident 6 had no current reports of missing items. Staff 24 stated it was reported a while ago that staff were unclear what process to use for missing personal items. In response, Staff 24 sent an email to all department heads with the detailed process, but acknowledged that this information may not have been communicated to the direct care staff.

When asked if any items were still missing on 7/13/23 at 12:45 PM, Resident 6 stated many of the items were found the night before, but the red nightgown was still missing.

, 2. Based on observation and interview it was determined the facility failed to maintain and provide a clean homelike environment for 6 of 25 sampled residents (#s 4, 7, 11, 19, 20 and 110) reviewed for environment. This placed residents at risk for living in an unclean and an unhomelike environment. Findings include:

a. Resident 2 admitted to the facility on 6/22/23 with diagnoses including pain.

On 7/10/23 at 9:59 am Resident 2 stated her/his room was not clean. Resident 2 stated her/his bathroom, including the toilet had not been cleaned since admission. Resident 2 stated she/he used the bathroom and toilet. Resident 2 stated she/he was a "tidy person" and the room did not resemble how her/his home was kept.

On 7/10/23 at 10:00 AM the the toilet was observed to be dirty with black and brown specks around inside of the toilet bowl.

On 7/10/23 at 11:30 AM Staff 2 (DNS) confirmed Resident 2's toilet was dirty.

On 7/13/23 at 11:59 AM Staff 14 (Housekeeping Manager) acknowledged the Resident 2's bathroom had not been cleaned including the toilet.

b. Resident 162 admitted to the facility on 7/4/23 with diagnoses including weakness.

On 7/10/23 at 10:23 AM Resident 162 stated her/his room had not been cleaned since admission, including the bathroom. Resident 162 stated staff used a container to empty the urine from her/his catheter into the toilet and then rinsed the container in the sink. Resident 162 stated she/he did not feel comfortable brushing her/his teeth in the sink due to the urine and the sink not being cleaned.

On 7/10/23 at 10:25 AM Resident 162's bathroom was observed to have the container used to empty the urine sitting on the counter by the sink.

On 7/13/23 at 11:59 AM Staff 14 (Housekeeping Manager) stated there was no documentation to indicate when resident rooms were cleaned. Staff 14 acknowledged Resident 20's bathroom should have been cleaned daily.

, c. Resident 312 was admitted to the facility on 6/28/23.

On 7/10/23 at 12:17 PM Resident 312 stated her/his room was not regularly cleaned. The resident reported white debris was on the floor near the bathroom doorway since the day she/he was admitted to the facility.

Observations of the resident's room from 7/10/23 to 7/13/23 revealed damage to the drywall near the bathroom door with chips of drywall and paint on the floor of the resident's room.

On 7/13/23 at 11:05 AM Staff 15 (Maintenance Director) explained that he relied on staff to use the TELS (online maintenance request system) for reports of damage. He was not notified of the damage.


3. On 7/13/23 the following observations were made with Staff 15 (Maintenance Director) and Staff 16 (Corporate Representative).


- Room 4A bathroom had missing and broken floor covering in front of the shower which created a non- cleanable surface.

- Room 11A had cracks surrounding the cove in the bathroom floor with additional damage near the shower.

- Room 7A shower had black stains at the edge of the shower and the flooring was cracked in several places.

On 7/13/23 at 11:05 AM Staff 15 explained that he relied on staff to use the TELS (online maintenance request system) for reports of damage. Staff 15 was waiting on bids to fix the building issues.

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (#6) reviewed for activities. This placed residents at risk for decreased participation in activities of interest. Findings include:

Resident 6 was admitted to the facility in 6/2023 with diagnoses including end stage renal disease.

The 6/9/23 Admission MDS coded her/him BIMS (Brief Interview for Mental Status) as a 10 indicating a moderate cognitive deficit. Resident 6 identified she/he had little interest or pleasure in doing things. Activity interests were identified to include access to newspapers/books/magazines, listening to music, access to animals, spending time outside and religious activities. Doing things with groups of people was somewhat important to the resident.

Resident 6's 6/9/23 Activity Profile further identified hobbies including crosswords and word search games, gardening, arts & crafts, bible studies, 1980s music and travel films.

The 7/6/23 Care Plan did not include the resident's activities of interest.

When interviewed on 7/11/23 at 8:31 AM and 11:11 AM, Resident 6 stated she/he liked to have meals in the common area with other residents but was not always given that choice, enjoyed reading and getting stuck into a good series on the TV.

In a 7/12/23 interview at 5:06 PM, Staff 21 (CNA) stated the resident was observed to watch TV in the evening, but he was unaware of any other activity interests.

In a 7/13/23 interview at 10:49 am, Staff 23 (Agency CNA) stated she relied on the care plan and kardex to help her understand the resident's needs. When asked about Resident 6's activities of interest, she stated there was no care plan entry so she had no knowledge.

In a 7/13/23 interview at 1:45 PM, Staff 22 (Activity Director) stated she completed a 72 hour activity profile, the MDS and CAAs, and finally a care plan which incorporated all of this knowledge for each resident in the facility. Staff 22 was unable to locate a care plan which addressed activities for Resident 6.

Based on interview and record review it was determined the facility failed to update the care plan for 1 of 1 sampled resident (#6) reviewed for UTI. This placed residents at risk for unmet needs and delayed healing. Findings include:

Resident 6 was admitted in 6/2023 with diagnoses including End Stage Renal Disease.

A 7/6/23 Physician's note identified intermittent dysuria (painful or difficult urination) and cloudy urine on 7/5/23. Urinary Analysis (UA) was ordered and the lab was collected on 7/7/23.

A 7/8/23 Physician's progress note identified the abnormal UA was consistent with infection and cephalexin (an antibiotic) for UTI was ordered for 7 days.

No Care Plan was found which addressed the new diagnosis of UTI.

In interviews on 7/12/23 at 5:06 PM and 7/13/23 at 10:49 AM, Staff 21 (CNA) and Staff 23 (Agency CNA) were unaware of the new infection or interventions to promote healing.

In a 7/13/23 interview at 3:33 PM, Staff 26 (RNCM) stated she was aware that Resident 6 was on alert for the antibiotic and it was noted in the Teleshare communication system (nursing communication), but there was no care plan in place which CNAs could access.

Based on interview and record review it was determined the facility failed to follow the plan of care for 1 of 2 sampled residents (#413) reviewed for falls. This placed residents at risk for falls. Findings include:

Resident 413 was admitted to the facility in 7/2022 with diagnoses including stroke and Parkinson's Disease.

The 7/19/22 Admission MDS revealed Resident 413 had severely impaired daily decision making skills.

The 8/11/22 Fall Care Plan instructed staff to not leave the resident unsupervised in the bathroom.

The 8/18/22 Progress Note revealed a CNA exited the resident's room, the nurse heard a "thud", went to the resident's bathroom and found Resident 413 on the floor.

The 8/18/22 Fall Investigation revealed Staff 21 (CNA) assisted Resident 413 to the bathroom and left the resident alone on the toilet. The investigation determined Staff 21 did not follow the care plan which resulted in the minor injury fall.

On 7/12/23 at 8:40 AM Staff 2 (DNS) verified Resident 413 sustained a minor injury fall as a result of Staff 21 not following the resident's care plan.

Based on observation, interview and record review it was determined the facility failed to maintain a coordinated plan of care for 1 of 1 sampled resident (#6) reviewed for dialysis. This placed residents at risk for lack of coordinated transportation to and from dialysis and unmet nutritional needs. Findings include:

Resident 6 was admitted to the facility in 6/2023 with diagnoses including end stage renal disease. The resident had physician's orders for dialysis three times a week which was provided offsite.

When interviewed on 7/12/23 at 8:35 AM, Resident 6 stated she/he had breakfast prior to leaving for dialysis, never took lunch with her/him to dialysis, but sometimes ate a protein bar when offered by dialysis staff. Resident 6 was observed preparing to leave for dialysis at 9:07 AM with a blanket, a packet of information for dialysis and a purse. Resident 6 asked for the purse and stated she/he needed to pay the driver. No lunch bag was observed.

On 7/12/23 at 5:22 PM, upon return from dialysis, the resident shared she/he was very hungry and began to eat dinner immediately when served. Resident 6 stated dialysis staff offered a protein bar but she/he did not eat it as Resident 6 was tired of the bars.

In a 7/13/23 interview at 10:24 AM, Staff 25 (Culinary Director) stated Resident 6's family member transported the resident to and from dialysis and provided lunch. Staff 25 confirmed she was not notified that transportation arrangements changed and a lunch for dialysis was needed.

In a 7/13/23 interview at 3:33 PM, Staff 26 (RNCM) stated she believed Resident 6's family member brought lunch to the dialysis location, but acknowledged there was no system in place to notify the facility if lunch was not provided to the resident.











, Based on observation, interview and record review it was determined the facility failed to provide appropriate provisions and maintain a coordinated plan of care for 1 of 1 sampled resident (#6) reviewed for dialysis. This placed residents at risk for unmet dialysis needs. Findings include:

Resident 6 was admitted to the facility in 6/2023 with diagnoses including end stage renal disease requiring dialysis (the process of removing excess water, solutes and toxins from the blood).

A 6/5/23 order directed staff to complete a dialysis communication report upon return from dialysis every Monday, Wednesday, and Friday.

The 6/9/23 Admission MDS indicated Resident 6 required dialysis. No additional information was provided.

The 6/5/23 dialysis care plan indicated Resident 6 required dialysis every Monday, Wednesday, and Friday. The goal indicated no complications from dialysis through the review date. No additional information was provided related to care prior to showers.

The 6/5/23 ADL care plan indicated Resident 6 required one person to provide some physical assist with bathing.

An 8/30/23 Dialysis Communication Note indicated the Dialysis Care Manager assessed Resident 6's Central Venous Catheter (CVC; a thin, flexible tube placed into a large vein above the heart), identified her/his bandage was exposed, and informed the resident she/he needed a catheter replacement.

A 9/1/23 Nursing Care Note indicated Resident 6 had appointment on 9/5/23 at 11:30 AM to have the CVC replaced.

A 9/1/23 order indicated an exposed dialysis catheter on the chest and staff were to cover with a bandage on 9/1/23 until a replacement on 9/5/23. Staff were to monitor for signs and symptoms of infection and increased pain and it was okay to remove the dressing if concerned.

A 9/7/23 order indicated a dialysis port to the chest, left side, and staff to monitor for signs and symptoms of infection and increased pain.

The 9/8/23 Dialysis Communication Report indicated the bottom portion was to be completed by the nursing staff upon the resident's return to the facility. No documentation was on the bottom of the form for the following:

-Blood pressure, pulse, respirations, and temperature
-Location of the dialysis access site
-Lung assessment
-Signs of edema (excessive fluid in the body)
-Problems and/or concerns
-Nurse signature

The 9/13/23 Dialysis Communication Report indicated the location of the dialysis access site was on the right chest (the access site was changed to the left side).

A 9/18/23 Social Service Note indicated staff spoke with Resident 6's daughter to follow up with her/his concern that staff were not covering Resident 6's port prior to showers.

A 9/18/23 order indicated staff to cover the dialysis port with waterproof dressing prior to her/his shower every evening shift on Tuesday, Thursday and Sunday.

On 9/19/23 at 12:50 PM Staff 8 (CNA) stated she was aware Resident 6 received dialysis three days a week and the resident's scheduled shower days were on the same days as dialysis. Staff 8 stated these were not the resident's preferred shower days. Staff 8 stated staff were supposed to cover the resident's CVC port with a waterproof patch, but the facility often ran out of the patches. When this happened staff covered the resident's port with a garbage bag and tape. Staff 8 stated she did not receive special training or education related to dialysis residents.

On 9/19/23 at 2:00 PM Staff 34 (CNA) stated she was aware Resident 6 received dialysis three days a week. Staff 34 stated she was told by staff to cover Resident 6's CVC port with a garbage bag and tape. Staff 34 stated she did not receive special training or education related to dialysis residents.

On 9/19/23 at 2:10 PM Resident 6 stated she/he received dialysis three times a week. Resident 6 was observed sitting upright groomed and dressed. Resident 6 pulled her/his shirt aside to reveal her/his new CVC access port on her/his left side. The insertion site was covered with a transparent dressing, and the catheter lumens were wrapped in gauze and not visible. Resident 6 stated a few weeks ago when she/he was at dialysis she/he told the dialysis nurse she/he had pain around her/his CVC port. Resident 6 stated the dialysis nurse told her/him the bandage was exposed and asked her/him if at any point the CVC site was exposed to water. Resident 6 told the dialysis nurse that staff often used a garbage bag to cover her/his CVC insertion site before giving her/his shower because they often ran out of waterproof patches. Resident 6 stated the dialysis nurse explained the risk of infection and told her/him she/he need to have her/his CVC site replaced due to a high risk of infection. Resident 6 stated she/he was still adjusting to having the CVC port on her/his left side and it was sometimes painful. Resident 6 stated when she/he asked staff about the waterproof patches staff told her/him that she/he had to purchase her/his own waterproof patches because the facility did not provide them. Resident 6 further stated a few days later the same staff came back and told her/him they found waterproof patches. Resident 6 stated she/he refused to take showers when staff could not provide waterproof patches because she/he was concerned about infection.

The 9/20/23 Dialysis Communication Report indicated the bottom portion was to be completed by the nursing staff upon the resident's return to the facility. No documentation was completed on the bottom of the form for the following:

-Blood pressure, pulse, respirations, and temperature
-Location of the dialysis access site
-Lung assessment
-Signs of edema (excessive fluid in the body)
-Problems and/or concerns
-Nurse signature

On 9/20/23 at 11:00 AM Staff 33 (LPN) stated nurses were required to complete a Dialysis Communication Report for Resident 6 before and after dialysis, but staff did not always have time to do it. Staff 33 stated the resident's Resident Care Manager (RCM) reviewed and monitored orders, but the nurses often found mistakes. Staff 33 stated the resident's RCM updated the care plans and she was not familiar with Resident 6's dialysis care plan. Staff 33 stated the facility often ran out of waterproof patched and CNAs were told to cover the resident's CVC port with "trash bag and tape" prior to giving the resident a shower. Staff 33 stated she was not concerned about the area getting wet and she was not worried about infection. Staff 33 further stated she was not well-versed in dialysis care and did not receive special training or education related to dialysis.

On 9/20/23 at 3:21 PM Staff 4 (LPN) stated Resident 6 had dialysis three days a week. Staff 4 stated she was not familiar with Resident 6's dialysis care plan and was not sure if it was up-to-date. Staff 4 stated staff were expected to cover the resident's CVC site prior to giving showers and she did not expect an order for a waterproof patch because it was a standard order. Sometimes the facility ran out of the waterproof patches and used a plastic bag and tape.

A 9/21/23 order directed staff to cover the dialysis port to the left chest with a waterproof dressing prior to showers every Tuesday, Thursday and Sunday.

Resident 6's current care plan for dialysis, last revised 9/21/23, indicated staff were directed to cover the CVC site with waterproof dressing and to not let water into the CVC port.

On 9/21/23 at 12:03 PM Staff 2 (DNS) acknowledged the facility failed to provide appropriate dialysis supplies and provide clear instructions related to dialysis care for Resident 6. Staff 2 acknowledged staff failed to complete dialysis communication reports. She also confirmed the comprehensive care plan did not reflect the necessary interventions to meet the dialysis needs of Resident 6 prior to 9/21/23 and confirmed the facility did not provide staff training for dialysis.

Based on interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 3 of 3 sampled residents (#s 2, 48 and 162) reviewed for staffing. This placed residents at risk for unmet ADL care needs. Findings include:

A list provided by the facility on 7/14/23 indicated the facility had 4 residents who required a mechanical lift for transfers and two other residents who required two staff for transfers.

Residents indicated the following concerns:
- A concern reported on 6/26/23 indicated Resident 48 waited up to 45 minutes for for assistance, including waiting to get assisted to the toilet and off the toilet. It was indicated weekends were worse.

- On 7/10/23 at 9:59 AM Resident 2 stated call lights took a long time. Resident 2 stated she/he had to go into the hall to look for staff to get assistance.

- On 7/10/23 at 10:54 AM Resident 19 stated she/he was "disappointed in the way [staff] did not respond to call lights." Resident 19 stated she/he had to call the front desk to get assistance because her/his call light was not answered. Resident 19 stated the facility was under staffed and it took up to an an hour sometimes for staff to answer her/his call light. Resident 19 stated a resident across the hall had to "throw things" out in the hall to get staff assistance.

Facility record review of call light logs revealed the following:
- From 6/6/23 to 7/7/23 there were 67 instances when Resident 48's call light times was between 20 and 63 minutes.

- From 6/22/23 to 7/10/23 there were 13 instances when Resident 2 call light times was between 20 and 45 minutes.

- From 6/14/23 through 7/10/23 there were 27 instances when Resident 19 call lights times was 20 to 52 minutes.

Facility Staff indicated the following concerns:
- 7/11/23 at 3:57 PM Staff 4 (LPN) stated they were short staff in multiple departments. Staff 4 stated there were days she was doing treatments, medications and CNA duties. Staff 4 stated weekends and shift change were the worst for call lights.

- 7/12/23 at 8:33 AM Staff 5 (CMA) stated there were times when there were no nurses working in the facility.

- On 7/12/23 at 9:30 AM Staff 11 (CNA) stated call lights could get "crazy." Staff 11 stated she had several residents who were two-person transfers and sometimes waited for a second staff person to assist which could take some time. Staff 11 stated sometimes residents had waited for call lights to be answered due to assisting other residents with transfers.

- On 7/12/23 at 1:23 PM Staff 12 (CNA) stated they were always short staffed. Staff 12 stated when the facility was "over staffed" CNAs were sent home. Staff 12 stated it was overwhelming at times with call lights going off and not having enough CNA staff to answer the call lights timely. Staff 12 stated residents often complained about the long call light times. Staff 12 stated at night there were only two CNA for the facility and only one CNA for a section. Staff 12 stated she had to to leave her section to assist another CNA in another section. Staff 12 stated call lights could be over 20 minutes.

- On 7/12/23 at 6:00 PM Staff 21 (CNA) stated it was scary to work at the facility. Staff 21 stated acuity did not matter in relation to CNAs. Staff 21 stated CNAs were overwhelmed as they were also expected to pick up housekeeping and maintenance duties in addition to caring for residents.

- On 7/13/23 at 9:37 AM Staff 10 (Staffing Coordinator) stated CNA staff were sent home before all CNAs arrived without ensuring there was enough coverage. Staff 10 acknowledged she staffed based on the census. Staff 10 stated night shift CNA staff complained about staffing.

On 7/13/23 at 10:29 AM Staff 2 (DNS) stated staffing was a frequent concern. Staff 2 stated the goal was for call lights to answered in 10 to 15 minutes. Staff 2 acknowledged CNA staff were not always staffed based on resident acuity and acknowledged the long call light times for Residents 2, 19 and 48.



















, Based on interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 4 of 4 sampled residents (#s 416, 417, 6, and 418) reviewed for staffing. This placed residents at risk for unmet care needs. Findings include:

Review of the Direct Care Staff Daily Report from 8/30/23 through 9/19/23 revealed the facility failed to provide the state minimum CNA staffing for nine out of 21 days.

On 9/18/23 at 10:10 AM Resident 416 stated she/he frequently waited 20 to 45 minutes for staff to answer her/his call light and the longest she/he waited was over an hour. Resident 416 stated staff told her/him the facility was understaffed.

The facility Call History reviewed from 9/7/23 through 9/16/23 indicated Resident 416 waited greater than 20 minutes for staff to answer her/his call light four times.

On 9/19/23 at 11:40 AM Resident 417 stated she/he was dependent on staff for assistance with ADLs and was waiting for staff to help her/him off the bed pan. Resident 417 stated she/he often had to wait 20 to 30 minutes because the facility was "always understaffed" especially on the weekends.

The facility Call History reviewed from 8/30/23 through 9/14/23 indicated Resident 417 waited greater than 20 minutes for staff to answer her/his call light seven times.

On 9/19/23 at 2:10 PM Resident 6 stated the facility was "constantly understaffed" and she/he often had to wait more than 15 minutes for staff to answer her/his call light. Resident 6 stated her/his scheduled shower days were on the same days she/he had dialysis three days a week and there was not enough staff to provide her/his showers.

On 9/19/23 at 12:30 PM Resident 418 stated the first night she/he admitted to the facility she/he was in a lot of pain and staff were too busy to address her/his pain concerns. Resident 418 stated it was not until she/he yelled out in the hallway for help before staff came to help her/him. Resident 418 stated staff told her/him they were short-staffed and would help as soon as they could.

On 9/19/23 at 12:00 PM Staff 32 (LPN) stated the facility continued to struggle with having sufficient CNAs on day and evening shifts and the weekends were the worst. Staff 32 stated residents expressed concerns they had to wait 20 to 30 minutes for call lights to be answered. Staff 32 stated she often stayed three to four hours over her shift to complete work duties and was not always able to take breaks. Staff 32 further stated it was difficult to provide quality care, pass medications timely and chart during her shift.

On 9/19/23 at 12:50 PM Staff 8 (CNA) stated staffing was "totally unorganized; chaotic" and she never knew if they were fully staffed. Staff 8 stated they did not staff to the acuity of residents and did not always have enough staff to meet the state required CNA staffing levels. Staff 8 stated residents reported to her long call light wait times and they frequently did not receive scheduled showers. Staff 8 stated it was difficult to provide quality care when short-staffed.

On 9/20/23 at 3:21 PM Staff 4 (LPN) stated "staffing was a disaster and there were not enough CNAs to provide quality care." Staff 4 stated residents complained that they had to wait 30 to 40 minutes for staff to answer call lights. Staff 4 stated it was difficult to complete assignments during her 12 hour shift and often stayed over. Staff 4 further stated the facility should not admit new residents until they had sufficient staff.

On 9/19/23 at 3:30 PM Staff 10 (Staffing Coordinator) confirmed the facility was short-staffed and did not meet the State CNA staffing requirements according to the Direct Care Staff Daily Reports from 8/30/23 through 9/16/23.

On 9/21/23 at 10:53 AM Staff 2 (DNS) stated she expected staff to answer residents' call lights timely to provide quality care. Staff 2 reviewed the Call History and Direct Care Staff Daily Report from 8/30/23 through 9/19/23 and confirmed the facility was short-staffed.

Based on interview and record review it was determined the facility failed to have a system in place for conducting annual performance reviews of CNA staff for 1 of 1 sampled Staff 8 (CNA) reviewed for annual performance reviews. This placed residents at risk for a lack of quality of care. Findings include:

A review of staff training records for CNAs employed at the facility over one year revealed: Staff 8 (CNA), hired 4/11/22, had no performance review documentation.

On 7/14/23 at 9:30 AM Staff 2 (DNS) acknowledged Staff 8 did not have a performance review completed as the facility did not currently have a system in place for annual performance reviews.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were complete for 27 out of 39 sampled days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include:

A review of the Direct Care Staff Daily Reports dated 6/1/23 through 7/10/23 revealed 27 out of 39 days the CNA and/or RN hours were blank for one or more shifts for the following days:
-6/2/23
-6/4/23
-6/7/23
-6/8/23
-6/9/23
-6/10/23
-6/11/23
-6/12/23
-6/13/23
-6/15/23
-6/16/23
-6/17/23
-6/18/23
-6/19/23
-6/22/23
-6/23/23
-6/24/23
-6/25/23
-6/28/23
-6/29/23
-6/30/23
-7/1/23
-7/2/23
-7/4/23
-7/6/23
-7/7/23
-7/8/23

On 7/13/23 at 9:37 AM Staff 10 (Staffing Coordinator) acknowledged the incomplete documented hours for the days identified.
















, Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report was accurate for 19 out of 21 days reviewed for staffing information. This placed residents and visitors at risk for lack of staffing information. Findings include:

A review of the Direct Care Staff Daily Reports from 8/30/23 through 9/19/23 revealed 19 out of 21 days the total number and actual hours worked RN, LPN and CNA staff was not accurate, and the total resident census was not documented as required for the following dates: 8/30 through 9/3, 9/5 through 9/17, and 9/19/23.

On 9/19/23 at 3:30 PM Staff 10 (Staffing Coordinator) reviewed the Direct Care Daily Staff Report for the above noted dates and acknowledged the postings were not accurate.

Based on interview and record review it was determined the facility failed to develop a Quality Assessment and Assurance (QAA) program that identified quality deficiencies and developed and implemented action plans to correct identified quality deficiencies. The facility failed to conduct an analysis of quality data, design interventions, test those interventions, and determine if the desired outcome was achieved or sustained for 1 of 1 facility reviewed for QAPI. This failed practice placed all residents at risk for not receiving the care and services for optimal resident outcomes. Findings include:

The 2/7/22 facility policy Quality Assurance and Performance Improvement (QAPI) Plan indicated the the QAPI committee was responsible to:
-Address Care and Services;
-Define and Measure Goals;
-Monitor Processes;
-Recognize Problems and Improvement Opportunities;
-Identify a Working QAPI plan

On 7/14/23 at 10:17 AM Staff 2 (DNS) stated the last QAPI meeting was held in January 2023 and addressed issues from the last quarter of 2022. Staff 2 stated the facility did not have QAPI meetings from January 2023 to current (7/14/23).

Based on observation and interview it was determined the facility failed to ensure appropriate hand hygiene procedures was followed by staff during direct patient contact for 1 of 1 facility reviewed for infection control. This placed residents at risk for spread of infection. Findings include:

On 7/10/23 at 11:12 AM Staff 5 (CMA) was observed wearing her surgical mask on her chin area while standing at the medication cart. Staff 5 prepared medication to dispense, placed the surgical mask over her nose and mouth area before entering a resident room without sanitizing her hands. Staff 5 stated she should have sanitized her hands before and after preparing medications, before entering and after exiting the resident room and touching her mask.

On 7/10/23 at 12:47 PM Staff 7 (NA) was observed to wear a surgical mask on her chin then move mask over her mouth and nose area before retrieving a tray in a resident room without performing hand hygiene. Staff 7 then assisted a resident seated in the dining room. Staff 7 stated she should have sanitized her hands before and after touching her mask and before the resident interaction.

On 7/11/23 at 12:12 PM Staff 6 (NA) was observed to retrieve a surgical mask from her pocket while seated next to a resident in the dining room area without sanitizing her hands. Staff 6 stated she should have sanitized her hands prior to donning the mask.

On 7/12/23 at 12:29 PM Staff 6 was observed with her surgical mask on her chin in the kitchen area. Staff 6 prepared a hot cup of coffee for a resident seated in the dining area, then walked into a resident room to provide care and placed mask on her face without sanitizing hands. Staff 6 retrieved a tray from the cart, delivered and set-up the tray for a resident and retrieved another meal tray. Staff 6 stated she should have sanitized her hands before and after tray delivery and after touching her mask.

On 7/12/23 at 12:39 PM Staff 8 (CNA) was observed to exit a resident room, move her surgical mask to her chin area, walk to the kitchen area and fill a cup of water and retrieve a juice box from the refrigerator. Staff 8 moved the surgical mask back over her nose and mouth area and walked into a resident's room. Staff 8 stated she should have completed hand hygiene before and after entering a resident's room and after touching a her mask.

On 7/12/23 at 2:49 PM Staff 2 (DNS) stated it was her expectation staff sanitize their hands before and after entering a resident room, between resident care and when touching their mask.

Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 1 of 1 sampled staff (#8) reviewed for in-service training. This placed residents at risk for lack of quality care. Findings include:

On 7/13/23 at 3:45 PM a request was made to review the facility's in-service records and documentation which tracked self-paced electronic training hours.

No staff in-service records were provided for Staff 8.

On 7/14/23 at 9:30 AM Staff 2 (DNS) stated she could not locate documentation to verify in-service trainings were completed over the last 12 months for Staff 8 or other staff. Staff 2 was unable to provide information to demonstrate there was a system to track in-service or self-paced electronic training hours for CNA staff.

Based on interview and record review it was determined the facility failed to complete reference checks for 4 of 5 sampled staff (#s 17, 18, 19 and 20) reviewed for reference checks. 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 (RN) was hired on 6/14/23.
-Staff 18 (CNA) was hired on 7/6/23.
-Staff 19 (CNA) was hired on 5/26/23.
-Staff 20 (CNA) was hired on 5/2/23.

There was no evidence reference checks were completed for Staff 17, 18, 19 and 20.

On 7/13/23 at 11:06 AM Staff 13 (Medical Records) confirmed reference checks were not completed for Staff 17, Staff 18, Staff 19 and Staff 20.

Based on interview and record review it was determined the facility failed to utilize an RN for a minimum of eight consecutive hours between the start of day shift and the end of the evening shift for 64 of 161 days reviewed for RN staffing. This placed residents at risk for unmet RN assessments, care and treatment needs. Findings include:

A review of the Direct Care Staff Daily Reports for July 2022, August 2022, September 2022, April 2023, May 2023, June 2023 and July 1-10 2023 revealed the following dates with no RN coverage on day or evening shift:

July 2022: 7, 24, 25, 27
August 2022: 1, 17, 18, 19, 21, 22, 26, 27, 28, 29
September 2022: 4, 5, 9, 10, 11, 12, 13, 18, 19, 24, 25, 26, 27
April 2023: 1, 5, 8, 13
May 2023: 1, 2, 3, 8, 10, 12, 17, 24, 25, 26, 28, 31
June 2023: 1, 2, 3, 7, 8, 9, 12, 13, 14, 15, 19, 20, 21, 25, 26, 27 and 28
July 2023: 3, 4, 5 and 10

On 7/11/23 at 9:29 AM and 7/13/23 at 9:37 AM Staff 10 (Staffing Coordinator) verified there was no RN on day or evening shift on the 64 identified dates.

Based on interview and record review the facility failed to meet the State minimum CNA staffing requirements for 46 of 121 days reviewed for CNA staffing. This placed residents at risk for unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports for August 2022, September 2022, April 2023 and May 2023 revealed the following days and shifts which did not meet the State minimum CNA staffing ratio:

August 2022:
Day shift: 12, 13, 15, 27, 28
Evening shift: 4, 6, 8, 9, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 30, 31
Night shift: 25

September 2022:
Day shift: 13, 14, 16 (two shifts), 19, 25, 26
Evening shift: 13, 14, 15, 16

April 2023:
Day shift: 2, 3, 9, 24
Evening shift: 1, 2, 4, 21

May 2023:
Day shift: 3, 5, 7, 13, 28 (two shifts)
Evening shift: 7

On 7/11/23 at 9:29 AM Staff 10 (Staffing Coordinator) verified the identified 46 of 121 days which did not meet the State minimum CNA staffing requirements for one or more shifts.









, Based on interview and record review it was determined the facility failed to meet State minimum CNA staffing requirements for nine of 21 days reviewed for CNA staffing. This placed residents at risk for unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports from 8/30/23 through 9/19/23 revealed the following days and shifts which did not meet the State minimum CNA staffing requirements:

8/2023:
Day shift: 8/30 and 8/31.
Evening shift: 8/31.

9/2023:
Day shift: 9/2, 9/3, 9/5, 9/10, 9/11 and 9/16.
Evening shift: 9/1, 9/2, 9/3 and 9/5.

On 9/19/23 at 2:34 PM Staff 10 (Staffing Coordinator) verified the above identified nine of 21 days did not meet the State minimum CNA staffing requirements for one or more shifts.

OAR-411-087-0100: Physical Environment: Generally

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

Refer to F698
********************
OAR-411-086-0060: Comprehensive Assessment and Care Plan

Refer to F656 and F657
********************
OAR-411-086-0100: Nursing Services: Staffing

Refer to F725 and F732
********************
OAR-411-086-0310: Employee Orientation and In-Service Training

Refer to F730
********************
OAR-411-085-0220: Quality Assurance

Refer to F865
********************
OAR 411-086-0330: Infection Control and Universal Precautions

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

Refer to F947
********************
OAR-411-086-0140: Nursing Services: Problem Resolution and Preventive Care

Refer to F689
********************







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

Refer to F698
********************
OAR 411-086-0100: Nursing Services: Staffing

Refer to F725 & F732

Based on interview and record review it was determined the facility failed to notify a residents responsible party of falls and hospitalizations for 3 of 6 sampled residents (#s 1, 3 and 5) reviewed for falls. This placed residents responsible parties at risk for being uniformed. Findings include:

1. Resident 3 admitted to the facility in 9/2020 with diagnoses including left leg infection and hypertension (high blood pressure).

The 9/23/20 Fall Investigation revealed Resident 3 rolled out of bed at 9:35 PM, landied on her/his knees and was discovered by a CNA. Resident 3's family was notified of the fall on 9/24/20 at 9:35 AM [when the family inquired about the fall].

The 9/24/20 72 Hour Huddle indicated Resident 3's family expressed concern they were not notified of the previous nights fall.

On 11/17/21 at 1:31 PM Staff 3 (DNS) verified Resident 3's family was not notified of Resident 3's 9/23/20 fall.

b. The 9/2020 TARs revealed a 9/21/20 wound vac (vacuum) order to be changed three times a week. Documentation revealed staff charted "9" on September 23 and 25. The TARs revealed an every other day wound care order to the bilateral heels. Documentation revealed staff charted "9" on September 23, 25, 27 and 29.

On 11/17/21 Staff 3 (DNS) stated when staff charted "9" it meant the treatments were not completed as ordered and verified Resident 3's physician was not notified of the missed wound treatments.

2. Resident 10 admitted to the facility on 7/1/20 with diagnoses including delirium. Resident 10 discharged from the facility on 7/3/20.

Resident 10's profile page listed Witness 7 as the emergency contact.

The hospital admission records listed Witness 7 as Resident 10's emergency contact.

There was no documentation in the medical record Witness 7 was contacted when Resident 10 was transferred to the hospital on 7/3/20.

On 11/18/21 at 11:59 AM Staff 3 (DNS) acknowledged when Resident 10 transferred to the hospital the facility did not notify Witness 7.

, 3. Resident 5 admitted to the facility in 4/2020 with diagnoses including Alzheimer's Disease and removal of an infected artificial hip joint.

A 4/30/20 at 10:38 AM skilled evaluation progress note confirmed Resident 5 had an episode of "non-responsiveness" and the NP initiated strong sternal rubs until Resident 5 was aroused.

The 5/6/20 injury investigation indicated the facility was aware of a bruise to Resident 5's right chest. The former administrator, former DNS, and Resident 5's physician were notified. There was no documentation Resident 5's responsible party was notified.

On 11/18/21 at 6:39 PM Staff 12 (LPN) stated she remembered the Assisted Living called and asked about a bruise. Witness 14 further recalled Resident 5 had lost consciousness during breakfast. The Nurse Practitioner (NP) was in the facility and assessed the resident. Staff 12 stated the NP "began doing intense sternal rubs and eventually Resident 5 was aroused".

On 11/24/21 at 11:20 AM Staff 3 (DNS) stated the family should have been notified of such an incident and was unable to provide any documentation that Resident 5's responsible party was notified.

Based on interview and record review it was determined the facility failed to report an allegation of neglect to the State Agency within the required timeframe for 1 of 3 sampled residents (#7) reviewed for falls. This placed residents at risk for neglect of care. Findings include:

Resident 7 admitted to the facility in 12/2020 with diagnoses including diabetes.

The 12/15/20 ADL Care Plan indicated Resident 7 required two person assistance when transferring and toileting.

The 12/26/20 Fall Investigation revealed Resident 7 sustained a non-injury fall when she/he was transferred to the toilet with the assistance of one person. The investigation further indicated the CNA was aware of Resident 7's two person transfer status and the CNA did not follow Resident 7's care plan.

The Facility Reported Incident (FRI) was received by the Stage Agency on 1/5/21.

On 11/17/21 at 1:07 PM Staff 3 (DNS) verified the FRI for Resident 7's 12/26/20 fall was not submitted to the State Agency within the required timeframe.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 2 of 5 sampled residents (#s 1 and 10) reviewed for tube feeding and notification of change. This placed residents at risk for lack of communication of necessary information at the time of discharge. Findings include:

1. Resident 1 admitted to the facility on 9/14/20 with diagnoses including stroke.

The 10/10/20 Discharge MDS revealed Resident 1 discharged from the facility on 10/10/20.

Review of the medical record revealed the discharge summary was not initiated or completed.

On 11/18/21 at 3:25 PM Staff 3 (DNS) acknowledged a discharge summary was not completed for Resident 1.

2. Resident 10 admitted to the facility on 7/1/20 with diagnoses including delirium.

The 7/4/20 Progress Note revealed Resident 10 was transferred to the hospital on 7/3/20.

Review of the medical record revealed no discharge summary was completed for Resident 10.

On 11/18/21 at 11:59 AM Staff 3 (DNS) verified a discharge summary was not completed for Resident 10.

Based on interview and record review it was determined the facility failed to monitor for a resident's change in condition after a fall and failed to assess skin conditions for 4 of 6 sampled residents (#s 2, 3, 5 and 7) reviewed for falls and skin conditions. This placed residents at risk for a decline in physical condition. Findings include:

1. Resident 3 admitted to the facility on 9/21/20 with diagnoses including left lower leg vascular graft infection and hypertension (high blood pressure).

a. The 9/23/20 Fall Investigation revealed Resident 3 sustained a fall on 9/23/20 at 9:45 PM.

Review of Resident 3's medical record revealed no ongoing assessment and monitoring after the 9/23/20 fall.

The 9/29/20 nursing note indicated Resident 3 was admitted to the hospital.

On 11/17/21 at 1:31 PM Staff 3 (DNS) verified alert charting was not initiated after the 9/23/20 fall and no monitoring was in place to monitor for latent injury.

b. The 9/21/20 Admission Nursing Database revealed Resident 3 was admitted to the facility with a left thigh surgical incision, a lower left leg wound vacuum (wound vac), a left heel pressure ulcer, and a right heel pressure ulcer. Wound dressings were in place to both heels.

The 9/2020 TARs revealed the following wound care orders:
*9/21/20 Wound vac care. Rinse wound with normal saline and clean the peri wound with normal saline and pat dry. Prep the peri-wound skin with barrier spray and drape. Apply one black sponge to the wound bed, bridge to upper leg, change three times a week. Documentation revealed staff charted "9" on September 23 and 25. The order was completed on 9/27/20.
*9/22/20 Wound care to bilateral heels. Cleanse with normal saline and apply a hydrogel or hydrocolloid dressing. Use skin prep to area surrounding the wound before applying the dressing every other day. Documentation revealed staff charted "9" on September 23, 25, 27 and 29.

On 11/17/21 at 1:31 PM Staff 3 (DNS) stated when staff charted "9" it meant the treatment was not completed. Staff 3 verified the ordered treatment to the bilateral heels was not completed as ordered. Staff 3 further stated the wound vac treatment was not completed on 9/23/20 and 9/25/20. Staff 3 verified Resident 3's physician was not notified of the missed wound treatments.

c. The 9/21/20 Admission Nursing Database revealed Resident 3 was admitted to the facility with a left thigh surgical incision, a lower left leg wound vacuum (wound vac), a left heel pressure ulcer, and a right heel pressure ulcer. Wound dressings were in place to both heels.

Review of Resident 3's medical record revealed no comprehensive skin assessments of the left thigh surgical incision, the lower left leg wound or the bilateral pressure ulcers.

On 11/16/21 at 4:40 PM Staff 2 (AIT - Administrator in Training) stated no skin and wound evaluations were completed for Resident 3's wounds.

2. Resident 7 admitted to the facility in 12/2020 with diagnoses including diabetes.

The 12/26/20 Fall Investigation revealed Resident 7 sustained a fall on 12/26/20.

Review of Resident 7's medical record revealed no ongoing assessment and monitoring for latent injury after the 12/26/20 fall.

On 11/17/21 at 1:07 PM Staff 3 (DNS) verified there was no documentation in the medical record of any ongoing assessment or monitoring after Resident 7's 12/26/20 fall.

, 3. Resident 2 admitted to the facility on 8/2020 with diagnoses including dementia and an unspecified fall.

The 8/14/20 Fall Investigation indicated Resident 2 sustained a fall on 8/14/20 and was transferred out to the hospital for evaluation.

The 8/17/20 Fall Investigation indicated Resident 2 was found on floor after a failed self-transfer attempt on 8/17/20.

A review of Resident 2's medical revealed no ongoing assessment and monitoring after the 8/14/20 fall and the 8/17/20 falll. Resident 2's medical record also revealed no documentation of second fall on 8/17/20..

On 11/24/21 at 11:20 AM Staff 3 (DNS) stated an incident of this type should have had alert charting completed for a minimum of three days. Staff 3 was unable to provide any documentation that Resident 2's fall on 8/14/20 and 8/17/20 had been monitored.

4. Resident 5 admitted to the facility in 4/2020 with diagnoses including Alzheimer's Disease and removal of an infected artificial hip joint.

A 4/30/20 at 10:38 skilled evaluation progress note confirmed Resident 5 had an episode of "non-responsiveness" and the NP (Nurse Practioner) initiated strong sternal rubs until Resident 5 was aroused.

The 5/6/20 injury investigation indicated the facility was aware of a bruise to Resident 5's right chest.

On 11/18/21 Staff 12 (LPN) stated she remembered Resident 5 had lost consciousness during breakfast. The NP was in house and assessed the resident. Staff 12 stated the NP "began doing intense sternal rubs and eventually Resident 5 was aroused".

A review of Resident 5's medical record revealed no ongoing assessment or monitoring after the event on 4/30/20

On 11/24/21 at 11:20 AM Staff 3 (DNS) stated an incident of this type should have been documented better and was unable to provide any documentation that Resident 5 had received ongoing monitoring or assessment.

Based on interview and record review it was determined the facility failed to provide necessary care and services to prevent pressure ulcers for 1 of 4 sampled residents (#8) reviewed for skin conditions. This caused Resident 8 to develop a facility acquired pressure ulcer and placed residents at risk of developing pressure ulcers. Findings include:

Resident 8 admitted to the facility on 5/15/21 with diagnoses including left femur (leg) fracture and heart failure.

The 5/13/21 Admission Nursing Database indicated Resident 8 did not have a pressure ulcer.

The 5/19/21 Admission MDS Pressure Ulcer CAA indicated Resident 8 was at risk for pressure injury related to the need for extensive assistance with bed mobility.

The 5/27/21 Skin and Wound Evaluation indicated Resident 8 had a new pressure ulcer measuring 2.31 cm x 2.24 cm with light serosanguineous drainage (consisting of both blood and serous fluid).

The 6/9/21 FRI indicated Resident 8 developed a Stage 3 (full thickness skin loss) facility acquired pressure ulcer on 5/27/21.

The 6/1/21 Skin and Wound Evaluation indicated the wound measured 3.39 cm x 2.18 cm and was covered in 80% slough (non-viable yellow, tan, gray, green or brown tissues.) Evidence of infection included increased pain, redness and inflammation, warmth and light serosanguineous drainage.

The 6/2/21 NAR (Nutrition at Risk) note indicated Resident 8 had an unstageable pressure ulcer (full thickness tissue loss in which the actual depth of the ulcer was completely obscured by slough and/or eschar (dead tissue) in the wound bed) to the sacrum.

On 11/18/21 at 5:00 PM Staff 3 (DNS) verified Resident 8 discharged from the facility on 6/4/21 with an unstageable pressure ulcer to the sacrum/coccyx area.

On 11/19/21 at 9:47 AM Staff 4 (Regional RN) acknowledged Resident 8 admitted to the facility with no pressure ulcers and on 5/27/21 a facility acquired Stage 3 pressure ulcer was identified.

Based on interview and record review it was determined the facility failed to follow the resident's plan of care to prevent falls for 1 of 3 sampled residents (#7) reviewed for falls. This placed residents at risk for falls and injury. Findings include:

Resident 7 admitted to the facility in 12/2020 with diagnoses including diabetes.

The 12/15/20 ADL Care Plan indicated Resident 7 required two person assistance when transferring and toileting.

The 12/26/20 Fall Investigation revealed Resident 7 sustained a non-injury fall when she/he was transferred to the toilet with the assistance of one person. The investigation further indicated the CNA was aware of Resident 7's two person transfer status and the CNA did not follow Resident 7's care plan. The Fall Investigation was not completed until 1/5/21.

On 11/17/21 at 1:07 PM Staff 3 (DNS) verified Resident 7's care plan was not followed at the time of the 12/26/21 fall and the Fall investigation was not completed until 1/5/21.

Based on interview and record review it was determined the facility failed to ensure accurate documention in medical records for 3 of 8 sampled residents (#s 2, 8 and 10) reviewed for skin conditions and notification of change. This placed residents at risk for inaccurate medical records. Findings include:

1. Resident 8 admitted to the facility on 5/15/21 with diagnoses including left femur (leg) fracture.

a. The 6/2/21 Discharge Summary and Plan indicated Resident 8 had a left coccyx unstageable pressure ulcer.

The 6/2/21 Discharge Skin Summary indicated Resident 8 had no skin impairments at the time of discharge.

On 11/18/21 at 5:00 PM Staff 3 (DNS) acknowledged Resident 8 discharged with an unstageable pressure ulcer to the coccyx and the the 6/2/21 Discharge Skin Summary was inaccurately documented.

b The 6/1/21 Skin and Wound Evaluation: revealed Resident 8 had an unstageable pressure ulcer to the sacrum.

The 6/2/21 NAR (Nutrition At Risk) notes indicated Resident 8 had a Stage 3 pressure ulcer to the coccyx and an unstageable pressure ulcer to the sacrum.

On 11/18/21 at 5:00 PM Staff 3 (DNS) stated Resident 8 only had an unstageable pressure ulcer and verified the Stage 3 pressure ulcer documented on the 6/2/21 NAR was inaccurate.

c. The 5/13/21 Admission Nursing Database indicated Resident 8 did not have an unstageable or Stage 3 or greater pressure injury in the six months prior to admission.

The 5/3/21 Discharge Summary and Plan from Resident 8's previous admission indicated Resident 8 had a Stage 3 pressure ulcer.

The 5/5/21 Discharge Return Not Anticipated MDS indicated Resident 8 had one unstageable pressure ulcer upon discharge.

On 11/18/21 at 5:00 PM Staff 3 (DNS) verified the 5/13/21 Admission Nursing Database inaccurately indicated Resident 8 did not have an unstageable or Stage 3 or greater pressure injury in the past six months.

2. Resident 10 admitted to the facility on 7/1/20 with diagnoses including delirium. The resident discharged on 7/3/20.

A 7/4/20 Progress Note indicated Resident 10 was admitted to the hospital the previous day.

Review of the medical record revealed no documentation of the hospital transfer and why Resident 10 was transferred to the hospital.

On 11/18/21 at 11:59 PM Staff 3 (DNS) stated their was no documentation in Resident 10's medical record of why and when Resident 10 was transferred to the hospital.

, 3. Resident 2 admitted to the facility on 8/2020 with diagnoses including dementia and an unspecified fall.

The 8/17/20 Fall Investigation indicated Resident 2 was found on floor after a failed self-transfer attempt on 8/17/20.

Resident 2's medical record revealed no documentation of the fall on 8/17/20.

On 11/24/21 at 11:20 AM Staff 3 (DNS) was unable to provide any documentation that Resident 2's fall on 8/17/20 had been documented in the clinical record.

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411-086-0130: Nursing Services: Notification

Refer to F580
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411-085-0360 Abuse

Refer to F609
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411-086-0160 Nursing Services: Discharge Summary

Refer to F661
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411-086-0110 Nursing Services: Resident Care

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

Refer to F686 and F689
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411-086-0300 Clinical Record

Refer to F842
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