Tigard Rehabilitation And Care

Resident 5 was admitted to the facility in 2022 with diagnoses including bipolar disorder. Review of Resident 5GÇÖs physician orders indicated the use of Abilify (antipsychotic) and bupropion (antidepressant) for bipolar disorder. A 10/16/25 Psychoactive Drug Review indicated Resident 5 readmitted to the facility on 7/3/25 with a diagnosis of bipolar disorder and was administered Abilify and bupropion. The review indicated no changes were recommended and her/his depressive symptoms were to be monitored and reassessed the following month. Review of Resident 5GÇÖs medical record indicated no psychoactive drug review was completed after 10/16/25. On 5/6/26 at 11:45 AM Staff 8 (SSD) stated psychoactive drug reviews were to be completed monthly. Staff 8 acknowledged Resident 5 was not reassessed with a psychoactive drug review since 10/16/25. On 5/8/26 at 9:04 AM Staff 2 (DNS) acknowledged Resident 5 did not have a psychoactive drug review since October of 2025.

Upon record review, resident 5 admitted to facility 3/24/26 and discharged 4/18/26. Upon review, it seems that the deficiency cited for F605 is referencing resident 9. Resident 9 remains in facility and has potential for negative impacts r/t this  deficiency. All residents residing in the facility have the potential to be impacted by  this deficiency.  To prevent further recurrence of this concern the facility will: A psychotropic drug review was completed for resident 9, with consultant  pharmacist, and all recommendations were followed up on as indicated . Education to be provided to RCM staff regarding facility policy and regulations  regarding psychotropic medication review requirements. An audit was conducted for all residents on psychotropic medications to ensure  that at minimum a quarterly psychotropic medication audit has been completed. Following the initial audit above, DNS or designee will audit all residents on  psychotropic medications prior to monthly psychotropic review meeting, to ensure  timely completion of psychotropic reviews. Any significant findings of this audit will be brought to QAPI as indicated.

Resident 42 was admitted to the facility in 1/2023 with diagnoses including urinary incontinence. Resident 42GÇÖs 1/22/26 Annual MDS revealed a BIMS score of 15, indicating the resident was cognitively intact, and the resident was always incontinent of bladder and bowel. Resident 42GÇÖs 2/6/26 care plan identified the resident had GÇ£episodes of bladder incontinence r/t limited mobility, and cognitive impairmentGÇ¥ and included the intervention to GÇ£Ensure resident has bedside urinal within reach, Encourage usage, Check and empty at regular intervals.GÇ¥ Observations from 5/4/26 through 5/6/26 between the hours of 11:50 AM and 4:30 PM revealed no urinal-á cup was present at Resident 42GÇÖs bedside. An interview on 5/6/26 at 4:33 PM, Resident 42 stated she/he never had a urinal at bedside and indicated she/he was physically unable to use a urinal prior to admission to facility.-á An interview on 5/7/26 at 9:09 AM, Staff 17 (CNA) stated Resident 42 did not have a bedside urinal and to her knowledge never used one. An interview on 5/7/26 at 2:35 PM, Staff 16 (LPN) stated Resident 42 did not have a bedside urinal and indicated use of a urinal was impossible for the resident due to the residentGÇÖs limitations. An interview on 5/8/26 at 9:26 AM, Staff 2 (DNS) stated -á urinal cup by the bed was listed as an option within the care plan template and a previous DNS may have selected the intervention in error. Staff 2 stated the intervention was not individualized or specific to Resident 42 and staff did not previously identify the discrepancy. -á

Resident 42's care plan updated to remove urinal, as resident is not able to utilize urinal. Resident 42 remains in facility and has potential for negative impacts r/t this  deficiency. All residents residing in facility with unidentified ADL decline and subsequent CP updates have potential to be impacted by this deficiency . Resident 42 was referred to physical and occupational therapy services 5/9/26 to   identify any decline, and care plan was updated to include changes to ADL function  as outlined by therapy and resident’s functional presentation. DNS or designee will conduct an audit of the ADL Significant Change Analysis Report - Section GG Tasks  to identify any residents with noted ADL decline  weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved . Residents identified with decline will be reviewed and will be referred to therapy as indicated, and care plan updates will be made based on therapy recommendations.

4. Resident 42 was admitted to the facility in 1/2023 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic Kidney Disease. (High blood pressure that has caused damage to the heart and kidneys, including heart failure and chronic kidney disease ranging from mild to severe stages). Resident 42GÇÖs 2/1/24 Physician Order GÇ£Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl), give 25 mg by mouth every 8 hours as needed related to ESSENTIAL (PRIMARY) HYPERTENSION for SBP greater than 160 or DBP greater than 80.GÇ¥ Review of Resident 42GÇÖs 4/2026 MAR indicated eleven instances when the blood pressure was outside of parameters, and the PRN medication was not provided. Resident 42 was not documented as receiving PRN Hydralazine HCl Oral Tablet 25 mg on the eleven instances from 4/5/26 through 5/3/26 despite blood pressure readings meeting parameters identified in the physician orders. On 5/7/26 at 2:23 PM, Staff 3 indicated he was not familiar with Resident 42. Staff 3 initially denied checking Resident 3's blood pressure. Staff 3 then reviewed the documentation and acknowledged checking Resident 3's blood pressure. Staff 3 was unable to provide a rationale for why the PRN medication was not administered. Staff 3 stated he ""probably"" rechecked the blood pressure later and it was fine. Staff 3 acknowledged no rechecks were documented.-á On 5/8/26 at 9:26 AM, Staff 2 (DNS) acknowledged Staff 3 should have administered Resident 42GÇÖs PRN Hydralazine in accordance with the physician orders on the eleven instances from 4/5/26 through 5/3/26. Refer to F842 and F684 , 3. Resident 10 admitted to the facility in 9/2024 with diagnoses including right femur fracture and history of ESBL (extended-spectrum beta lactamases, enzymes that make any common antibiotics ineffective) infection. On 5/7/26 at 9:21 AM Staff 3 (RN) stated he was preparing the wound care treatments to bring into Resident 10GÇÖs room. Staff 3 entered Resident 10GÇÖs room with a CDC Enhanced Barrier Precautions (EBP) sign prominently displayed on the residentGÇÖs room door. Staff 10 had gloves and a face mask on but did not wear a gown. Staff 3 completed wound care to Resident 10GÇÖs left knee, doffed his gloves, exited the room, and returned to the treatment cart.-á On 5/7/26 at 9:30 AM Staff 3 stated he had minimal resident contact and wore gloves and a mask when performing wound care on Resident 10. Staff 3 stated he did not feel it was necessary to wear a gown. Staff 3 reviewed the CDC EBP sign on Resident 10GÇÖs door and Staff 3 stated he was unsure if the resident was still on precautions or if the sign was old. On 5/7/26 at 2:07 PM Staff 14 (Corporate IP) stated she expected all staff to follow EBP when performing wound care.-á -á , 2. Resident 5 admitted to the facility in 2022 with diagnoses including diabetes. A 2/20/26 physician order indicated the use of Novolog insulin. The order indicated 2 units of insulin was to be given before meals and was only to be administered if the CBG (capillary blood sugar) was greater than 150.-á Review the 4/2026 and 5/2026 DAR (Diabetic Administration Record) indicated from 4/1/26 to 5/6/26, Resident 5 was administered insulin when her/his blood sugars were below 150.-á Staff 3 (RN) was noted to have administered insulin to Resident 5 one or more times when her/his blood sugar level was under 150 for the following dates: 4/17/26 4/24/26 5/1/26 5/6/26 On 5/6/26 at 10:30 AM Staff 3 stated he was not aware the order indicated to only administer insulin for blood sugars over 150. Staff 3 stated he did not fully read the order and used his GÇ£clinical judgementGÇ¥ as the residentGÇÖs blood sugar tended to run high after meals. -áStaff 3 acknowledged he was supposed to follow the physicianGÇÖs order and acknowledged he administered insulin to Resident 5 when her/his blood sugar was under 150 on the identified dates. -á , 1. The True Metrix Blood Glucose System manufacturer instructions indicated to disinfect the meter between each person with EPA-registered wipes. The 7/2023 facility policy for Glucometer Disinfection indicated to disinfect after each individual patient use with EPA registered wipes. On 5/6/26 at 7:39 AM Staff 3 (RN) was observed to obtain a CBG for Resident 53. Staff 3 exited the room, placed the glucometer on the cart and did not disinfect it. Continuous observations were made between 7:39 AM and 7:59 AM of Staff 3 completing other nursing tasks. On 5/6/26 at 7:59 AM Staff 3 gathered supplies including the unsanitized glucometer and prepared to enter Resident 9GÇÖs room. The surveyor asked Staff 3 how often glucometers were cleaned and Staff 3 stated they were cleaned several times in a shift, or if visibly soiled, but he did not clean it between every patient. Staff 3 stated within an eight hour period he GÇ£probably cleaned it three times.GÇ¥ Staff 3 proceeded into Resident 9GÇÖs room without disinfecting the glucometer. The State Surveyor intervened and when cued, Staff 3 returned to the cart and disinfected the glucometer. On 5/6/26 at 8:17 AM Staff 2 (DNS) stated the expectation was for staff to use disinfecting wipes between resident use. Refer to F880.

All residents have the potential to be impacted by this deficient practice. Staff 3 was removed from work and suspended on 5/7/2026. Staff 3 is no longer employed with the facility. Following identification of deficiency, all glucometers were disinfected prior to their next use. Licensed staff were in-serviced on the importance of infection control procedures for glucometers, wound care, as well as following physician orders related to enhanced barrier precautions. To ensure continued compliance, the DNS or designee will complete 5 random audits weekly to ensure compliance with the policy for glucometer cleaning, wound care infection control, and following enhanced barrier precautions weekly x4 weeks and then monthly thereafter until substantial compliance is achieved. Results will be reported to QAPI as indicated.

Resident 42 was admitted to the facility in 1/2023 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 Chronic Kidney Disease. (High blood pressure that has caused damage to the heart and kidneys, including heart failure and chronic kidney disease ranging from mild to severe stages). Resident 42GÇÖs 1/22/26 Annual MDS revealed a BIMS score of 15, which indicated the resident was cognitively intact.-á Resident 42GÇÖs 7/21/24 Physician Order indicated GÇ£Obtain BP (Blood Pressure) see PRN Hydralazine order for DBP (Diastolic Blood Pressure) greater than 90 and SBP (Systolic Blood Pressure) greater than 140 three times a day.GÇ¥ Resident 42GÇÖs 2/1/24 Physician Order indicated GÇ£Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl), give 25 mg by mouth every 8 hours as needed related to essential (primary) hypertension for SBP greater than 160 or DBP greater than 80.GÇ¥ A review of Resident 42's clinical record revealed no indication that the discrepancy between the two physician orders was identified or clarified.-á Review of Resident 42GÇÖs blood pressure readings from 4/1/26 through 5/7/26 revealed multiple readings outside ordered parameters, including: 0700 hours: 4/1/26 134/95 4/3/26 144/70 4/4/26 150/70 4/5/26 156/82 4/7/26 142/74 4/11/26 161/87 4/12/26 155/85 4/17/26 143/72 4/24/26 148/78 4/25/26 146/70 4/30/26 142/84 5/1/26 156/77 5/3/26 144/83 -á 1500 hours: 4/2/26 134/95 4/3/26 144/65 4/4/26 148/70 4/5/26 156/82 4/12/26 155/85 4/17/26 143/65 4/24/26 146/70 4/28/26 148/79 4/30/26 142/84 5/1/26 146/78 5/3/26 144/83 5/7/26 149/80 -á 2300 hours: 4/2/26 141/89 4/7/26 140/84 5/1/26 141/71 Review of the 4/2026 and 5/2026 MARs revealed no indication the PRN Hydralazine was provided on identified dates.-á On 5/7/26 at 2:23 PM, Staff 3 (RN) initially he did not check Resident 42GÇÖs blood pressure; however, after reviewing documentation showing he entered the readings, Staff 3 stated he probably rechecked the blood pressure 30 minutes later and it was GÇ£fine,GÇ¥ which was why the PRN Hydralazine was not administered. Staff 3 acknowledged rechecks were not documented. Staff 3 further indicated he did not identify the discrepancy between the physician orders and stated if he noticed it, he would have notified the physician. On 5/7/26 at 5:21 PM, Staff 18 (LPN) indicated she was familiar with Resident 42 and routinely obtained the residentGÇÖs blood pressure readings. Staff 18 stated she did not recall the specific dates in April and did not recall administering PRN Hydralazine. Staff 18 acknowledged she was unaware of the discrepancy in physician orders and stated she would have contacted the physician had she identified it. On 5/8/26 at 9:26 AM, Staff 2 (DNS) acknowledged there were errors and discrepancies in the physician orders and the PRN Hydralazine was not administered according to the orders. -á

Staff 3 is no longer employed by The Facility. All residents who need to have orders to have their blood pressure monitored have the potential to be impacted by this deficient practice. Licensed nurses and medication aides were in-serviced on the importance of monitoring blood pressure when it’s ordered. The DNS or designee will conduct random audits to ensure blood pressure is taken when ordered. The audits will be done weekly x4 weeks and then monthly thereafter until substantial compliance is achieved. The DNS will report the results of the audits to QAPI as indicated.

Resident 49 was admitted to the facility in 11/2024 with diagnoses including muscle wasting atrophy (a condition of thinning muscle tissue, resulting in weakness). A 11/14/25 Occupational Therapy Discharge Summary indicated Resident 49 was to participate in a restorative range of motion program to maintain the highest level of function for the resident's upper extremities. A 11/16/25 Annual MDS indicated Resident 49 had range of motion impairment to both upper and lower extremities on one side and required minimal assistance with upper body dressing. A 2/16/26 Quarterly MDS indicated Resident 49 had range of motion impairment to both upper and lower extremities on one side and required substantial/maximal assistance with upper body dressing. A 2/25/26 care plan indicated Resident 49 was at risk for pain related to decreased mobility and a listed interventions for staff to attempt to decrease pain was exercise. No additional information was found related to the preservation of Resident 49's mobility. On 5/4/26 at 11:05 AM Resident 49 stated she/he did not receive therapy and had concerns related to her/his mobility. Resident 49 stated she/he noticed a decrease in her/his ability to do normal daily activities which was related to the stiffness in her/his joints. Resident 49 denied pain and stated the decline in her/his ability to do things independently was related to GÇ£not moving my body enough.GÇ¥ On 5/6/26 at 9:28 AM Staff 17 (CNA) stated Resident 49 experienced a decline in range of motion over the past few months. Staff 17 stated she recently noticed the resident struggle to complete tasks like oral care without assistance due to the resident being unable to reach certain items on her/his overbed table which was something the resident did not struggled with before. Staff 17 stated Resident 49GÇÖs care plan did not indicate the resident was to receive range of motion exercises. On 5/7/26 at 11:07 AM Staff 26 (Occupational Therapist) stated the last time Resident 49 was assessed by therapy was in 11/2025 and at that time the resident had some ability to dress her/his upper body with minimal assistance. Staff 26 stated the recommendation by therapy was for Resident 49 to receive range of motion exercises daily to maintain her/his current level of mobility to prevent decline. On 5/7/26 at 2:03 PM Staff 2 (DNS) stated Resident 49GÇÖs care plan did not reflect the recommendations given by therapy to preserve the residentGÇÖs range of motion and confirmed that led to a decline in the residentGÇÖs range of motion ability.

Resident 49 was referred to OT and began therapy 5/11/26. All residents in the facility have the potential to be impacted by this deficient practice. An initial audit was conducted to identify residents with ADL decline. DNS or designee will conduct an audit of the  ADL Significant Change Analysis Report - Section GG Tasks  to identify any residents with noted ADL decline  weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved . Residents identified with decline will be reviewed and will be referred to therapy as indicated, and care plan updates will be made based on therapy recommendations. Results of these audits will be brought to QAPI as indicated.

2. Resident 28 was admitted to the facility in 6/2024 with diagnoses including a stroke and dysphagia (difficulty swallowing). Resident 28GÇÖs 2/16/26 Speech Evaluation indicated the resident had clinical signs and symptoms of dysphagia while using a straw with thin liquids. Resident 28GÇÖs 4/4/26 Quarterly MDS indicated the resident was at risk of choking and required a mechanically altered diet. Resident 28GÇÖs 4/20/26 care plan indicated the resident was at risk for aspiration and was required to be upright during meals with distant supervision and no straws. An observation on 5/6/26 at 12:19 AM revealed a bright red sign posted above Resident 28GÇÖs bed which read GÇ£STOP NO STRAWSGÇ¥. At this time Resident 28 was observed to have a half empty cup of grape juice on her/his overbed table which contained a straw.-á On 5/6/26 at 12:24 PM Staff 30 (CNA) stated residents with aspiration precautions had a bright red stop sign posted in their room, above their bed, which was an indicator the resident had a special texture diet and could not have straws. On 5/6/26 at 12:25 PM Staff 2 (DNS) and the surveyor observed Resident 28 with a straw in her/his half empty juice cup and Staff 2 acknowledged Resident 28 was an aspiration risk and it was not safe for her/him to use a straw. , 1. Resident 30 admitted to the facility in 1/2026 with diagnoses stroke and dysphagia (swallowing difficulty). A 1/23/26 Admission MDS indicated Resident 30 had a BIMS score of 8 indicating the resident was moderately cognitively impaired. The MDS indicated the resident had a swallowing disorder including coughing or choking during meals. A review of Resident 30GÇÖs care plan she/he was on aspiration precautions 1:1 assistance for all meals, encourage resident to be up in wheelchair for all meals, encourage self -feeding with taking bite size pieces on weighted spoon and fork with meals. Attend to left side, slow rate, small bites, upright, thin liquids and soft and bite sized diet. A review of Resident 30GÇÖs progress note revealed on 2/8/26 at 9:00 AM the resident was given a regular sausage and eggs for breakfast. Resident 30 required an GÇ£upward pressure to abdomenGÇ¥ by staff to dislodge the piece of sausage from the residentGÇÖs throat and clear her/his airway. A review of Resident 30GÇÖs progress revealed on 3/26/26 at 6:15 PM the resident requested a sandwich and was given a meat sandwich by a Staff 31 (CNA). Resident 30 took several bites and began to choke. Staff 31 provided back pats to Resident 30 who coughed up pieces of food. -áResident 30 continued to cough up food and choke and required the Heimlich maneuver (abdominal thrusts used in first-aid to clear upper airway obstruction caused by food, toys, or other foreign objects in conscious individuals who cannot breathe, speak or cough effectively) from Staff 5 (Maintenance Director) who was nearby moving furniture. On 5/6/26 at 9:48 AM Staff 5 stated he was moving furniture between two offices when he noticed Staff 31 and Staff 32 (LPN) racing by looking for the crash cart around the nursesGÇÖ station. Staff 5 stated Resident 30 looked purple and appeared to be choking. Staff 5 stated he reached behind Resident 30 and gave her/him the Heimlich maneuver and large piece of meat flew out of her/his mouth. On 5/6/26 at 4:40 PM Staff 32 stated she was informed by Staff 31 she had given Resident 30 a meat sandwich and was choking. Staff 32 began to look for the LiveVac choking device (an airway clearance device developed for resuscitating a victim with an airway obstruction when current choking protocols have been followed without success) on the crash cart. On 5/6/26 at 5:16 PM Staff 31 stated she was not the assigned CNA for Resident 30 whom requested a sandwich after dinner. Staff 31 gave Resident 30 a meat sandwich without checking the residentGÇÖs current diet. Staff 31 stated she had worked with Resident 30 one previous time and she/he was on a regular diet and assumed she/he had the same diet texture. Staff 31 was next to the resident while she/he was eating the sandwich and provided the initial back pats to dislodge the smaller pieces. Resident 30 requested water and continued to cough then became silent. Staff 31 informed Staff 32 of the incident and began looking for LiveVac choking device. Staff 31 while looking for the LiveVac choking device, Staff 5 administered the Heimlich maneuver. On 5/6/26 at 3:30 PM the facility was informed that the facilityGÇÖs failure to ensure residents received the correct diet texture and straws who are at aspiration risk constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 5/6/26 at 5:21 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: All residents have the potential to be impacted by this deficient practice. The residents with order not to use a straw will be placed on alert charting -áto monitor for signs of aspiration, the physician was notified, and a speech evaluation was ordered by the physician. The aspiration orders for all residents will be compared to the aspiration signs and binders to ensure accurate precautions are in place for the residents. All licensed nurses, CMAs, and CNAs will be inserviced on the aspiration risk and management policy and aspiration binder prior to starting their next shift. Licensed nurses, CMAs, and CNAs will not be allowed to work until the inservice is completed. To ensure continued compliance with the aspiration policy, dining room and hallway monitoring will be conducted to ensure residents who are aspiration risk are supervised appropriately for all 3 meals. The results of these audits will be reported to the DNS, who will report this to the QAPI committee. These audits will be completed for 1 month minimum or until compliance is achieved. On 5/11/26 at 9:40 AM it was determined the immediacy was removed on 5/9/26 after verification of completion of the IJ removal plan. -á -á

All residents have the potential to be impacted by this deficient practice. Residents 28 and 30 with were placed on alert charting to monitor for signs of aspiration, the physician was notified, and a speech evaluation was ordered by the physician. The aspiration orders for all residents will be compared to the aspiration signs and binders to ensure accurate precautions are in place for all residents with aspiration precautions. All Licensed Nurses, CMAs, and CNAs were in-serviced on the aspiration risk and management policy and aspiration binder. To ensure continued compliance with the aspiration policy, dining room and hallway monitoring will be conducted to ensure residents who are aspiration risks are supervised appropriately for all 3 meals via meal manager program. Audits will be conducted on 5 residents with aspiration precautions weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved . The results of these audits will be reported to the DNS, who will report this to the QAPI committee as indicated.

A 2/20/26 physician order indicated the use of Novolog insulin. The order indicated 2 units of insulin was to be given before meals and was only to be administered if the CBG (capillary blood sugar) was greater than 150. Review the 4/2026 and 5/2026 DAR (Diabetic Administration Record) indicated from 4/1/26 to 5/6/26, Resident 5 was administered 2 units of insulin a total of 55 times when her/his blood sugars were below 150. Staff 3 (RN) was noted to have administered insulin one or more times to Resident 5 when her/his blood sugar level were under 150 for the following dates: 4/17/26 4/24/26 5/1/26 5/6/26 Staff 4 (LPN) was noted to have administered insulin one or more times to Resident 5 when her/his blood sugar level were under 150 for the following dates: 4/2/26 4/6/26 4/9/26 4/13/26 4/14/26 4/16/26 4/20/26 4/21/26 4/23/26 4/27/26 4/28/26 5/4/26 5/5/26 On 5/6/26 at 10:30 AM Staff 3 stated he was not aware the order indicated to only administer insulin for a blood sugar level over 150. Staff 3 stated he did not fully read the order and used his GÇ£clinical judgementGÇ¥ as the residentGÇÖs blood sugar tended to run high after meals. -áStaff 3 further stated he should go by the physicianGÇÖs order and acknowledged he administered insulin to Resident 5 when her/his blood sugar was under 150 for the identified dates. -á On 5/7/26 at 10:14 AM Staff 4 stated he was not aware Resident 5GÇÖs physician order indicated insulin was only to be administered for a blood sugar level over 150 due to the way the order was written. Staff 4 acknowledged he administered insulin to Resident 5 when her/his blood sugar was under 150 for the identified dates. On 5/8/26 at 9:04 AM Staff 2 (DNS) acknowledged Resident 5 was not administered insulin per physician orders.

Resident 5 was monitored for side effects related to not receiving insulin as ordered. All residents with insulin orders were reviewed to ensure they are receiving insulin as ordered. All residents in the facility receiving insulin have the potential to be impacted by this deficient practice. Licensed nurses were in-serviced on insulin administration and ensuring that insulin is administered as ordered. The DNS or designee will conduct random audits to ensure insulin is given as ordered. The audits will be done weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved. The DNS will report the results of the audits to QAPI as indicated.

1. On 5/6/26 at 7:51 AM one open, undated vial of tuberculin (used for testing in the diagnosis of Tuberculosis) was observed in the medication room refrigerator. The manufacturer's instructions indicated to discard the medication 30 days after opening. On 5/6/26 at 7:51 AM Staff 3 (RN) acknowledged the vial of tuberculin was open and not labeled with an open date. On 5/6/26 at 8:17 AM Staff 2 (DNS) stated the expectation was for open medications to be labeled with open dates. 2. On 5/6/26 at 8:17 AM the medication room refrigerator was observed to contain insulin and vaccines and the temperature log was observed to be incomplete on the following dates: 4/1/26; 4/2/26; 4/3/26; 4/4/26; 4/6/26; 4/7/26; 4/8/26; 4/9/26; 4/10/26; 4/11/26; 4/12/26; 4/13/26; 4/14/26; 4/15/26; 4/16/26; 4/17/26; 4/18/26; 4/20/26; 4/21/26; 4/22/26; 4/23/26; 4/24/26; 4/25/26; 4/27/26; 4/28/26; 4/29/26; 4/30/26; 5/1/26; 5/2/26; 5/4/26 and 5/5/26. On 5/6/26 at 8:17 AM Staff 2 (DNS) acknowledged the medication room refrigerator contained insulin and vaccines and acknowledged the temperature logs were incomplete. Staff 2 stated the expectation was for staff to complete the temperature logs twice daily. 3. On 5/6/26 at 8:17 AM the medication room refrigerator temperature logs indicated the temperature was 34 F on 4/19/26 at 7:10 AM. The temperature requirements on the form indicated the temperatures were to be kept at 36 F to 46 F. On 5/6/26 at 8:17 AM Staff 2 (DNS) acknowledged the medication room refrigerator contained insulin and vaccines and acknowledged the temperature log indicated the temperature was 34 degrees on 4/19/26. Staff 2 stated the expectation was for temperatures to be kept between 36 F and 46 F. 4. On 5/6/26 continuous observations were made from 11:14 AM to 11:42 AM of the medication cart on the 100 hall, the keys were hanging out of the cart and it was left unlocked and unattended. On 5/6/26 at 11:42 AM Staff 2 (DNS) acknowledged the medication cart was left unlocked and unattended, the keys were hanging out of the cart and the cart contained medications. 5. On 5/8/26 at 9:27 AM the 200 hall treatment cart was observed to contain two open vials of Admelog insulin without open dates. On 5/8/26 at 9:27 AM Staff 13 (LPN) acknowledged the two vials of Admelog insulin were open without open dates. On 5/8/26 at 9:40 AM Staff 2 (DNS) stated the expectation was for open insulin to be labeled with open dates.

The identified vial of insulin, Tuberculin, and Covid vaccination were removed from circulation and discarded when identified. All residents receiving medications in the facility have the potential to be impacted by this deficient practice. Licensed staff was in-serviced on the importance of monitoring medication storage and refrigerator temperatures twice per day. The DNS or designee will conduct random audits to ensure medication refrigerator temperatures are checked twice daily. The audits will be done weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved. The DNS will report the results of the audits to QAPI as indicated.

The facilityGÇÖs 2001 Food Preparation and Service Policy indicated food and nutrition service staff were to wear hair restraints (hair net, hat, beard restraint, etc.) so that hair did not contact food. On 5/4/26 at 10:10 AM Staff 6 (Cook) was observed in the kitchen at the counter prepping food wearing a bandana around her head and her hair in a clip. Staff 6's hair was not fully covered, and she was not wearing a hair restraint. On 5/4/26 at 10:11 AM Staff 6 acknowledged she was not wearing a hair restraint. -áStaff 7 (Dietary Manger) stated staff were to wear hair restraints and acknowledged Staff 6 was not wearing a hair restraint.

All residents have the potential to be impacted by this deficient practice. Dietary staff will wear hairnets when they are in the kitchen. Dietary staff were inserviced on the importance of wearing hairnets while they are working in the kitchen. The Administrator or designee will conduct random audits to ensure staff working in the kitchen are wearing hairnets. The audits will be done weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved . The Administrator will report the results of the audits to QAPI as indicated.

1. On 5/6/26 continuous observations were made from 11:14 AM to 11:42 AM of the 100 hall medication cart, it was left unattended and the computer screen was open and displayed Resident 41GÇÖs name, date of birth and medication administration information. On 5/6/26 at 11:42 AM Staff 2 (DNS) acknowledged the medication cart was left unattended and the computer screen was open and displayed information including Resident 41GÇÖs -áname, date of birth and medication administration information. Staff 2 stated the computer screen was supposed to be locked when the cart was unattended. 2. On 5/8/26 continuous observations were made from 9:04 AM to 9:06 AM of the 200 hall medication cart, it was left unattended and the computer screen was open and displayed Resident 30GÇÖs name, date of birth and medication administration information. On 5/8/26 at 9:06 AM Staff 12 (LPN) acknowledged the medication cart was left unattended and the computer screen was open and displayed information including Resident 30GÇÖs -áname, date of birth and medication administration information. On 5/8/26 at 9:40 AM Staff 2 (DNS) stated the expectation was for staff to lock the computer screen when it was unattended.-á-á

All residents residing in the facility have the potential to be impacted by this    deficiency. To prevent further recurrence of this concern the facility will: All staff that access medication and treatment carts were in-serviced on facility policies regarding privacy and   confidentiality of resident records, including ensuring that computers are locked  when not in use. Audit to be completed by DNS or designee to evaluate screens and carts are locked on t reatment/medication carts weekly x4 weeks and then monthly thereafter  until substantial compliance is achieved. Results of these audits will be brought to QAPI as indicated.

2.

Based on observation, interview and record review the facility failed to use proper PPE for contact-based precautions 1 of 6 of sampled residents (#10) reviewed for infection control. This placed residents at risk for cross-contamination. Findings include: According to the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html):-á -+-á-á-á-á-á-á-á-á-á-á-á-á Use Contact Precautions for patients with known or suspected infections that present an increased risk for contact transmission. -+-á-á-á-á-á-á-á-á-á-á-á-á Use personal protective equipment (PPE) appropriately including gloves and gown. -+-á-á-á-á-á-á-á-á-á-á-á-á Wear a gown and gloves for all interactions that may involve contact with the patient or patient's environment. -+-á-á-á-á-á-á-á-á-á-á-á-á Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. -+-á-á-á-á-á-á-á-á-á-á-á-á If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. A review of the revised 12/2024 facility Enhance Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs). 1. EBP infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activitiesGǪ 7. EBPGÇÖs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do no otherwise apply. -á-á-á-á-á-á-á-á-á-á-á-á-á a. Gloves and gown are applied prior to performing the high contact resident care activity b. personal protective equipment (PPE) is changed before caring for another resident. c. face protection may be used if there is also a risk of splash or spray 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: -á-á-á-á-á-á-á-á-á-á-á-á-á a. dressing; -á-á-á-á-á-á-á-á-á-á-á-á-á b. bathing/showering; -á-á-á-á-á-á-á-á-á-á-á-á-á c. providing hygiene or grooming; -á-á-á-á-á-á-á-á-á-á-á-á-á d. changing briefs or assisting with toileting; -á-á-á-á-á-á-á-á-á-á-á-á-á e. transferring; -á-á-á-á-á-á-á-á-á-á-á-á-á f. providing bed mobility; -á-á-á-á-á-á-á-á-á-á-á-á-á g. changing linens; -á-á-á-á-á-á-á-á-á-á-á-á-á h. prolonged, high-contact with items in the residentGÇÖs room, with residentGÇÖs equipment or with the residentGÇÖs clothing or skin -á-á-á-á-á-á-á-á-á-á-á-á-á i. device care or use (central line, urinary catheter, etc); and -á-á-á-á-á-á-á-á-á-á-á-á-á j. wound care (any skin opening requiring a dressing). Resident 10 admitted to the facility in 9/2024 with diagnoses including right femur fracture and history of ESBL (extended-spectrum beta lactamases, enzymes that make any common antibiotics ineffective) infection. On 5/7/26 at 9:21 AM Staff 3 (RN) stated he was preparing the wound care treatments to bring into Resident 10GÇÖs room. Staff 3 entered Resident 10GÇÖs room with a CDC Enhanced Barrier Precautions (EBP) sign prominently displayed on the residentGÇÖs room door. Staff 10 had gloves and a face mask on. Staff 3 completed wound care to Resident 10GÇÖs left knee, doffed his gloves and exited the room. After the wound care treatment, Staff 3 exited Resident 10GÇÖs room and returned to his treatment cart. On 5/7/26 at 9:30 AM Staff 3 stated he had minimal resident contact and wore gloves and a mask when performing wound care on Resident 10 and did not feel that wearing a gown was necessary. Reviewed the CDC EBP sign on Resident 10GÇÖs door and Staff 3 stated he was unsure if the resident was still on precautions or the sign was old. On 5/7/26 at 2:07 PM Staff 14 (Corporate IP) stated she expected all staff to follow EBP when performing wound care and expected all the contact precaution signage be up to date for all the residents. , Based on observation, interview and record review it was determined the facility failed to ensure the community use glucometer was properly sanitized between resident use for 1 of 1 sampled resident (#9) reviewed during CBG checks. This failure, determined to be an immediate jeopardy situation, placed all residents who required CBG checks at significant risk for bloodborne illness. Findings include: The True Metrix Blood Glucose System manufacturer instructions indicated to disinfect the meter between each person with EPA-registered wipes. The 7/2023 facility policy for Glucometer Disinfection indicated to disinfect after each individual patient use with EPA registered wipes. On 5/6/26 at 7:39 AM Staff 3 was observed to obtain a CBG for Resident 53. Staff 3 exited the room, placed the glucometer on the cart and did not disinfect it. Continuous observations were made between 7:39 AM and 7:59 AM of Staff 3 completing other nursing tasks. On 5/6/26 at 7:59 AM Staff 3 gathered supplies including the unsanitized glucometer and prepared to enter Resident 9GÇÖs room. The surveyor asked Staff 3 how often glucometers were cleaned, Staff 3 stated several times in a shift, or if it was visibly soiled, but he did not clean it between every patient, and within an eight hour period-á he GÇ£probably cleaned it three times.GÇ¥ Staff 3 proceeded into Resident 9GÇÖs room without disinfecting the glucometer, the State Surveyor intervened and Staff 3 returned to the cart and disinfected the glucometer. On 5/6/26 at 8:17 AM Staff 2 (DNS) stated the expectation was for staff to use disinfecting wipes between resident use. On 5/6/26 at 8:35 AM Staff 2 (DNS) provided a list of 20 residents who required CBG checks. On 5/6/26 at 10:30 AM Staff 3 stated that he worked on all three halls. Resident 9GÇÖs clinical record indicated she/he admitted to the facility in 2022 with diagnoses including Hepatitis C. Resident 60GÇÖs clinical record indicated she/he admitted to the facility in 2025 with -ádiagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA). -á-á On 5/6/26 at 3:30 PM the facility was informed that the facilityGÇÖs failure to disinfect the community use glucometer between residents constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 5/6/26 at 5:21 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: 1. All residents have the potential to be impacted by this deficient practice. All residents who were potentially exposed were put on alert charting to monitor for adverse effects. The physician was notified and is monitoring care. 2. All glucometers will be disinfected prior to next use. Staff 3 will receive individual counseling on the policy and risks to residents. 3. All licensed nurses will be in serviced on the policy prior to the start of their shift. All nurses will be observed following the policy correctly prior to being cleared to work independently. Licensed nurses will not be allowed to work until the in service is completed. 4. To ensure continued compliance, the DNS or designee will complete five random auits weekly to ensure compliance with the policy for glucometer cleaning. Results will be reported to QAPI. This will be completed for one month minimum or until compliance is reached. -áOn 5/11/26 at 9:40 AM it was determined the immediacy was removed on 5/9/26 after verification of completion of the IJ removal plan. , The True Metrix Blood Glucose System manufacturer instructions indicated to disinfect the meter with EPA-registered wipes between each resident.-á The 7/2023 facility policy for Glucometer Disinfection indicated to disinfect the glucometer after each individual patient use with EPA registered wipes. On 5/6/26 at 7:39 AM Staff 3 (RN) was observed to obtain a CBG for Resident 53 in the resident's room using a True Metrix Blood Glucose System glucometer. Staff 3 exited the room, placed the glucometer on the cart and did not disinfect the glucometer. Continuous observations were made between 7:39 AM and 7:59 AM of Staff 3 completing other nursing tasks. On 5/6/26 at 7:59 AM Staff 3 gathered supplies including the same soiled (unsanitized) glucometer used for the previous resident, and prepared to enter Resident 9GÇÖs room. The surveyor asked Staff 3 how often glucometers were cleaned and Staff 3 stated they were cleaned several times per shift, or when visibly soiled. Staff 3 stated he did not clean the glucometer between every patient, and within an eight hour period he GÇ£probably cleaned it three times.GÇ¥ Staff 3 proceeded into Resident 9GÇÖs room without disinfecting the glucometer, and the State Surveyor intervened. When cued by the State Surveyor, Staff 3 returned to the cart and disinfected the glucometer. On 5/6/26 at 8:17 AM Staff 2 (DNS) stated staff were to use disinfecting wipes on the glucometer between each resident. On 5/6/26 at 8:35 AM Staff 2 (DNS) provided a list of 20 residents who required CBG checks, which included Resident 9 who had a diagnosis of Hepatitis C, and Resident 60 who had a diagnosis of Methicillin Resistant Staphylococcus Aureus (MRSA).-á On 5/6/26 at 10:30 AM Staff 3 stated he worked on all three of the facility's halls. On 5/6/26 at 3:30 PM the facility was informed that the facilityGÇÖs failure to disinfect the community use glucometer between residents constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 5/6/26 at 5:21 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: - All residents have the potential to be impacted by this deficient practice. All residents who were potentially exposed were put on alert charting to monitor for adverse effects. The physician was notified and is monitoring care. - All glucometers will be disinfected prior to next use. Staff 3 will receive individual counseling on the policy and risks to residents. - All licensed nurses will be in serviced on the policy prior to the start of their shift. All nurses will be observed following the policy correctly prior to being cleared to work independently. Licensed nurses will not be allowed to work until the in service is completed. - To ensure continued compliance, the DNS or designee will complete five random audits weekly for glucometer cleaning. Results will be reported to QAPI. This will be completed for one month minimum or until compliance is reached. The immediacy was removed on 5/9/26 after verification of completion of the IJ removal plan. 2. Based on observation, interview and record review the facility failed to use proper PPE for residents on Enhanced Barrier Precautions for 1 of 6 sampled residents (#10) reviewed for infection control. This placed residents at risk for cross-contamination. Findings include: According to the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html):-á -+-á-á-á-á-á-á-á-á-á-á-á-á Use Contact Precautions for patients with known or suspected infections that present an increased risk for contact transmission. -+-á-á-á-á-á-á-á-á-á-á-á-á Use personal protective equipment (PPE) appropriately including gloves and gown. -+-á-á-á-á-á-á-á-á-á-á-á-á Wear a gown and gloves for all interactions that may involve contact with the patient or patient's environment. -+-á-á-á-á-á-á-á-á-á-á-á-á Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The facility's Enhanced Barrier Precautions (EBP) policy, revised 12/2024, indicated EBP were utilized to prevent the spread of multi-drug-resistant organisms (MDROs) and included the following:-á - EBP infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.-á - EBPGÇÖs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. - Gloves and gown are applied prior to performing the high contact resident care activity - Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs included wound care.-á Resident 10 admitted to the facility in 9/2024 with diagnoses including right femur fracture and history of ESBL (extended-spectrum beta lactamases, enzymes that make any common antibiotics ineffective) infection. On 5/7/26 at 9:21 AM Staff 3 (RN) stated he was preparing the wound care treatments to bring into Resident 10GÇÖs room. Staff 3 entered Resident 10GÇÖs room which had a CDC Enhanced Barrier Precautions (EBP) sign prominently displayed on the door. Staff 10 had gloves and a face mask on, but did not wear a gown. Staff 3 completed wound care to Resident 10GÇÖs left knee, doffed his gloves, exited the room, and returned to the treatment care.-á On 5/7/26 at 9:30 AM Staff 3 stated he had minimal resident contact and wore gloves and a mask when performing wound care on Resident 10. Staff 3 stated he did not feel that wearing a gown was necessary. Staff 3 reviewed the CDC EBP sign on Resident 10GÇÖs door and stated he was unsure if the resident was still on precautions, or if the sign was old. On 5/7/26 at 2:07 PM Staff 14 (Corporate IP) stated she expected all staff to follow EBP when performing wound care.

Staff 3 is no longer employed by The Facility. All residents have the potential to be impacted by this deficient practice. All residents who were potentially exposed were put on alert charting to monitor for adverse effects. The physician was notified and is monitoring care. All glucometers will be disinfected prior to next use. All Licensed Nurses were in-serviced on the policy prior to the start of their shift. All Nurses will be observed following the policy correctly prior to being cleared to work independently. Licensed Nurses will not be allowed to work until the in-service is completed. To ensure continued compliance, the DNS or designee will complete 5 random audits weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved . Results will be reported to QAPI as indicated.

A review of the revised 3/2022 facility Pneumococcal Vaccine policy for residents revealed the following: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. -Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. A review of the revised 3/2022 facility Influenza Vaccination policy for residents. -All residents and staff are encouraged to receive the vaccine unless there is a medical contraindication and providing education about the risk and benefits of vaccination. 1. Resident 11 was admitted to the facility in 2022 with a diagnosis of Parkinsonism. A review of Resident 11's immunization record revealed she/he had received Prevnar13 on 7/2023 and was eligible but was not offered the CDC recommended pneumococcal vaccine. On 5/7/26 at 2:01 PM Staff 14 (Corporate IP) acknowledged Resident 11 was eligible for the pneumococcal vaccine but was not offered to the resident.-á 2. Resident 28 was admitted to the facility in 2024 with a diagnosis of stroke. A review of Resident 28 immunization record revealed the resident received the latest pneumococcal vaccine on 3/2025 and influenza vaccine on 2/2026. A review the Resident 28's EMR revealed the pneumococcal and influenza consents were not present electronically or on paper.-á On 5/6/26 at 11:42 AM Resident 28 did not recall receiving education regarding the risk and benefits for the pneumococcal or influenza vaccines. On 5/6/26 at 12:24 PM Staff 2 (DNS) stated he was unable to locate the pneumococcal or influenza vaccination consents for Resident 28. Staff 2 stated the previous DNS was in charge of the immunizations and kept all the files her office.-á

Resident 11 was offered a pneumococcal vaccination and consents were obtained. Vaccine scheduled to be administered. Resident 28 was provided with risk/benefit information regarding vaccines that were already received. Current residents will be reviewed and offered a flu or pneumococcal vaccination, and if consent is received, vaccinations will be administered. Licensed staff will be in-serviced on ensuring residents are offered a flu and/or pneumococcal vaccine and obtaining a consent when appropriate. The DNS or designee will conduct random audits to ensure newly admitted residents are offered a flu and/or pneumococcal vaccine and that a consent is in place when appropriate weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved . The DNS will report the results of the audits to QAPI as indicated.

Review of the CDC's ""Staying Up To Date with COVID-19 Vaccines"", dated 11/19/25, https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, documented GÇ£CDC recommends a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-makingGǪGetting the 2025-2026 COVID-19 vaccine is especially important if youGǪ..are living in a long-term care facilityGǪ.GÇ¥ 1. Resident 11 was admitted to the facility in 2022 with a diagnosis of Parkinsonism. A review of Resident 11GÇÖs immunization record revealed Resident 11 was not offered the COVID-19 vaccine. On 5/7/26 at 2:01 PM Staff 14 (Corporate IP) stated Resident 11 was eligible for the COVID-19 vaccine, but it was not offered to the resident.-á 2. Resident 62 was admitted to the facility in 2024 with a diagnosis of osteomyelitis of the vertebrae. A review of Resident 62GÇÖs immunization record revealed Resident 62 was not offered the COVID-19 vaccine. On 5/7/26 at 2:06 PM Staff 14 (Corporate IP) stated Resident 62 was eligible for the COVID-19 -ávaccine, but it was not offered to the resident.-á

Resident 62 was offered and consented to a COVID vaccine, vaccine sto be given. Resident 11 was offered a COVID vaccine and declined. Current residents were reviewed and offered a covid vaccine if appropriate. Licensed staff were in serviced on ensuring residents are offered a covid vaccine when appropriate. The DNS or designee will conduct random audits to ensure residents are offered a covid vaccine when appropriate weekly x4 weeks, and then monthly thereafter until substantial compliance is achieved. The DNS will report the results of the audits to QAPI as indicated.

On 5/6/26 at 11:01 AM during an interview with Staff 16 (Staffing Coordinator), a review of three randomly selected employee files for staff employed longer than two years was conducted. The review revealed the following: Staff 20 (Activities Director) was hired on 4/8/24. A Preliminary Fitness Determination was not completed upon hire and was not completed until 5/13/25. Staff 21 (LPN) was hired on 4/26/24. A Preliminary Fitness Determination was not completed upon hire and was not completed until 1/10/25. Staff 22 (CNA) was hired on 2/5/24. A Preliminary Fitness Determination was not completed upon hire and was not completed until 7/18/25. On 5/6/26 at 11:13 AM, Staff 16 stated after being hired into the position in December 2025, they discovered during an audit that some staff members had begun orientation and work duties prior to receiving a Preliminary Fitness Determination. -á On 5/7/26 at 2:57 PM, Staff 1 (Administrator) acknowledged that a Preliminary Fitness Determination was not completed for Staff 20, 21 and 22 as required.

All residents in the facility have potential to be impacted by this deficient practice, should a staff member be hired to work that does not pass the required criminal history check. To prevent further occurrence an initial audit was conducted to ensure that all staff working are current with their criminal history check. Admin or designee will complete an audit to ensure that staff working are current with their background check status weekly x4 weeks and then monthly thereafter until substantial compliance is achieved.

Resident 6 was admitted to the facility on 4/17/25 with diagnoses including heart failure and diabetes. A 4/17/25 Clinical Admission Progress Note, completed by Staff 4 (LPN), indicated Resident 6 had some redness with a small healing blister to her/his front left knee that was present upon admission. The 4/18/25 care plan revealed Resident 6 had impaired skin integrity due to a current blister on the left thigh/shin and immobility. A review of Resident 6GÇÖs medical record, including a review of the 4/2025 TAR, revealed no assessment of the wound and no monitoring of the wound.-á-á Resident 6 discharged to the hospital on 4/22/25 for an unrelated diagnosis. On 11/13/25 at 2:45 PM Staff 4 confirmed he completed Resident 6GÇÖs clinical admission assessment that included a full body skin check. Staff 4 stated when skin impairments were identified he placed a note on the TAR to monitor them. Staff 4 confirmed Resident 6 had a blister on her/his left knee. Staff 4 reviewed the TAR and acknowledged he did not implement monitoring of Resident 6GÇÖs blister. On 11/14/25 at 1:48 PM Staff 25 (LPN Resident Care Manager) confirmed there were no assessments completed for Resident 6GÇÖs blister on the left knee. On 11/14/25 at 2:25 PM Staff 2 (DNS) stated if a skin impairment like a blister was noted upon admission it was expected to be documented in the admission progress note, added to the TAR, the resident placed on alert charting, and a risk management note started. Staff 2 acknowledged Resident 6GÇÖs blister was not assessed or monitored during her/his stay at the facility.

1. Resident #6 was discharged from the facility. 2. All residents in the facility are potentially affected by this alleged deficient practice. Facility performed a skin sweep on residents to identify any new non-pressure skin wound(s). Each resident will have their skin examined to ensure non-pressure skin wound(s) are identified. If new non-pressure skin wound(s) are identified, their physician will be notified and appropriate treatments into place on the TAR. 3. DNS educated licensed nurses to ensure that all identified non-pressure skin wounds for new admissions are documented in the admission progress note, that corresponding treatment orders are entered into the TAR, and that an alert is placed on the resident. 4. DNS and/or designee will review four random skin assessments on resident(s) weekly x 4, then monthly x 2 to ensure identified non-pressure skin wound(s) have treatment orders in place. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Director of Nursing Services is responsible for compliance.

The facility's 4/2018 Pressure Ulcer/Skin Breakdown - Clinical Protocol - Assessment and Recognition specified the nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (leaking fluid) or necrotic (dying/dead) tissue and pain assessment. The 2019 National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide indicated the following recommendations regarding pressure ulcer assessment: -á - Assess the pressure ulcer initially and re-assess it at least weekly to monitor progress towards healing; -á - Document the results of all wound assessments; -á - Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Resident 7 was admitted to the facility in 10/2025 with a diagnosis of osteomyelitis of vertebrae (bone infection). Resident 7's 10/29/25 Admission MDS was not completed. -á A Progress Note dated 11/1/25 completed by Staff 26 (LPN) indicated she was informed by a CNA of an ""open sore on the upper part"" of Resident 7's buttock. A 11/1/25 Skin Integrity Report, initiated by Staff 26, indicated a new open sore on the upper part of the residentGÇÖs buttock and indicated the Resident Care Manager and Physician was notified. A note added on 11/3/25 indicated a new pressure injury to the left buttock wound which measured 1.5 x 1.1 cm and a new pressure injury to the coccyx which measured 3.1 x 5 x 0.3 cm. There was no evidence in Resident 7's health record to indicate a comprehensive assessment of the wound including measurement, location, stage, and other characteristics was completed after the wound was identified on 11/1/25 and before 11/3/25. Resident 7's 11/3/25 Physician Orders included the following: wound treatment to coccyx and sacrum wound bed, wash, pat dry, apply hydrogel to the sacrum and medihoney to coccyx wound bed, place large sacral dressing to cover both wounds. every day and PRN. There was no evidence wound care orders were obtained prior to 11/3/25.-á Resident 7's TAR revealed wound care was not provided until 11/4/25. On 11/14/25 at 12:20 PM Staff 26 stated she remembered a CNA notified her on 11/1/25 that Resident 7 had a new open area. Staff 26 stated she looked at the open area on resident 7's left buttock, cleaned the wound, covered it, and initiated a Skin Integrity Report. Staff 26 stated she did not measure the wound, did not obtain orders from the provider, did not document any wound treatment, and did not initiate any house wound orders on the TAR. On 11/14/25 at 12:57 PM Staff 2 (DNS) stated when a new skin issue was discovered, a Skin Integrity Report was to be initiated. She expected the nurse on duty to assess and measure the wound right away, complete wound care, implement a treatment protocol on the TAR, and place the resident on alert charting. Staff 2 acknowledged Resident 7's wound was identified on 11/1/25 and was not comprehensively assessed and measured until 11/3/25. Staff 2 confirmed there was no evidence in Resident 7's health record to indicate wound care was provided from 11/1/25 through 11/3/25.

1. Resident #7 was discharged at the time and readmitted back to the facility on 11/14/2025. Facility validated that appropriate wound treatment orders were in place. 2. All residents in the facility are potentially affected by this alleged deficient practice. Facility performed a skin sweep on all residents to identify any new pressure ulcer wound(s). Each resident will have their skin examined to ensure any pressure ulcer wound(s) are identified. If new pressure ulcer wound(s) are identified, their physician will be notified and appropriate treatments into place on the TAR. 3. DNS educated licensed nurses on wound assessment process, including measuring the wound, initiating a Skin Integrity Report, providing wound care, implementing the treatment protocol in the TAR, and placing the resident on alert charting. 4. DNS and/or designee will perform four random skin checks on resident(s) weekly x 4, then monthly x 2 to identify any new potential pressure ulcer wound(s). Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Director of Nursing Services is responsible for compliance.

The facilityGÇÖs policy for reconciling controlled substances, revised 11/2022, stated the system for reconciling the receipt, dispensing and disposition of controlled substances included the following: -Records of personnel access and usage; -Medication administration records; -Declining inventory records; and -Destruction, waste and return to pharmacy records. -Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile and inventory the count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the DNS. A 3/27/25 FRI indicated narcotic medication for two residents was missing and unaccounted for. A 3/31/25 investigation report revealed the facility was unable to determine what happened to the missing narcotic medication. On 11/14/25 at 11:13 AM Staff 8 (CMA) stated she remembered hearing about missing narcotic medication and denied knowing any information related to the incident. On 11/14/25 at 1:03 PM Staff 6 (LPN) stated she remembered reports of two missing narcotic cards but denied knowledge of what happened to the medication. On 11/14/25 at 12:32 PM Staff 3 (Former DNS) stated during a review of one of the facilityGÇÖs narcotic books on 3/26/25 it was determined two narcotic cards were missing. Staff 3 stated as a result of the investigation completed on 3/31/25, an immediate audit of all narcotics was completed, and education was provided to all staff responsible for managing medication. The deficient practice was identified as Past Noncompliance based on the following: The deficient practice was identified by the facility and was corrected on 4/1/25 when the facility completed a root cause analysis of the incident and identified a system failure related to managing narcotic medication. The plan of correction included: A full audit of all narcotic books was completed; no additional discrepancies were found. Education was provided to staff to include the facility's updated protocol for counting narcotic medication which included to count the number of narcotics in each book and record the amount next to staff initials on the signature/sign off page upon each shift change. All narcotics were inputted into new narcotic books to reflect correct records of each narcotic medication.

Resident 5 admitted to the facility in 2011 with diagnoses including anxiety, mood and personality disorder. The 7/20/23 Care Plan indicated Resident 5 had behaviors of refusing cares, refusing all wound cares and other cares including bathing and hygiene tasks. Resident 5 was not easily directed and interventions by staff escalated the residentGÇÖs agitation. Resident 5 had history of being verbally and physically aggressive toward staff. Interventions included: to not argue with the resident and to discontinue attempts to treat if she/he became agitated and reapproach later. A 1/6/25 Facility Reported Incident indicated the following: - -á -á -á -á -á - On 1/4/25 Resident 5 told Staff 21 (RN) to go to Hell when attempting to complete wound care. Staff 21 was heard by CNA Staff reply to Resident 5, GÇ£IGÇÖm already in Hell. YouGÇÖre SatanGÇÖs bitch, arenGÇÖt you?GÇ¥ Staff 21 also threatened to call the police on Resident 5 for assault because the resident grabbed the collar of Staff 21GÇÖs isolation gown.-á - -á -á -á -á -á - Staff 19GÇÖs (CNA) witness statement indicated she and Staff 20 (CNA) went to provide a brief change to Resident 5. Staff 19 indicated Resident 5 was not accepting cares, but they were able to start changing the residentGÇÖs brief. Staff 21 came into the room to complete wound care. Resident 5 became upset because of the brand of cream being used. Resident 5 became agitated and grabbed Staff 21GÇÖs gown, tore it and told her to GÇ£Go to Hell."" Staff 21 was heard replying, GÇ£IGÇÖm already there and youGÇÖre SatanGÇÖs bitch.GÇ¥ Staff 21 stated she was going to call the police and press charges on Resident 5 for assault.-á - -á -á -á -á -á- Staff 20's witness statement indicated she and Staff 19 went to change Resident 5GÇÖs brief and Staff 21 also went into the room to complete wound care. Resident 5 did not want to be changed and was not calming down. Staff 21 informed her and Staff 19, GÇ£it was fine, keep changing [her/him].GÇ¥ Resident 5 was upset about the cream being used and both Resident 5 and Staff 21 were yelling back and forth at each other.-á - -á -á -á -á -á - Staff 21 indicated Resident 5 was calling her names and told her to go to Hell. Staff 21 told the resident wound care had to be done, and she/he needed to be changed, the resident continued to yell. Staff 21 indicated Resident 5 grabbed her and she told the resident she could report her/him. Staff 21 indicated she stated she was in Hell but did not recall saying anything else.-á - -á -á -á -á -á - Resident 5 indicated she/he told Staff 21 to get out and Staff 21 told her/him she was going to call -á GÇ£themGÇ¥ to take her/him away. Resident 5 was unable to recall any other statements made by Staff 21. - -á -á -á -á -á- The investigation indicated Resident 5GÇÖs care plan was not followed related to staff not discontinuing attempts to treat and provide care when the resident became agitated. No psychosocial harm was found, and Staff 21 was terminated. Abuse was unable to be ruled out related to the verbal abuse toward Resident 5.-á On 7/10/25 at 11:07 AM Resident 5 was unable to recall the incident that occurred between her/him and Staff 21. On 7/10/25 at 1:10 PM Staff 19 stated she and Staff 20 went into Resident 5GÇÖs room with Staff 21 to change the residentGÇÖs brief and complete wound care. Staff 19 stated they were all wearing gowns due to the resident being on Enhanced Barriers Precautions. Staff 19 stated Resident 5 lashed out and grabbed Staff 21GÇÖs gown and told her to GÇ£go to HellGÇ¥. Staff 19 stated Staff 21 told the resident that she was already there, and she/he was GÇ£SatanGÇÖs bitch.GÇ¥ Staff 19 stated they were able to change the resident, but she/he continued to lash out and Staff 21 threatened to call the police on the resident for assaulting staff. Staff 19 stated Resident 5 had a history of being resistive to care. Staff 19 stated when Resident 5 was being resistive to cares staff were to leave the room, reassess and reapproach. Staff 19 stated Staff 21 told her and Staff 20 to keep going with providing the brief change and to not worry about it even though Resident 5 was resistive. On 7/10/25 at 12:14 PM Staff 20 stated Resident 5 had known behaviors of refusing cares. Staff 20 stated her, and Staff 19 went into Resident 5GÇÖs room to change her/his brief and Staff 21 was also in the room to complete wound care. Staff 20 stated Resident 5 was not complying with care and refusing to be changed. Staff 20 stated Staff 21 told her and Staff 19 to go ahead and change the resident even though she/he was GÇ£freaking outGÇ¥ and told them to get out. Staff 20 stated both Staff 21 and Resident 5 were yelling at each other. Staff 20 stated she heard Staff 21 telling Resident 5 she/he was GÇ£SatanGÇÖs bitch.GÇ¥ Staff 20 stated when Resident 5 was resistive to cares, staff were to walk away and reapproach. On 7/10/25 at 12:57 PM Staff 21 stated Resident 5 was hateful and on 1/4/25 Resident 5 was calling her names, trying to hit and kick her and told her to go to Hell. Staff 21 stated she told Resident 5 that she was already there and then proceeded to say something under her breath. Staff 21 stated CNA staff overheard her and reported it. Staff 21 stated she did not argue about what she reportedly said. Staff 21 further stated she was directed by Staff 15 (Former DNS) to GÇ£forceGÇ¥ brief changes at least once a day which triggered the residentGÇÖs behaviors. On 7/14/25 at 11:45 AM Staff 15 stated on 1/4/25 Staff 21 attempted to complete a treatment on Resident 5. Resident 5 was noncompliant, and verbiage was said by Staff 21. Staff 15 denied having any conversations with Staff 21 to GÇ£forceGÇ¥ brief changes on Resident 5. Staff 15 stated staff were to encourage cares to be completed and if Resident 5 continued to refuse then to reapproach at a later time. On 7/10/25 at 1:30 PM Staff 1 (Administrator) acknowledged the 1/4/25 incident between Staff 21 and Resident 5 resulted in abuse. No further information was provided.

Resident #5 was assessed to ensure she remains free from verbal abuse. The Administrator or Designee reviewed current residents to ensure that they remain free from verbal abuse. The Administrator or Designee re-educated staff on the policies and procedures related to protecting the resident’s right to be free from abuse. The Administrator or Designee will do random audits to ensure that residents remain free from verbal abuse weekly X 2 weeks, then monthly X 2 months. The Administrator or Designee will report the results of these audits at the facility monthly Quality Assurance meeting for 60 days or until substantial compliance has been achieved. The Administrator is responsible for ensuring compliance.

Based on interview and record review it was determined the facility failed to ensure residents received communication in a language they could understand for 1 of 1 resident (#52) reviewed for behavior. This placed residents at risk for lack of involvement in care. Findings include: Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes. A 10/12/24 Admission MDS revealed Resident 52's preferred language was Spanish and she/he needed an interpreter to communicate with health care staff. A 10/28/24 care plan revealed Resident 52 spoke Spanish. A review of the medical record revealed the following English language documents were issued to and signed by Resident 52: - 10/14/24 Portable Orders for Life-Sustaining Treatment (POLST), - 10/22/24 Notice of Medicare Non-Coverage, - 10/29/24 Notice of Medicare Non-Coverage, - 1/9/25 SNF Discharge Instructions/Recapitulation of Stay. On 1/14/25 at 11:52 AM Witness 2 (Complainant) stated she visited with Resident 52 and she/he complained the facility provided documents to her/him in English only and requested she translated documents to Resident 52. Unable to interview Resident 52 due to her/his phone being disconnected. On 1/15/25 at 5:04 AM Staff 11 (CNA) stated Resident 52 spoke Spanish with very little English. On 1/15/25 at 12:00 PM Staff 18 (Social Services Director) stated Resident 52 had variable English skills and required a translator for communication. Staff 18 did not know if Resident 52 read English and stated she/he needed her/his Notice of Medicare Non-Coverage to be issued in Spanish. On 1/15/25 at 2:40 PM Staff 19 (LPN) confirmed Resident 52 spoke Spanish with very little English. On 1/17/25 at 10:42 AM Staff 2 (DNS) stated Resident 52 spoke Spanish and the facility failed to provide documents to her/him in a language she/he could understand.

1. Resident 52 was discharged from the facility. 2. All residents in the facility who primarily understands a language other than English are potentially affected by this alleged deficient practice. Printed Spanish versions of Notice of Non-Medical Coverage (NOMNC) and Detailed Explanation of Non-Coverage (DENC) to have on hand to provide to residents. 3. Facility Administrator educated department heads on providing documents such as the NOMNC and DENC in a language that they can understand. 4. Social Services Director (SSD) and/or designee will monitor that NOMNCs, DENCs, and Discharge Summaries given to residents are in a language that they can understand weekly x 4, then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is responsible for compliance.

Based on interview and record review it was determined the facility failed to ensure resident mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication. Findings include: A facility Mail and Electronic Communication policy, revised in 2017, stated, "Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries)." During the resident council meeting on 1/14/25 at 2:00 PM residents stated their mail was not delivered to them on Saturdays. On 1/15/25 at 10:04 AM Staff 20 (Activities Director) stated mail was delivered Monday through Friday only. Staff 20 stated mail delivered to the facility on Saturdays was not given to resdients until the next Monday morning. On 1/15/25 at 11:31 AM Staff 1 (Administrator) stated resident mail was to be delivered to the residents on the same day it was delivered to the facility.

1. Facility Department Heads and/or designee are to ensure mail gets delivered every Saturday. 2. All residents in the facility are potentially affected by this alleged deficient practice. Administrator ensure there is a department head and/or designee on Saturday to provide mail to the residents within 24 hours of receiving the mail. 3. Facility Administrator educated department heads on the importance of having mail delivered to residents everyday including Saturdays. 4. Administrator and/or designee will monitor mail is delivered to residents on Saturdays weekly x4, then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is responsible for compliance.

Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 1 of 1 sampled resident (#52) reviewed for behavior. This placed residents at risk for unmet needs. Findings include: Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes. An 10/16/24 Utilization Review assessment revealed Resident 52 had chronic suicidal ideation comments. An 10/26/24 Progress Note revealed Resident 52 yelled and swung at staff, was combatiative, and refused to have her/his vitals done. A 11/5/24 Progress Note with a licensed clinical social worker revealed Resident 52 was referred to her by the facility for a depressed mood. Resident 52 expressed feeling depressed following recent medical complications and loss of independence, had depressed mood, sadness, feelings of helplessness, difficulties concentrating, and some irritability. Resident 52 expressed recent suicidal ideation with no intent or plan. A review of Resident 52's medical record revealed no monitoring for mood or behaviors. A review of Resident 52's comprehensive care plan revealed nothing related to mood, history of suicidal ideation, adjustment, or behaviors. On 1/15/25 at 5:04 AM Staff 11 (CNA) stated Resident 52 was in a "weird slump for a bit" when asked about her/his mood. On 1/15/25 at 12:00 PM Staff 18 (Social Services Director) stated she was unaware of any mood issues for Resident 52. On 1/15/25 at 10:46 AM Staff 21 (CNA) stated Resident 52 complained about not having family support and expressed wanting to die. On 1/15/25 at 2:40 PM Staff 19 (LPN) stated Resident 52 expressed being tired of being sick and wanted to be done with life. Staff 19 referred her/him to Staff 18. On 1/16/25 at 12:42 PM Staff 4 (LPN Resident Care Manager) stated Resident 52 had a chronic low mood and had suicidal ideation without a plan or active suicidal behaviors. Staff 4 stated Resident 52 was seen by a licensed clinical social worker for her/his mood issues. On 1/17/25 at 7:32 AM Staff 18 stated Resident 52 had "passive" suicidal ideation and saw mental health support in the facility but that was about adjustment issues and not related to any suicidal behaviors. Staff 18 stated she did not feel Resident 52 had actual suicidal ideation or mood issues so she did not do a care plan related to it. On 1/17/25 at 10:42 AM Staff 2 (DNS) stated Resident 52 had mood and behavior issues and she expected those issues to be addressed in her/his care plan.

1. Resident 52 was discharged from the facility. 2. All residents in the facility are potentially affected by this alleged deficient practice. Director of Nursing Services (DNS) completed an audit on residents who are seen by the Licensed Clinical Social Worker (LCSW). 3. Administrator educated the department heads who develops/implements on the importance of developing a comprehensive person-centered care plan for behavior. 4. Administrator and/or designee will monitor comprehensive care plans for behavior weekly x 4, then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Director of Nursing Services is responsible for compliance.

Based on interview and record review it was determined the facility failed to provide care to wounds for 1 of 1 sampled resident (#52) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds. Findings Include: Resident 52 admitted to the facility in 10/2024 with diagnoses including diabetes. An 10/5/24 hospital progress note revealed Resident 52 had a a right foot ulcer. An 10/8/24 Clinical Admission revealed a right lateral (outer edge) foot diabetic foot ulcer was identified. Daily Skilled Evaluations completed 10/9/24 through 10/18/24, 10/20/24 through 11/1/24, 11/4/24, and 11/5/24, identified Resident 52's right lateral foot diabetic ulcer was not evaluated. 10/14/24, 10/17/24, 10/25/24, 11/1/24, and 11/19/24 Physician Progress Notes revealed no information related to Resident 52's right lateral foot diabetic ulcer. A 11/21/24 Skin Check assessment revealed Resident 52 was identified to also have a venous ulcer (a chronic wound that occurs when blood pools in the veins of the legs, damaging the skin and causing an open sore) on the left front lower leg and a venous ulcer on the left shin; both were indicated to have been identified on admission. A 11/26/24 Progress Note revealed Resident 52 had newly identified wounds to her/his left lower extremity, right foot, and buttocks. New wound orders were requested. A 11/26/24 Skin Integrity Issue investigation revealed Resident 52 had a wound noted on 10/8/24 but there were no orders for treatment. Staff 6 (Assistant DNS) completed a skin assessment of Resident 52 and discovered two additional wounds to her/his left lower leg and one pressure wound. Resident 52 stated the wound to the left leg was present for years. Orders for wound care were requested and obtained at that time for the four wounds. On 11/27/24 physician orders were received for wound care to Resident 52's wounds. On 1/16/25 at 11:10 AM Staff 6 stated she was aware of Resident 52's wounds. Staff 6 stated the facility identified Resident 52 had a wound on her/his right foot at the 10/8/24 admission, but orders for treatment were not obtained until 11/27/24. Staff 6 reviewed the 11/21/24 Skin Check assessment and confirmed the left front lateral lower leg wound and left shin venous ulcer wounds were identified as present on admission and Resident 52 stated the wounds were there for a long time. Staff 6 stated the facility failed to provide treatment for these wounds until 11/27/24.

1. Resident 52 was discharged from the facility. 2. All residents in the facility are potentially affected by this alleged deficient practice Resident 52 had a skin assessment done on 11/26/24 by Assistant Director of Nursing (ADNS). From this skin assessment, the ADNS discovered two additional wounds on his left lower leg and one pressure wound the left leg that was present. 3. DNS educated licensed nurses on the skin and wound process, orders in place on admission for any known or assessed skin impairments, proper use and documentation within N ADV Skin Check UDA, importance of risk management with each new impairment, and obtaining new wound/skin impairment pictures for all new skin impairments if they fall under the picture needed category. 4. DNS and/or designee will perform a skin assessment on random resident(s) weekly x4, then monthly x 2 to ensure all wounds are accounted for on the skin assessment. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Director of Nursing Services is responsible for compliance.

Based on interview and record review it was determined the facility failed to ensure residents were assessed after weight loss was identified for 1 of 3 sampled residents (# 34) reviewed for nutrition. This placed residents at risk continued weight loss. Findings include: Resident 34 admitted to the facility on 6/24/24 with diagnoses including malnutrition and type 1 diabetes. The 8/13/24 Care Plan indicated Resident 34 had a nutritional problem related to ongoing malnutrition and weight loss since admit. The goal was for Resident 34's weight to be within acceptable parameters set by the RD and Interdisciplinary team. Interventions included distant supervision, high protein foods and supplements. Review of Resident 34's Weight Summary report indicated the following: - 6/25/24 weight of 200.6 pounds. - 7/10/24 through 9/4/24 weight averaging 205.5 pounds. - 9/16/24 no weight taken. - On 9/23/24 Resident 34's weight was 174.6 pounds (32.5-pound weight loss). On 9/26/24 a progress note indicated the identified weight of 174.6 pounds and a reweigh was requested. Review of the Weight Summary Report indicated Resident 34 was not weighed again until 10/7/24 with a weight of 175.2 pounds (two weeks after the 9/26/24 reweigh request). Review of Resident 34's medical record indicated no new nutritional interventions were implemented between 9/26/24 and 10/7/24. Review of Resident 34's progress notes indicated she/he was sent to the hospital on 10/14/24 related to diabetes and returned to the facility on 10/19/24. A 10/15/24 nutritional progress note indicated a reweigh was previously requested. Resident 34 was due for review by the Nutritional at Risk (NAR) group but left to the hospital and would be reviewed in NAR upon return. Review of NAR Assessments indicated no review of Resident 34 was completed between 9/26/24 (first identified weight loss) and 10/14/24 (two and a half weeks later) when the resident discharged to the hospital. The first noted NAR assessment was completed on 10/22/24 (three days after readmission to the facility). Observations made from 1/13/25 through 1/15/25 revealed Resident 34 was able to feed himself with adaptive equipment. Resident 34 was observed to eat 100% of her/his meals. On 1/16/25 at 9:39 AM and 3:22 PM Staff 13 (RD) stated she reviewed the weight report weekly and determined who needed to be further assessed for being at risk for weight loss. Staff 13 stated a re-weigh request was to be completed by the following morning to determine accuracy. Staff 13 stated a resident was to be reviewed in NAR within a week of being identified for weight loss. Staff 13 acknowledged Resident 34's re-weigh recommendation was not completed timely, and Resident 34 was not reviewed in NAR until 10/22/24 resulting in a delay in nutritional interventions.

1. Resident #34 was identified as having a significant weight loss. 2. All residents in the facility are potentially affected by this alleged deficient practice DNS completed an audit on significant weight change for the residents of the facility. It was noted that 12 residents were noted to have a significant weight change. Provider notified of all new residents that were noted of having a significant weight change. 3. DNS educated Licensed Nurses on the weight change process. 4. DNS and/or designee will monitor significant weight changes weekly x 4, then month x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Director of Nursing Services is responsible for compliance.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 4 randomly selected CNA staff (#s 7, 8, 9 and 10) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 1/14/25 at 1:30 PM Staff 2 (DNS) was asked for the annual performance reviews for Staff 7 (CNA), Staff 8 (CNA), Staff 9 (CNA), and Staff 10 (CNA). No performance reviews were provided. On 1/15/25 at 10:40 AM Staff 15 (Staffing Coordinator) acknowledged no performance reviews were completed for the identified CNA staff.

1. It was identified that CNA #7, #8, #9, and #10 have not had their performance review. 2. All CNAs employed by the facility are potentially affected by this alleged deficient practice DNS performed an audit for the last 3 months on CNAs that are due for their performance review. 3. Administrator educated DNS on the importance of performance review for employees. 4. Administrator and/or designee will monitor performance review for employees weekly x 4, then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is responsible for compliance.

Based on observation, interview and record review the facility failed to ensure refrigerator temperatures were monitored, and food was labeled and dated for 2 of 2 refrigerators reviewed for food storage. This placed residents at risk for potential foodborne illnesses. A review of the facility policy "Refrigerator and Freezer" policy revealed refrigerator and freezer temperatures were to be checked daily and all food items were to be marked with dates. Responsibility for implementating the policy was assigned to supervisors or their designee. On 1/13/25 at 8:25 AM the refrigerator used to store resident food items, located in the resident dining room, was observed to have a temperature recording log, however, the temperature was only recorded on 1/10/25. On 1/14/25 at 1:09 PM Staff 16 (Dietary Manager) stated he was not aware of the process for monitoring the resident foods refrigerator utilized by the care team. He stated he had taken the temperature of the refrigerator on 1/10/25 when he placed the log on the front of the refrigerator. On 1/15/25 at 9:59 AM foods were observed with no dates or names in both compartments of the resident refrigerator in the dining room. Staff 17 (CNA) stated she was not sure what the policy was for labeling and dating foods. The resident snack refrigerator behind the nurses station was also observed. The temperature log only had one recorded temperature, dated 1/14/15. In an interview on 1/16/25 at 1:00 PM Staff 16 acknowledged refrigerator temperatures were to be monitored and recorded daily, and refrigerator food was to be labeled and dated.

1. There were no temperatures noted on temperature logs for the refrigerator located in the dining room and the refrigerator located behind the nurses station. DNS and Dietary Manager (DM) noted the temperature onto the temperature log. 2. All residents are potentially affected by this alleged deficient practice. DNS performed an audit of the facility and located all the fridges that are actively in use. It was noted that there were additional refrigerators located in residents room. Those located in the residents room had any expired items thrown away, food labeled, and temperature taken by DNS/ADNS/Infection Preventionist (IP)/Regional Nurse Consultant (RNC). 3. DNS educated Licensed Nurses and Certified Nursing Assistants on the importance of labeling food items and ensuring refrigerator temperature are within range. 4. DNS and/or designee will monitor all active refrigerators temperature are within range and is documented weekly x 4, then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is responsible for compliance.

Based on interview and record review it was determined the facility failed to ensure the state minimum bariatric CNA staffing ratios were maintained for 8 of 31 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include: On 1/14/24, the facility provided documenation indicating four residents were approved for the bariatric rate. A review of the Direct Care Staff Daily Reports from 12/13/24 through 1/13/25 revealed the following days when the state minimum bariatric CNA staffing ratios were not met for one or more shifts: - 12/13/24 - 12/14/24 - 12/20/24 - 12/26/24 - 12/27/24 - 12/29/24 - 12/30/24 - 1/13/25 On 1/15/25 at 10:40 AM Staff 15 (Staffing Coordinator) acknowledged the state minimum bariatric CNA staffing ratios were not met for the identified dates. No further information was provided.

It was identified that 8 of 31 days from 12/13/24 to 01/13/25, the minimum bariatric CNA staffing ratio were not maintained. 2. All residents in the facility are potentially affected by this alleged deficient practice Reviewed Direct Care Staff Daily Reports from 01/14/2025 to present to ensure the state minimum bariatric CNA staffing ratios are maintained. 3. Administrator educated Staffer/HR on the importance of maintaining the state minimum bariatric CNA staffing ratios. 4. Administrator and/or designee will monitor that the facility maintains the stat minimum bariatric CNA staffing ratios weekly x4, then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendations as determined by the committee or until substantial compliance has been achieved. The Administrator is responsible for compliance.

******************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F552 and F576 ******************************** OAR 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 ******************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 ******************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventative Care Refer to F692 ******************************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F730 ******************************** OAR 411-086-0250 Dietary Services Refer to F812 ********************************

Based on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 3 sampled residents (#2) reviewed for dignity and respect. This placed residents at risk for a decrease in their quality of life. Resident 2 admitted to the facility in 11/2023, with diagnoses including hyperlipidemia (a condition caused by high levels of fat in the blood). Resident 1 admitted to the facility in 2/2024, with diagnoses including chronic systolic heart failure. A 7/17/24 Facility Reported Incident indicated Resident 1 was observed having a verbal altercation with Resident 2 in the facility parking lot. It was reported the altercation began after Resident 2 requested Resident 1 to return a spare wheelchair that Resident 1 had borrowed. Resident 1 during the verbal altercation was observed spitting in Resident 2's face before staff intervened and separated both residents. A 7/17/24 witness statement by Staff 3 (Medical Records Director) and Staff 4 (ADNS) indicated Resident 1 spat in the face of Resident 2 during the resident's verbal altercation. On 10/1/24 at 3:23 PM Resident 2 stated Resident 1 had "spit in her/his face" during the argument. Resident 2 stated she/he felt offended and disrespected and it was emotionally difficult for her/him. Resident 2 confirmed she/he had not been abused by Resident 1 during the altercation. Resident 2 stated she/he declined a physical assessment be conducted by staff and had not been injured during the altercation between Resident 1. On 10/2/24 at 12:13 PM Resident 1 denied spitting in Resident 2's face but confirmed she/he had "gotten in her/his face" during the verbal altercation as she/he was "pissed off." On 10/2/24 at 12:42 PM Staff 3 indicated that she witnessed Resident 1 "talking aggressively" regarding Resident 2's wheelchair. Staff 3 stated that during the altercation, Resident 1 was witnessed spitting in the face of Resident 2. Staff 3 stepped in and separated both parties and escorted Resident 2 back to her/his room for clinical assessment. Staff 3 stated Resident 2 had declined assessment due to no injuries being sustained during the incident. On 10/2/24 at 12:52 PM Staff 4 stated she observed Resident 1 yelling in the face of Resident 2. Staff 4 stated Resident 1 was upset with Resident 2 when she/he asked for a wheelchair that Resident 1 had borrowed. Staff 4 confirmed that during the incident, Resident 1 was witnessed spitting in the face of Resident 2. Staff 4 stated she assisted Staff 3 in separating both residents and stayed with Resident 1 outside while she/he calmed down. Staff 3 stated both residents were placed on safety monitoring and confirmed no additional incidents occurred. On 10/10/24 at 12:55 PM Staff 2 (DNS) and Staff 4 (ADNS) confirmed findings and provided no additional information.

F557 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Staff de-escalated Resident 1 and removed Resident 2 from the area. Resident 2 was assessed for any psychosocial harm. Resident 1’s room was changed to be near nursing station and 1:1 monitoring was initiated. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken: Activities Director (AD) conducted full house interviews with residents of the facility regarding dignity. Residents that were identified to be affected by the deficient practice will have grievance forms filled out by the resident themselves and given to Social Services and/or designee. Date(s) when corrective action will be completed: November 5th, 2024 What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Staff will be educated on the facility’s policy on Dignity by Director of Nursing Services/Administrator or designee. Date(s) when corrective action will be completed: November 5th, 2024 How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: Activities Director and/or designee will perform a weekly audit x 4 of random residents, then monthly x 2. Any negative findings will be brought to the QAPI committee for review and recommendation as determined by the committee or until substantial compliance has been achieved. The Administrator is reasonable for compliance. Date(s) when corrective action will be completed: November 5th, 2024

OAR 411-085-0310 - Residents' Rights: Generally

Refer to F557 ********************

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 2 sampled residents (#1) reviewed for abuse. This placed residents at risk for potential repeat sexual abuse incidents. Findings include: Resident 1 was admitted to the facility in 11/2023, with diagnoses including severe sepsis and post-traumatic stress disorder. A 11/8/23 Admission MDS Assessment, Section C: Cognitive Patterns, identified Resident 1 with severe cognitive impairment. Resident 1's 11/17/23 Care Plan identified the resident with a history of trauma related to domestic violence with interventions, including maintaining personal space boundaries and announcing self before approaching. Resident 2 was admitted to the facility in 8/2023, with diagnoses including encephalopathy and dementia with behavioral disturbance. An 11/24/23 Quarterly MDS Assessment, Section C: Cognitive Patterns, identified Resident 2 with severe cognitive impairment. Resident 2's 8/18/23 Care Plan identified the resident with inappropriate sexual behavior related to touching and kissing other residents. A 4/29/24 Facility Reported Incident revealed Resident 2 was found with her/his hand down Resident 1's brief while she/he was asleep. Resident 2 was reported to have been removed from the room after and was transferred to a different hallway soon after the incident. Tigard police were notified on the morning of 4/30/24 who identified Resident 1 with a history of engaging in inappropriate sexual behaviors. On 5/2/24 at 12:59 PM, Resident 2 stated she/he went to visit Resident 1 on 4/29/24 but did not recall touching Resident 1 during their visit. On 5/2/24 at 1:24 PM, Staff 3 (CMA) stated she witnessed Resident 2 with her/his hand inside the front of Resident 1's brief towards the resident's genitals exposing her/his right hip and buttocks. A review of facility progress notes and risk management report indicated Resident 2 was discovered in Resident 1's room on the evening of 4/29/24 and placed her/his hand down Resident 1's brief while she/he was asleep. Facility immediately placed Resident 2 on the opposite side of the facility. On 5/2/24 at 2:08 PM, Staff 5 (Receptionist) stated Resident 2 had been placed on a one on one monitoring schedule to assure resident safety and prevent further occurrence of sexually inappropriate behaviors. Observation of Resident 2 from 5/2/24 to 5/3/24 revealed the resident with an assigned one on one staff member. On 5/3/24 at 11:25 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 2 placed her/his hand down the front of Resident 1's brief while she/he was sleeping in her/his room. Staff 2 stated Resident 2 was placed with a one on one staff member indefinitely.

1. Resident #2 was immediately moved to a different hallway and placed on a 1 to 1. A hall-wide (the hall where resident #2 previously resided) abuse questionnaire was completed for all female residents regarding sexual abuse and any allegations were immediately investigated. 2. All residents have the potential to be affected by this alleged deficiency. 3. All staff will be educated on abuse/neglect policies and procedures and mandatory reporting to facility abuse coordinator by the Administrator or designee prior to Tuesday, June 4, 2024. All resident charts with sexual inappropriateness care plans will have their care plans reviewed and updated as needed to ensure the effectiveness of current interventions. 4. The Administrator or designee will complete regular staff education audits to ensure staff know proper abuse/neglect procedures and whom the abuse coordinator in the facility is. The Director of Nursing Services or designee will review new sexually inappropriate care plans for any new residents for intervention effectiveness These audits will be conducted 1x/week for 4 weeks and then 1x/month for 3 months. All findings will be reported to the monthly QAPI committee for review.

OAR 411-085-0360 - Abuse

Refer to F600 ********************

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of money for 1 of 2 sampled residents (#11) reviewed for misappropriation. This placed residents at risk for loss of property. Findings include: Resident 10 was admitted to the facility in 9/2023 with diagnoses including fracture of the left pubis. A 12/29/23 Admissions Assessment identified Resident 10 with moderate cognitive impairment. Resident 10's 2/15/24 Care Plan identified the resident with behavioral issues including yelling and panhandling cash for cigarettes from other residents and staff. Resident 11 was admitted to the facility in 3/2023 with diagnoses including viral hepatitis and anemia. A 12/24/23 Quarterly Assessment identified Resident 11 with severe cognitive impairment. Resident 11's 8/18/23 Care Plan identified Resident 11 with ineffective coping related to cognitive memory deficits including poor insight and difficulty with problem solving. A 3/8/24 Incident Report revealed Resident 10 was found to have taken money from Resident 11 in Resident 11's room. Resident 10 was then asked by the facility to return the money to Resident 11 and had refused. Resident 10 was then witnessed placing the money in her/his pocket before leaving the facility to purchase cigarettes. On 4/8/24 at 11:40 AM Resident 10 stated she/he had taken Resident 11's money for the use of purchasing cigarettes at the local gas station. On 4/10/24 at 2:52 PM Staff 5 (LPN) confirmed findings and stated Resident 10 had a history of panhandling residents with cognitive impairment for money as a means to purchase cigarettes. On 4/11/24 at 2:15 PM Staff 1 (Administrator) stated the facility substantiated misappropriation of Resident 11's money.

1. Resident #11's finances were reviewed to ensure no theft or other misappropriation had taken place. 2. All residents with severe cognitive impairments can be affected by this alleged deficient practice. 3. All staff will be educated on abuse/neglect/misappropriation policies and regulations by the Administrator or designee before May 14, 2024. 4. The Social Services Director or designee will conduct regular hall audits/resident interviews for misappropriation. The audit will be completed 1x/week for 4 weeks and then 1x/month for 3 months. All findings will be reported to the QAPI committee for review. 5. Compliance date: May 14, 2024

Based on interview and record review it was determined the facility failed to treat a diabetic wound per physician orders for 1 of 3 sampled residents (#8) reviewed for skin conditions. This placed residents at risk for worsening wounds. Findings include: Resident 8 admitted to the facility in 5/2023, with diagnosis including diabetes. Resident 8's 10/10/23 physican orders instructed staff to clean the right toe diabetic wound with wound cleanser, apply a thin layer of AD (ointment) to the wound and periwound, and to secure the wound with bordered foam. The dressing was to be changed three times per week and as needed. Resident 8's October 2023 TAR revealed no wound care was done between 10/11/23 through 10/27/23. On 4/10/24 at 11:15 AM, Staff 2 (DNS) verified wound treatments were not completed from 10/11/23 through 10/27/23.

1. Resident #8’s wound treatment orders were updated and followed beginning 10/28/23 as prescribed/written. 2. All residents with wounds can be affected by this alleged deficient practice. 3. All licensed nurses will be educated on same-day order implementation by the Director of Nursing services before May 14, 2024. 4. Wound consultant/provider system integration started April 19, 2024, so provider progress notes may be uploaded, and facility wound nurse may implement orders same day. The RCMs and DNS started weekly wound audits and weekly wound meetings to review proper implementation of orders and care plan beginning April 4, 2024. 5. The Director of Nursing Services or designee will conduct regular audits of residents’ charts for triple check of wound orders, provider/consultant progress notes, and wound assessment pictures. This audit will be completed on all residents for 1 week, then 5 random residents per week for 3 weeks, and then 5 random residents per month for 3 months. All results and findings will be reported to facility’s monthly QAPI committee for review.

*********************** OAR 411-085-0360 - Abuse Refer to F602 **************************** OAR 411-086-0110 - Nursing Services: Resident Care Refer to F684 *******************************

Based on interview and record review it was determined the facility failed to ensure resident narcotic medications were not misappropriated for 1 of 1 resident (# 4) reviewed for pain medications. This placed residents at risk for loss of property. Findings include: Resident 4 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure. Resident 4's 10/31/23 Admission MDS identified Resident 4 with moderate cognitive impairment. Resident 4's 10/24/23 Care Plan revised on 10/30/23 indicated resident 4 had pain related to restless leg syndrome, cellulitis, and a wound to the lower left leg. Resident 4's Medication Administration Record identified the use of Fentanyl Transdermal Patches to manage Resident 4's pain. A review of Resident 4's November Narcotic Administration Record reviewed form 11/9/23 to 11/13/23 revealed a missing Fentanyl Transdermal Patch. On 12/8/23 at 10:09 AM Staff 2 (DNS) acknowledged that the Fentanyl Transdermal Patch could not be located. On 12/11/23 at 11:45 AM Staff 1 (Administrator) confirmed the facility was unable to locate the Fentanyl Transdermal Patch.

1. After reviewing tag 602, resident #4s patch has been replaced and the resident does not have any signs and symptoms of increased pain. 2. All residents receiving narcotic medication have the potential to be affected by this alleged deficient practice. 3. All licensed nurses and certified medication aids were re-educated on the 6 rights of medication administrator and NARC book page completion before 01/10/2024. 4. The director of nursing services will audit the NARC book for page completion for signature, date, and time requirements for 1 per week for 4 weeks and then monthly for 2 months. All audit results will be submitted to the monthly QAPI Committee for review and recommendations times 2 months unless further monitoring is required.

Based on observation, interview and record review it was determined the facility failed to follow resident care plans related to substance use disorder for 1 of 1 sampled resident (# 2) reviewed for safety and coordination of care. Findings include: Resident 2 was admitted to the facility in 2023 with diagnoses including schizoaffective disorder and stimulant abuse. An 11/1/23 Admission MDS identified Resident 2 had no cognitive impairment. Resident 2's Care Plan dated 11/1/23 revised on 11/14/23 indicated resident 2 had an active substance use disorder characterized by the resident's continued pursuit to obtain illegal substances from outside sources. This act was identified to place Resident 2 at risk for further injury to her/himself. An 11/27/23 Nursing Care Note identified Resident 2 was unarousable while care staff attempted to provide catheter care. Resident 2's head was positioned in a downward angle. Care staff contacted emergency care services and resident 2 was noted to have refused to be transferred to the hospital. An 11/28/23 Provider Note indicated after the emergency event, Resident 2 tested positive for illegal substances. On 12/4/23 at 10:17 AM Staff 3 (RCM) confirmed resident 2 tested positive for illegal substances per physician order. On 12/4/23 at 10:51 AM Staff 6 (CNA) revealed Resident 2 had a lighter in her/his room. On 12/11/23 at 11:45 AM Staff 1 (Administrator) confirmed findings and provided no additional information.

1. Resident number 2 is no longer in the facility at this time. Staff was educated on procedures with smoking paraphernalia in December 2023. 2. All residents can be affected if the environment is not safe. 3. Staff will undergo comprehensive education on the facility's substance use policy and procedures along with the smoking policy and procedures. This training will enhance staff awareness and competence in identifying, managing, and reporting incidents related to substance use. Nurses will be educated on smoking assessments as well. 4. All residents will be assessed for smoking. Assessments will be completed on admission, quarterly, and annually from now on. 5. The Director of Nursing or designee will conduct regular audits of resident charts to review smoking assessments. This audit will involve reviewing five charts per week for the next four weeks, followed by monthly audits for an additional two months. These audits aim to ensure that smoking assessments are appropriately documented, analyzed, and addressed.

Based on observation, interview and record review it was determined the facility failed to assess and develop individualized interventions specific to the expression to continue using illegal substances for 1 of 1 sampled resident (#2) reviewed for behavioral emotional health. This placed residents at risk for a decline in mood and potential risk for reduced quality of life. Findings include: Resident 2 was admitted to the facility in 10/2023 with diagnoses including schizoaffective disorder and stimulant abuse. Resident 2's Care Plan dated 11/1/23 revised on 11/14/23 indicated resident 2 had an active substance use disorder characterized by the resident's continued pursuit to obtain illegal substances from outside sources. This act was identified to place Resident 2 at risk for further injury to her/himself. Resident 2's 11/1/23 Care Plan identified the facility was to provide Resident 2 with continued resources related to drug addiction counseling. On 12/4/23 at 12:19 PM Staff 4 (SSD) stated Resident 2 declined the offer of drug support services and counseling. Staff 4 indicated these services were offered and documented in Resident 2's clinical record. Staff 4 confirmed no additional drug addiction services or resources were provided to Resident 2. A review of Resident 2's clinical record revealed no attempts or continued resources were provided to Resident 2 for drug addiction resources and services. On 12/11/23 at 11:45 AM Staff 1 (Administrator) confirmed findings and provided no additional information.

1. Resident number 2 was reoffered behavioral health services and declined on 12/11/2023. The resident has been discharged from the facility. 2. All residents can be affected negatively by care plan interventions not being followed. 3. Audits will be conducted to gather comprehensive information on substance abuse among residents. Those with a history of substance abuse will be identified, care planned, and offered necessary services to address their unique needs. Services will be offered on admissions, quarterly, and annually. 4. Nursing and social services staff have undergone education on CMS Tag F740 requirements, as well as the facility's substance use policy and procedures. Training will be concluded by 01/10/2024, ensuring staff competence in providing appropriate care and support. 5. To monitor the effectiveness of behavioral services, the administrator or designee will conduct random audits of two residents per week over a four-week period to ensure behavioral services have been offered. Findings will be reviewed in Quality Assurance (QA) meetings monthly times 2 months to assess compliance and make necessary adjustments.

*********************** OAR 411-085-0360 Abuse Refer to F602 ****************************** OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care Refer to F689 ****************************** OAR 410-180-0340 Professional Standards Refer to F740

Based on interview and record review it was determined the facility failed to offer the resident the opportunity to participate in the care planning process for 1 of 4 sampled residents (#19) reviewed for care planning. This placed residents at risk for not being involved in the care planning process. Findings include: Resident 19 admitted to the facility on 5/3/23 with diagnoses including anxiety disorder. On 8/7/23 at 10:11 AM Resident 19 stated she/he would like to attend her/his care conference and did not recall attending one in the past. On 8/8/23 Resident 19's medical record was reviewed and revealed no care conferences were completed since she/he admitted to the facility. On 8/8/23 at 11:03 AM Staff 3 (Social Services Director) acknowledged Resident 19 did not have a care conference completed since she/he admitted to the facility on 5/3/23.

1. Resident #19 was offered a care conference and will have it completed on September 7, 2023. 2. All residents have the potential to be affected by this deficient practice. 3. The Interdisciplinary Team will be re-educated by the Administrator on the requirement of care conferences within 72 hours of admission, quarterly, upon significant changes, and whenever the resident requests. Care conferences will be scheduled based upon the MDS schedule to ensure completion within 14 days of ARD date and will be documented in a Care Conference Multidisciplinary Assessment by IDT members. 4. Administrator or designee will audit the Care Conference calendar and Care Conference Multidisciplinary Assessments for completion. Audits will be completed 1x/week for 4 weeks and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an Advance Directives for 1 of 3 sampled residents (#14) reviewed for Advanced Directives. This placed residents at risk for not having their health care preferences honored. Findings include: A record review on 8/7/23 revealed no advance directive or documentation to indicate Resident 14 was informed of or provided written information concerning their right to formulate an advance directive. On 8/9/23 at 2:33 PM Resident 14 stated she/he completed an Advance Directive during her/his hospital stay prior to admission. On 8/10/23 at 11:34 AM Staff 3 (Social Services) stated the facility provided an Advanced Directive form to Resident 14 upon admission. Staff 3 (Social Services) confirmed the facility did not follow up to ensure a copy of the Advance Directive was obtained and placed in the medical record.

1. Resident #14 was offered advanced directive resources on August 31, 2023 and resident accepted at this time. 2. All residents have the potential to be affected by this deficient practice. Medical records of all residents will be audited by the Medical Records Director or designee for documentation of Advance Directives being offered and given if requested by the residents 3. Interdisciplinary Team will be re-educated on the Advanced Directive Policy and Procedure by the Regional Nurse Consultant. All residents Advanced Directives will be reviewed on admission, and at quarterly care conferences. Documentation of discussions will be made in the residents electronic health record. 4. Administrator or designee will audit 5 residents for evidence of advanced directives being offered to resident. Audits will be completed 1x/week for 4 weeks and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI committee for review and recommendations.

Based on interview and record review it was determined the facility failed to provide NOMNC (Notice of Medicare Non Coverage) and SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) information for 2 of 3 sampled residents (#s 247 and 248) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: Resident 247 admitted to the facility with Medicare Part A services on 1/19/23. The last day of coverage for skilled services was 2/13/23. Resident 247 remained in facility. A review of the medical record revealed no evidence a NOMNC was provided to Resident 247 when skilled services ended. Resident 248 admitted to the facility with Medicare Part A services on 1/20/23. The last day of coverage for skilled services was 3/3/23. The resident remained in the facility until 5/5/23. A review of the medical record revealed no evidence SNF ABN was provided to Resident 248 when skilled services ended. On 8/8/23 at 11:57 AM Staff 3 (Social Services Director) was unable to find the required beneficiary forms for Resident 247 and Resident 248 in their records.

1. NOMNC (Notice of Medicare Non Coverage) and ABNs (Advanced Beneficiary Notices) were unable to be provided/signed by Resident #247 and #248 as they have discharged from the facility. 2. All residents discharging from skilled/Medicare services have the potential to be affected by this deficient practice. 3. The Interdisciplinary Team will be re-educated by Administrator on the requirement of issuing NOMNCs and ABNs to residents coming off skilled services within 48 hours of last treatment day. The signed NOMNCs and ABNs will then be scanned into the residents charts and a hard copy will be kept in a NOMNC/ABN binder kept in the Social Services Directors office. 4. Administrator or designee will audit resident charts and the NOMNC/ABN binder for completion of 3 residents per week. Audits will be completed 1x/week for 1 week, 1x/week for 4 weeks, then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on observation and interview it was determined the facility failed to maintain a safe environment for 1 of 1 courtyard areas reviewed for environment. This placed residents at risk for accidents. Findings include Observations from 8/8/23 through 8/10/23 revealed no safety warnings or other cautionary measures in place for a broken and raised section (two to three inches) of a pathway in the courtyard. On 8/8/23 at 12:23 PM Resident 15 was observed in her/his wheelchair in the courtyard. The resident had difficulty navigating the broken section of the pathway. The resident was unable to crossover the broken pathway and appeared to be stuck. On 8/9/23 at 10:03 AM Resident 15 stated that she/he went outside daily and regularly got stuck on the broken section of the pathway. She/he then stated staff would usually notice or Resident 15 would use her/his cell phone to call for help. On 8/9/23 at 10:48 AM Staff 5 (Maintenance Director) stated he was aware of the broken section of the pathway in the courtyard. He further stated he had only been at the facility approximately one month and was trying to address several identified concerns.

1. The courtyard pathway concrete was fixed/redone on August 11, 2023. 2. All residents have the potential to be affected by this deficient practice. 3. All staff will be re-educated by Administrator on the requirement/importance of resident safety and reporting potential hazards to their supervisor or the Administrator as quickly as possible. This education will also include the importance of utilizing safety warnings or other cautionary measures to warn residents of potential environmental safety hazards. 4. Administrator or designee will audit the facility for potential environmental hazards and the use of safety warnings or other cautionary measures 1x/week for 4 weeks and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on interview and record review it was determined the facility failed to follow and implement physician orders and provide bowel medication in a timely manner for 2 of 6 sampled residents (#s 26 and 43) reviewed for medications and tube feeding. This placed residents at risk for medical complications from constipation and adverse side effects of medications. Findings include: The facility's undated Bowel Care Protocol indicated if a resident did not have a BM (bowel movement) in 72 hours a licensed nurse was to perform an abdominal assessment and offer Miralax (a laxative) in eight ounces of liquid. It was okay to use the Miralax on top of existing Miralax order, if it existed. If there were no results in 24 hours they were to notify the physician. For any resident on narcotics, request an order for scheduled or PRN stool softeners or Miralax. 1. Resident 26 admitted to the facility on 8/2022 with diagnoses including dementia and depression. a. Resident 26's Physician Order Report signed by the physician on 7/28/23 revealed an order for Miralax powder. Staff were to administer 17 grams mixed in four to eight ounces of fluid and drink daily for bowel care at 6:00 AM and 10:00 AM. Resident 26's BM log from 7/19/23 through 8/8/23 revealed the following: -7/19/23 through 7/24/23 (six days) Resident 26 did not have a BM. -7/29/23 through 8/3/23 (six days) Resident 26 did not have a BM. A review of the resident's clinical record from 7/19/23 through 8/8/23 revealed no documentation bowel care was implemented or the resident was assessed for constipation. On 8/9/23 at 1:24 PM Staff 26 (LPN) stated she was not sure if Resident 26 struggled with BMs, and the facility had "standing orders" for bowel care protocol but was not sure what the bowel protocol was. On 8/10/23 at 6:55 PM Staff 31 (Agency/LPN) stated she thought Resident 26 struggled at times with BM's. Staff 31 stated she received a bowel care list from the night shift nurse for residents who had not had a BM in three days and the CMAs administered bowel care protocol. Staff 31 stated each resident had their own bowel protocol. b. Resident 26's Physician Order signed by the physician on 7/20/23 directed staff to administer naproxen (pain medication) two times daily. A review of Resident 26's 7/2023 MAR revealed she/he did not receive her/his naproxen from 7/21/23 through 7/27/23 (six days) because the medication was not available. On 8/11/23 at 10:16 AM Staff 2 (Resident Care Manager/LPN) stated staff were expected to implement and follow the bowel care protocol. Staff 2 acknowledged there was no evidence to indicate bowel protocol was implemented. Staff 2 acknowledged Resident 26 did not receive her/his naproxen for six days. Staff 2 stated naproxen was an OTC (over the counter) medication and staff were expected to report to Staff 32 (Business Office Manager) when supplies were low because he was in charge of ordering medications. 2. Resident 43 admitted to the facility on 7/2023 with diagnoses including stroke and chronic pain syndrome. Resident 43's Physician Order signed by the physician on 7/17/23 directed staff to administer whey protein powder 12 grams enterally two times daily for additional caloric intake. A review of Resident 43's MAR revealed she/he did not receive whey protein on 7/17/23, 7/18/23 and 7/19/23 in the AM and on 7/22/23, 7/23/23 and 7/25/23 in the PM because the whey protein was not available. Resident 43's Physician Order signed by the physician on 7/18/23 directed staff to administer atorvastatin (a blood pressure) medication and duloxetine (anti-depressant) medication one tablet daily. A review of Resident 43's MAR revealed she/he did not receive her/his atorvastatin on 7/18/23 or her/his duloxetine on 7/18/23 and 7/19/23 because the medications were not available. On 8/9/23 at 1:24 PM Staff 26 (LPN) acknowledged Resident 43 missed her/his atorvastatin and duloxetine because she/he was a new admission and the pharmacy did not have the medications available due to a "cut off time." Staff 26 stated she attempted to pull the duloxetine from the omnicell (automated medication dispenser) but it was not the correct dosage. Staff 26 further stated the whey protein was ordered through the pharmacy but the facility supplied the whey protein and did not have any in stock so she placed an order. On 8/11/23 at 10:16 AM Staff 2 (Resident Care Manager/LPN) acknowledged Resident 43 did not receive her/his atorvastatin on 7/18/23, duloxetine on 7/18/23 and 7/19/23 or the whey protein. Staff 2 stated there was a miscommunication between the pharmacy regarding Resident 43's medications and the pharmacy never received the fax regarding the atorvastatin and duloxetine medications. Staff 2 stated the whey protein was an OTC (over the counter) supply and staff were expected to report to Staff 32 (Business Office Manager) when supplies were needed or low because he was in charge of ordering medications.

1. Resident 26 and 43 were reviewed and receiving all MD orders as prescribed. Bowel medications reviewed and implemented per MD orders. 2. All residents have the potential to be affected by this deficient practice. 3. All CNAs will be re-educated by the Director of Nursing Services on documenting bowel movements. The facility implemented a new bowel follow-up protocol which includes overview of residents not having a bowel movement in 9 shifts and utilizing the Bowel Care Administration flow sheet. The Resident Care Manager or designee will be re-educated by the Director of Nursing Services on reviewing daily documentation of EMAR notes indicating medications not available with timely follow-up to pharmacy regarding status. Education will be provided to all other licensed nurses by the Director of Nursing that if medication is not available, an immediate call to pharmacy must be completed and a notification to physician of possible missed dose with proper documentation. 4. The Resident Care Manager or designee will audit resident bowel list for any residents missing bowel movements for 9 shifts or more 5 times per week. The Resident Care Manager or designee will audit resident EMAR notes for documentation of missed medications, progress notes, and pharmacy and physician notification 5 times per week All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure elopement interventions were in place for 1 of 3 sampled residents (#26) reviewed for accidents. This placed residents at risk for lack of supervision and increased elopement risk. Findings include: Resident 26 admitted to the facility in 8/2022 with diagnoses including dementia and depression. A review of Resident 26's clinical record from 4/11/23 through 7/13/23 revealed the resident wandered throughout the halls and facility with the use of her/his walker, entered other residents rooms and at times, was difficult to redirect. Resident 26's Physician Order Report signed by the physician on 7/13/23 revealed the resident was an elopement risk with a "start date of 6/5/23 and her/his elopement precautions was to make sure the resident had her/his name band on at all times and staff were to document her/his whereabouts and if the resident was exhibiting exit seeking behavior." A review of Resident 26's 7/2023 and 8/2023 TARs revealed she/he had six out of 64 instances where she/he had exit seeking behaviors. Resident 26's Comprehensive Care Plan dated 7/14/23 and revised on 7/28/23 revealed Resident 26 was an elopement risk with a history of attempts to leave the facility unattended, wandered aimlessly and had impaired safety awareness. Staff were directed to add daily outdoor time to Resident 26's treatment plan to decrease her/his elopement risk. Staff were to encourage supervision/escort for all outings and family was in agreement. "Identify pattern of wandering: Is wondering purposeful, aimless or escapist? Is resident looking for something." Staff were to redirect the resident if attempts to exit the facility independently. A Brief Interview For Mental status dated 7/18/23 indicated Resident 26's cognitive status was moderately impaired with a score of eight out of 15 points. An Elopement Incident Report dated 7/22/23 revealed the following: -At approximately 2:00 PM Staff 31 (Agency/LPN) came out of a residents room and a CNA reported Resident 26 was missing. -All staff searched inside and outside the building on all halls but could not locate Resident 26. -Staff reported at approximately 2:15 PM to Staff 31 that Resident 26 was located at the Goodwill approximately 700 feet away from the facility and had used her/his motorized wheelchair. -The resident returned to the facility and indicated it was "just a nice day" and wanted to "get out" and she/he stated "I just wanted to keep everyone on their toes and laughed." -Resident 26 was not injured and educated regarding her/his safety. -Facility management changed the exit door code and abuse and neglect was ruled. A Progress Note dated 7/31/23 at 9:55 AM revealed Staff 1 (Administrator) observed Resident 26 walk out of the front door with her/his walker and Staff 1 stopped and redirected the resident back into the building. Resident 26 was frustrated and stated "this is discrimination." At 4:10 PM Staff 1 observed Resident 26 attempt to type in the code at the front door and Staff 1 approached the resident and asked what she/he was doing? The resident stated she/he wanted some fresh air and wanted to go "right now." Staff 1 stated she would sit with her/him out back and Resident 26 agreed. Random observations from 8/7/23 through 8/10/23 revealed Resident 26 wandered throughout the building with the use of her/his walker or her/his motorized wheelchair. On 8/10/23 at approximately 1:00 PM Resident 26 was at the front entrance of the facility and pushed on the locked door in an attempt to leave the building and staff redirected Resident 26 back to her/his room. On 8/9/23 at 1:24 PM Staff 26 (LPN) stated Resident 26 was an elopement risk and wandered in the hallways "often." Staff 26 stated she was not present when Resident 26 left the building but Staff 1 changed the code to the front entrance and Resident 26 had not attempted to leave the facility since the 7/22/23 incident. Staff 26 was unaware if the resident was wearing a wrist band. On 8/10/23 at 11:02 AM Staff 30 (Agency/CNA) stated she was not aware Resident 26 was a elopement risk and did not believe the resident had a wrist band on. On 8/10/23 at 11:18 AM Staff 29 (CNA) stated she was assigned to Resident 26 on 7/22/23 when she/he left the facility during the day and went to the Goodwill. Staff 29 stated she went to check on Resident 26 and "could not find" her/him. Staff 29 stated she was not sure how the resident left the facility. Staff 29 stated she alerted Staff 31 (Agency/LPN) and all staff searched the entire building inside and out. Staff 29 stated another staff located Resident 26 at the Goodwill store (which was across the street) and the resident was brought back to the facility. The resident was gone approximately 40 minutes. Staff 29 stated Resident 26 was an elopement risk and had witnessed exit seeking behaviors such as pushing buttons on the front door or standing at the front of the exit door but had never left the building unsupervised. Staff 29 stated Resident 26 did not have a wrist band with her/his name on it. On 8/10/23 at 11:57 AM Staff 27 (CNA) stated she worked on 7/22/23 and thought another resident or visitor let Resident 26 out of the facility and was found by Staff 24 (RN) at the Goodwill. Staff 27 stated she had not witnessed Resident 26 show exit seeking behaviors but she/he wandered in the halls and asked staff "have you seen my son." Staff 27 stated she did not recall if the resident had a wrist band with her/his name on it or that she/he was an elopement risk. On 8/10/23 at 12:19 PM Staff 24 stated she was on her break on 7/22/23 outside and Resident 26 was outside on her/his own and was not supposed to be without supervision. Staff 24 stated she brought her/him back from the Goodwill but was not sure how she/he got out of the facility. Staff 24 stated Resident 26 "was fine, no injuries" and used her/his motorized scooter to get to the Goodwill. Staff 24 stated Resident 26 was an elopement risk and wandered throughout the facility but had not witnessed any attempts to leave the facility. Staff 24 stated she was unsure if the resident had a wrist band. On 8/10/23 at 6:55 PM Staff 31 (Agency/LPN) stated she worked on 7/22/23 when Resident 26 left the building and Staff 29 alerted her that Resident 26 could not be located. Staff 31 stated all staff searched inside and outside of the facility and Staff 24 found the resident at the Goodwill and brought her/him back to the facility. Staff 31 stated she assessed Resident 26 and asked what she/he was doing and her/his response was "I was bored and wanted to get out of here and keep staff on there toes." Staff 31 stated she was not sure how the resident got out of the facility but she/he could have "possibly" known the code. Staff 31 stated the resident was an elopement risk and staff were expected to document her/his behaviors in the TARs. Staff 31 stated she was unaware if the resident had a wrist band. On 8/11/23 at 10:45 AM Staff 1 and Staff 21 (DNS) stated they were notified of Resident 26's elopement the morning of 7/23/23. Staff 1 stated all the doors to the facility were locked and she changed the code access to get in and out of the building. Staff 1 and Staff 21 indicated staff were expected to keep "eyes on and redirect" Resident 26 if she/he showed exit seeking behaviors. Staff 1 and Staff 21 stated they did not utilize a wander guard and were not aware of the "elopement precaution: Make sure resident has name on band at all times" and acknowledged staff were also unaware Resident 26 did not have a name or wrist band on at all times. Staff 1 and Staff 21 acknowledge that not all staff were aware Resident 26 was an elopement risk.

1. The front door code was changed and the label indicating the code was moved to a different, less noticeable location on July 25, 2023. Resident #26 was evaluated for safety in his/her power wheelchair by therapy. Resident Care plan was reviewed and new interventions implemented. Resident #26s behavior monitor for elopement was implemented on August 30, 2023. 2. All residents with elopement seeking behaviors have the potential to be affected by this deficient practice. 3. Administrator will re-educate all staff on elopement risk residents and the Code Pink. The Director of Nursing Services will re-educate CNAs on giving report during shift change to include high risk residents (including elopement risk residents) and their behaviors and all licensed nurses on accuracy of documentation of individualized behavior monitors and intervention outcomes prior to September 20, 2023. 4. The Director of Nursing Services or designee will audit accuracy of documentation for behavior monitors, interventions, and outcome 5 times a week. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on interview and record review it was determined the facility failed to complete nurse aide training performance reviews every 12 months and provide regular in-service training based on the outcome of these reviews for 1 of 1 CNA (#12) reviewed for annual nurse aide training performance. This placed residents at risk for lack of care by competent staff. Findings include: On 8/8/23 a review of the facility's staff training records for CNAs employed over one year revealed the following: -Staff 12 (CNA), hired 6/15/22, had no performance review and no documentation of regular in-service training. On 8/10/23 at 1:02 PM Staff 16 (Clinical Operations Education Director) confirmed the facility did not have a system in place to conduct annual nurse aide training performance reviews for Staff 12.

1. Nurse aide training performance reviews and regular in-service training was started on August 31, 2023. 2. All residents have the potential to be affected by this deficient practice. 3. The Director of Nursing Services will be educated by the Administrator on the in-service requirements and tracking for nursing aides annually. The Director of Nursing Services or designee will complete annual reviews for all nursing staff that have been employed for at least one year prior. Any staff found to not meet expectations will be provided education on related topics. 4. HR/Staffing Coordinator or designee will audit tracking of competency and performance reviews 1x/week for 4 weeks and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee and the Clinical Operations & Education Director for review and recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure the medication error rate was less than 5%. There were 28 medication administration opportunities with 8 errors resulting in an error rate of 28%. This placed residents at risk for adverse medication side effects. Findings include: The undated facility policy for care of tube feeding (gastrostomy) indicated the following: 5.e. "Medications will be administered by gravity. If problems with gravity and administration occur, a very small amount of pressure with the syringe to attempt flow and then remaining administration will be by gravity, unless otherwise noted by the physician." Resident 9 admitted to the facility in 2023 with diagnoses including stroke. The 7/27/23 Physician Order indicated Resident 9 was to receive the following medications: -acetaminophen 500 mg 2 tabs via gastric tube TID; -docusate sodium (laxative) 100 mg via gastric tube BID; -ezetimibe (cholesterol medication) 10 mg via gastric tube once daily; -ferrous sulfate (supplement) 325/65 mg via gastric tube once daily; -folic acid (supplement) 1 mg via gastric tube once daily; -polyethylene glycol (laxative) 3350/17 gm via gastric tube once daily; -Konvomep (antiulcer medication) oral suspension 2/84 mg/ml 20 ml via gastric tube TID; -sennosides syrup (laxative) 8.8 mg/5 ml give 5 ml via gastric tube once daily. On 8/9/23 at 9:32 AM Staff 10 (LPN) was observed to administer the following medications: -acetaminophen 500 mg 2 tabs pushed quickly into the feeding tube with syringe and plunger. -docusate sodium 100 mg pushed quickly into the feeding tube with syringe and plunger. -ezetimibe 10 mg pushed quickly into the feeding tube with syringe and plunger. -ferrous sulfate 325/65 mg pushed quickly into the feeding tube with syringe and plunger. -folic acid 1 mg pushed quickly into the feeding tube with syringe and plunger. -polyethylene glycol 3350/17 gm pushed quickly into the feeding tube with syringe and plunger. -Konvomep oral suspension 2/84 mg/ml TID 20 ml pushed quickly into the feeding tube with syringe and plunger. -sennosides syrup 8.8 mg/5 ml give 5 ml pushed quickly into the feeding tube with syringe and plunger. On 8/9/23 at 9:32 AM and 1:26 PM Staff 10 acknowledged she pushed each of Resident 9's medications quickly into the feeding tube with the syringe and plunger instead of letting the medications flow by gravity. On 8/9/23 at 1:42 PM Staff 21 (DNS) stated the expectation was for staff to individually separate all gastric tube medications, and allow them to flow by gravity and complete flushes in between.

1. Resident #9 was placed on alert on August 9, 2023 to monitor for adverse side effects from the medication error. The physician was notified and indicated no concern for adverse side effects. All licensed nurses on August 9, 2023 were immediately educated by the Director of Nursing Services on medication administration via tubes. 2. All residents receiving medications via tubes/IVs have the potential to be affected by this deficient practice. 3. All licensed nurses were re-educated by the Director of Nursing prior to September 20, 2023 on Sapphires Administering Medications through an Enteral Tube and the requirement of having an MD order to push medications. 4. The Director of Nursing or designee will audit tube medication administration for 3 times a week for 2 weeks, 1x/week for 4 weeks, and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on observation, interview and record review it was determined the facility failed to ensure hot food was served at preferable temperatures for 1 of 1 lunch meal reviewed for food concerns. This placed residents at risk for inadequate food temperatures. Findings include: On 8/7/23 interviews with Residents 39 and 297 revealed meals were often served cold. When meals were received, the hot foods were usually cold and had to be warmed up. A review of Resident Council minutes from 4/2023 through 7/2023 revealed cold food was an ongoing concern. The Resident Council minutes did not document actions taken to address the cold food. On 8/9/23 a lunch meal test tray was requested by the survey team. During the lunch meal service a total of 49 minutes passed between the first meal tray being placed in the first meal cart to when the survey team received the lunch meal test tray. The lunch meal consisted of roasted pork loin and broccoli. Both items were determined to be lukewarm in temperature. On 8/9/23 at 1:33 PM Staff 8 (Activities Director) stated cold food was an ongoing concern that was brought up in the Resident Council meetings she facilitated. She stated the only response she received from the Dietary Department was to encourage residents to eat in the main dining room which was right next to the kitchen. Staff 8 stated this was not always possible during outbreaks of infectious disease such as COVID-19. On 8/9/23 at 2:09 PM Staff 6 (Dietary Manager) was informed of food temperatures being lukewarm for the lunch meal test tray. He stated he was aware of resident complaints of cold food and acknowledged this was an ongoing challenge. When asked what was done to address the concern , Staff 6 replied residents were encouraged to eat in the main dining room. Staff 6 stated he was working on a plan to address the cold food concern.

The kitchen staff started using half-lids on food wells during meal service to keep food warmer on August 10, 2023. All residents receiving meals have the potential to be affected by this deficient practice. All kitchen staff will be re-educated by the Administrator or designee on Sapphires Preventing Foodborne Illness  Food Handling Policy and Procedure prior to September 20, 2023. The Dietary staff currently are utilizing the use of the plate toppers and the oven to maintain heat until ready to place all trays into the Cambros for meal serving. Food will be held in ovens until ready for tray line in order to keep food warmer. All residents in the dining room will be served seperately and first in order for food to come out quicker and warmer. The current steam table will be evaluated/inspected to ensure it is reaching required temperatures. The Director of Nursing Services will re-educate CNAs on keeping Cambro doors closed during meal pass prior to September 20, 2023. Administrator will audit food temperatures of last trays coming off of tray pass for 1x/day for 2 weeks, 1x/week fir 4 weeks, and then 1x/months for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on observation and interview it was determined that the facility failed to prepare and serve food in a safe and sanitary environment for 1 of 1 kitchen observed for food service. This placed residents at risk for foodborne illness. Findings include: 1. Observations from 8/9/23 at 9:53 AM through 8/10/23 at 9:40 AM revealed the ceiling of the kitchen had three round uncovered air vents (approximately 12 inches in diameter) which all had surrounding areas which were blackened colored, jagged, had hanging loose debris and were blowing air over the food prep area and serving areas. On 8/9/23 air was observed blowing over the food service area during the lunch meal service. On 8/9/23 at 2:09 PM Staff 6 (Dietary Manager) stated the missing vent covers were being cleaned and painted. 2. On 8/9/23 between 11:49 AM and 12:30 PM during lunch meal service observations Staff 7 (Cook) did not change her gloves or conduct hand hygiene after touching multiple surfaces in the kitchen, including the food prep areas and utensils. Staff 7 used the same gloved hand to handle rolls and sandwiches to put on plates served to residents. On 8/9/23 at 2:09 PM the observations of Staff 7 were discussed with Staff 6. No additional information was provided.

1. The air vent coverings were replaced on August 10, 2023. Staff 7 and the Dietary Manager were re-educated on safe food handling and hand hygiene on August 9, 2023. 2. All residents receiving meals have the potential to be affected by this deficient practice. 3. The Maintenance Director and all dietary staff will be re-educated on safe and sanitary environments. Vents in the kitchen will be removed and cleaned monthly at night after meal/kitchen service and will be replaced before meal/kitchen service starts the next morning. All dietary staff will be re-educated on Preventing Foodborne Illness, and Food Handling Policy and Procedure by the Administrator. 4. Administrator or designee will audit air vents for safe and sanitary environment 3x/week for 1 week, 1x/week for 4 weeks, and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations. Administrator or designee will audit food handling safety and sanitation and hand hygiene during meal preparation for 1x/day for 1 week, 1x/week for 4 weeks, and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on observation and interview it was determined the facility failed to ensure the garbage area dumpsters were covered for 1 of 1 facility garbage areas reviewed for sanitation. This placed residents at risk for exposure to pests and rodents. Findings include: Observations of the facility garbage dumpster were made on 8/7/23 and 8/9/23 through 8/11/23. The garbage dumpster was located outside of the facility kitchen. The garbage dumpster was left open despite having covers. A strong odor was noticeable from the open trash dumpster. From 8/9/23 to 8/11/23 there were multiple bags of trash inside the dumpster. On 8/9/23 at 2:09 PM the observations of the uncovered garbage dumpster were shared with Staff 6 (Dietary Manager). Staff 6 stated he was unaware the garbage dumpster was uncovered. On 8/10/23 at 10:05 AM Staff 1(Administrator) was informed of and shown the uncovered garbage dumpster. She stated she was not aware the garbage dumpster was to be covered at all times.

1. The garbage dumpster was closed on August 10, 2023 after being brought to the Administrators attention. 2. All residents have the potential to be affected by this deficient practice. 3. All staff will be re-educated by Administrator on the requirement of keeping dumpsters covered at all times and Food-Related Garbage and Refuse Disposal Policy. 4. Administrator will audit garbage area dumpsters 1x/day for 2 weeks, 1x/week for 4 weeks, and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on interview and record review it was determined the facility failed to ensure records were complete and accurate for 3 of 6 sampled residents (#s 7, 14 and 44) reviewed for medications and death. This placed residents at risk for inaccurate medical records. Findings include: 1. Resident 44 admitted to the facility on 4/20/23 with diagnoses including heart failure, chronic pulmonary disease and diabetes. A review of Resident 44's 4/20/23 admission orders revealed she/he was coded a DNR (Do Not Resuscitate) and no CPR (Cardiopulmonary Resuscitation) was to be initiated. A signed copy of Resident 44's 4/23/23 POLST (Physician Orders for Life-Sustaining Treatment) revealed she/he was a [Full Code] and to initiate CPR. A 4/25/23, 5/4/23 and 6/2/23 Late Nursing Note entry indicated Resident 44's code status: "DNAR - No CPR. Do Not Attempt Resuscitation "(allow natural death)." A 6/9/23 Nursing Noted indicated Staff 25 (LPN) "around 2200 hours found Resident 44 unresponsive with no pulse or respirations. After finding full code in resident's profile, CPR was immediately started." On 8/11/23 at 11:00 AM Staff 1 (Administrator) and Staff 21 (DNS) stated Resident 44 was a "Full Code" and CPR was initiated per Resident 44's 4/23/23 POLST which was located at the nurses station. Staff 1 and Staff 21 acknowledged Resident 44's medical records were inaccurate and staff were expected to document accurate information into each resident's medical record regarding POLST status. 2. Resident 7 admitted to the facility on 9/2022 with diagnoses including peripheral vascular disease (lack of blood flow to the extremties) and bilateral below the knee amputation. Resident 7's Annual MDS dated 7/10/23 revealed her/his BIMS score was 15 which indicated she/he was cognitively intact. A review of Resident 7's bowel records from 7/19/23 through 8/8/23 revealed Resident 7 did not have a BM (bowel movement) from 7/19/23 through 7/23/23 (five days). No evidence was found in Resident 7's medical record that bowel protocol was implemented. On 8/9/23 at 8:18 AM Staff 27 (CNA) stated Resident 7 used the bedside commode or a bed pan. Staff 27 stated Resident 7 did not struggle with constipation and had regular BMs and staff were expected to document in Resident 7's medical record when she/he had a BM. On 8/10/23 at 11:02 AM Staff 30 (CNA) and at 11:18 AM Staff 29 (CNA) stated Resident 7 was able to toilet herself/himself onto the bedside commode or used a bed pan. Staff 30 and Staff 29 stated Resident 7 had regular BMs and would report a concern if she/he was constipated. Staff 30 and Staff 29 stated they were to document BMs in Resident 7's medical record. On 8/10/23 at 1:56 PM Staff 2 (Resident Care Manager/LPN) stated Resident 7 was able to state her/his needs and would alert staff if she/he was constipated. Staff 2 stated she expected staff to document or ask Resident 7 if she/he had a BM and document the response into Resident 7's medical record. Staff 2 acknowledge Resident 7's BM records were inaccurate. , 3. Resident 14 admitted to the facility in 6/2023 with diagnoses including stroke. On 8/9/23 at 2:33 PM Resident 14 stated she/he used a bedside commode and had regular bowel movements. On 8/9/23 a review of Resident 14's bowel records revealed documentation for bowel movements were not accurately recorded on the following dates: 7/19/23 through 7/26/23 (eight days), 7/28, 7/29, 7/31/23 through 8/2/23 (three days), 8/4/23, 8/5/23 and 8/6/23 (three days). A review of Resident 14's medical record revealed no other bowel documentation was found. On 8/10/23 at 2:55 PM Staff 2 (Resident Care Manager/LPN) acknowledged bowel records for Resident 14 were inaccurate for 7/19/23 through 7/26/23; 7/28/23,7/29/23, 7/31/23 through 8/2/23, 8/4/23, 8/5/23 and 8/6/23. Staff 2 stated Resident 14 used the bathroom and required one-person assistance for toileting and CNAs were expected to document when Resident 14 had a bowel movement.

The MD was re-educated by the Medical Director on the importance of accurate documentation in resident charts on September 1, 2023. An audit was completed on August 31, 2023 to ensure listed code status matched signed POLSTs in all resident charts. All residents have the potential to be affected by this deficient practice. All CNAs will be re-educated by the Director of Nursing Services on documenting bowel movements for residents prior to September 20, 2023. The facility implemented a new bowel follow-up protocol on August 31, 2023 which includes overview of residents not having a bowel movement for 9 shifts and utilizing the Bowel Care Administration flow sheet, which includes date of residents last bowel movement, the first step in the bowel care regiment administration, and follow up communication to MD as per protocol. Medical Records Director will audit new admissions for accurate records regarding POLST status and documentation 1x/week for 4 weeks and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations. The Resident Care Manager or designee will audit resident bowel list and CNA documentation of bowel movements every morning for any residents not having a bowel movements for 9 shifts and start the Bowel Care Administration flow sheet to be provided to the LNs for completion of bowel care protocol. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on interview and record review it was determined the facility failed to have the Medical Director or designee attend the QAA (quality assessment and assurance) committee for 2 of 3 quarters reviewed for QAA. This placed residents at risk of not receiving care and services for optimal resident outcomes. Findings include: Documentation of QAA meeting minutes were requested from 1/2023 through 8/2023 and the only documentation provided was the sign in sheets from 4/2023 and 8/2023 which revealed the Medical Director attended on 4/21/23 but did not attend on 8/8/23. No other documentation was provided. On 8/11/23 at 12:01 PM Staff 1 (Administrator) and Staff 21 (DNS) stated they held monthly QAA meetings and all major department supervisors attended. Staff 1 and Staff 21 stated the Medical Director did not attend the Quarterly QAA meetings on a regular basis but was highly encouraged to attend. Staff 1 stated she could not find any documentation from 1/2023 through 3/2023 the Medical Director attended the quarterly QAA meetings.

1. A QAPI Committee meeting has been scheduled for September 26, 2023, and the Medical Director is scheduled to attend. 2. All residents have the potential to be affected by this deficient practice. 3. The Interdisciplinary Team will be re-educated by the Administrator on the Quality Assurance and Performance Improvement (QAPI) Plan Policy and the requirement of Medical Directorship presence at least quarterly. 4. Administrator or designee will audit QAPI meetings to ensure Medical Directorship presence at least quarterly 1x/month for 12 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

1.

Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens. Findings include: Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, "Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water." A review of the current Facility Assessment revealed no evidence a risk assessment had been completed and there was no information referring to a facility policy or procedure to prevent the growth and spread of water-borne pathogens in the facility's main water system. On 8/10/23 at 2:00 PM Staff 5 (Maintenance Director) and on 8/11/23 at 9:08 AM Staff 1 (Administrator) confirmed the facility did not have a prevention plan, policy or system in place for the prevention of a spread of water-borne pathogens, such as Legionella, in the facility's main water system. 2. Based on observation and interview it was determined the facility failed to follow CDC (Centers for Disease Control and Prevention) Infection Control Guidelines related to PPE usage for 1 of 2 sampled residents (#31) reviewed for infection control. This placed residents at risk for potential infection and cross contamination. Findings include: The CDC's 7/12/22 implementation of Nursing Home PPE guidelines for Infection Control included PPE was to be properly discarded before exiting a patient's room to prevent the spread of pathogens. On 8/8/23 Resident 31 was sent to the hospital and returned to the facility the same day with a diagnosis of COVID-19 infection. She/he was placed in a private room on the 100 hall which had no other residents at the time. Observations on 8/8/23 outside of Resident 31's room revealed a plastic storage bin with PPE and a small garbage bin. Signage posted on the resident's door stated the resident was on transmission based precautions. On 8/8/23 Resident 17 was temporarily moved to a private room on the 100 hall due to not getting with her/his roommate. On 8/9/23 at 12:42 PM the small garbage bin outside of Resident 31's room was observed to contain used PPE. The facility's 9/6/22 Policy and Procedure for Transmission-Based Precautions directed staff to dispose of PPE before leaving the resident's room. On 8/11/23 at 8:55 AM Staff 21 (DNS) acknowledged the small garbage bin outside of Resident 31's room should only contain plastic wrappers from the new PPE. Staff 21 stated all used PPE should be disposed of before leaving the resident's room.

A Legionella water testing was completed on August 31, 2023 on standing water found on the side of the facility. The Facility Assessment was updated on August 31, 2023 to include Sapphires Legionella Water Management Program Policy and Procedure and a Legionella water-test will be completed once the kit arrives. All nursing staff were re-educated by the Director of Nursing on August 9, 2023 on proper donning/doffing PPE requirements. All residents have the potential to be affected by this deficient practice. Maintenance Director, Director of Nursing Services, and Administrator will be re-educated by Regional Nurse Consultant prior to September 20, 2023 on Sapphires Legionella Water Management Program Policy and Procedure and the requirement of testing at least annually. The Director of Nursing Services and Administrator will be re-educated by Comagine Improvement Advisor, SQI Specialist on proper infection control guidelines for COVID-19 on September 13, 2023. Administrator will audit the facility for standing water and the testing for Legionella 1x/month for 6 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations. Director of Nursing Services will audit proper donning/doffing procedures 1x/day for 1 week, 1x/week for 4 weeks, and then 1x/month for 3 months. All audit results will be submitted to monthly QAPI Committee for review and recommendations.

Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 sampled CNAs (#s 11, 12, 13, 14 and 15) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 8/8/23 a review of the facility's staff training records revealed the following: -Staff 11 (CNA), hired 3/27/23 had no documentation they completed 12 hours of in-service training. -Staff 12 (CNA), hired 6/15/22 had no documentation they completed 12 hours of in-service training. -Staff 13 (CNA), hired 10/14/22 had no documentation they completed 12 hours of in-service training. -Staff 14 (CNA), hired 1/5/23 had no documentation they completed 12 hours of in-service training. -Staff 15 (CNA), hired 2/1/23 had no documentation they completed 12 hours of in-service training. On 8/8/23 at 9:06 AM Staff 16 (Clinical Operations Education Director) confirmed the facility was unable to provide documentation to verify any in-service trainings were completed over the last 12 months nor did they have a system to track required 12-hour minimum annual training hours.

1. Competency of nursing aides started on August 31, 2023. 2. All residents have the potential to be affected by this deficient practice. 3. The Director of Nursing Services will be re-educated by the Clinical Operations & Education Director on the requirement of annual competency of nursing aides. All newly hired nursing aides will have competency completed upon onboarding by preceptor, will be signed off, and will continue to be evaluated annually on the anniversary of hire. 4. HR/Staffing Coordinator or designee will audit bi-weekly for 8 weeks and then 1x monthly for 3 months on what staff currently need competencies to be completed and will give the Director of Nursing Services this information. Administrator will then audit 1x/month for 7 months for the completion of competency training. All audit results will be submitted to monthly QAPI Committee and the Clinical Operations & Education Director for review and recommendations.

Based on interview and record review it was determined the facility failed to complete reference checks for 4 of 5 Staff (#s 3, 9, 10 and 11) reviewed for background checks. This placed residents at risk for care provided by unqualified staff. Findings include: On 8/9/23 employee records were reviewed for Staff 3 (Social Services), Staff 9 (Dietary Aide), Staff 10 (LPN) and Staff 11 (CNA). There was no documentation reference checks were completed. On 8/9/23 at 9:15 AM Staff 4 (HR/Staffing Coordinator) stated that reference checks for Staff 3, 9, 10 and 11 were not completed during background checks.

1. Reference checks for staff # 3, 9, 10, and 11 have been completed. 2. All residents have the potential to be affected by this deficient practice. 3. The HR/Staffing Coordinator and Administrator will be re-educated by Corporate Human Resources Director or designee on the requirement of completing reference checks during the background check process. 4. Administrator or designee will audit all new hires for reference checks 1x/week for 4 weeks and then 1x/month for 2 months.

**************************** OAR 411-085-0310 Residents' Rights: Generally Refer to F553 **************************** 411-086-0040 Admission of Residents Refer to F578 **************************** OAR 411-086-0230 Residents' Rights: Charges and Rates Refer to F582 **************************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F584, F689 **************************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684, F759 **************************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F730, F947 **************************** OAR 411-086-0250 Dietary Services Refer to F804, F812, F814 **************************** OAR 411-086-0300 Clinical Records Refer to F842 **************************** OAR 411-085-0220 Quality Assurance Refer to F868 **************************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 ****************************

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 3 sampled residents (#4) reviewed for abuse. This placed residents at risk for psychosocial trauma. Findings include: Resident 4 admitted to the facility in 2022 with diagnoses including dementia. Resident 5 admitted to the facility in 2022 with diagnoses including dementia. A 11/13/22 Event Report indicated Resident 5 touched Resident 4's breasts without consent when the two residents were talking in the hallway. The incident was witnessed by Staff 10 (CNA). A facility investigation document dated 11/14/22 indicated Resident 5 acknowledged touching Resident 4's breasts. Resident 4 indicated she/he did not want to be touched by Resident 5. On 5/12/23 at 11:01 AM Resident 4 stated Resident 5 touched her/his breasts one time and she/he did not like it. Resident 4 stated she did not cry or lose sleep about it but "wanted to smack" Resident 5. On 5/12/23 at 12:21 PM Staff 12 (SS) indicated Resident 4 was monitored after the incident but had no change from baseline behaviors. On 5/16/23 at 1:30 PM Staff 10 stated she witnessed Resident 5 touch Resident 4's breasts and she separated the residents. On 5/18/23 at 3:05 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged this incident occurred.

1. Resident 4's chart has been reviewed for any s/sx of psychosocial harm or abuse allegations and updated. There are no s/sx of psychological distress or harm with this resident feels safe in the facility. Care plans will be updated for both residents 4 and 5. safety interventions put into place to monitor resident 4, staff are monitoring interactions between 2 residents, staff monitoring resident 4 and 5 when out of room. 2. All residents are at risk for possible abuse or neglect if incidents are not reported and investigated. 3. Resident number 4 has been offered mental health services. 4. Staff meetings will be concluded by 06/15/2023 to review abuse and neglect policies and procedures, including reporting guidelines. 5. The DNS or designee will complete 5 Random residents will be interviewed for possible abuse weekly times 4 weeks, then monthly x 3. Results will be taken to QAPI monthly by the DNS for root cause analysis and PIP review to sustain compliance. 6. Date of compliance is 6/16/2023.

Based on interview and record review it was determined the facility failed to thoroughly investigate an allegation of sexual abuse for 1 of 3 sampled residents (#4) reviewed for allegations of abuse. This placed residents at risk for psychosocial harm. Findings include: The facility's Abuse Prevention Policy and Procedures, updated 5/7/14, included the following: "As soon as a report of alleged or suspected abuse is received, the investigation shall begin in order to rule out or identify abuse. The investigation will include at a minimum the following steps: - Identification of the parties involved - Identification of witnesses - Interviews of all the parties involved, including the resident (if interviewable)." Resident 4 admitted to the facility in 2022 with diagnoses including dementia. Resident 6 admitted to the facility in 2022 with diagnoses including dementia. A 2/19/23 Event Report indicated Resident 4 reported to Staff 12 (Agency LN) that Resident 6 touched her/his breasts without consent. No witnesses were identified and no witness statements were included. The report indicated Resident 6 did not remember the incident, but did not include an interview with Resident 6. The investigation did not include statements from other staff members. On 5/17/23 at 3:05 PM Staff 12 stated she did not witness the incident. Staff 12 stated she thought another resident witnessed the incident, but did not recall which resident that was. During interviews on 5/16/23 and 5/17/23 Staff 2 (DNS) stated there was no additional investigative information to provide regarding this incident.

1. Resident 4's chart and care plan has been reviewed and updated. The facility will conduct investigations as able for events that occurred year ago. 2. All residents are at risk for possible abuse or neglect if incidents are not reported and investigated timely. The facility will review abuse allegations from the last year as able. Abuse questionnaires will be done on all residents to rule out abuse. 3. Resident number 4 has been offered mental health services. 4. Staff meetings will be concluded by 06/15/2023 to review abuse and neglect policies and procedures, including reporting guidelines. Staff meetings will also include education on FRI reporting and guidelines. The IDT team will be educated on the abuse investigation process and reporting requirements. 5. The DNS or designee will complete 5 Random residents will be interviewed for possible abuse weekly times 4 weeks, then monthly x 3. Results will be taken to QAPI monthly by the DNS for root cause analysis and PIP review to sustain compliance. 6. Date of compliance is 6/16/2023.

Based on interview and record review it was determined the facility failed to provide bowel medication in a timely manner for 1 of 3 sampled residents (#7) reviewed for bowel care. This placed residents at risk for medical complications from constipation including bowel impaction. Findings include: Resident 7 admitted to the facility in 2023 with diagnoses including acute pain. Resident 7's 3/2023 MAR included the use of oxycodone (narcotic pain medication). Resident 7's care plan did not include information related to the risks of using narcotic medication, including constipation. Resident 7's bowel records from 3/2023 indicated she/he had a bowel movement on 3/18/23 and did not have another bowel movement until 3/25/23 (one week later). A review of Resident 7's clinical record revealed no indication the resident was offered bowel medication until 3/24/23 (six days after the resident's last bowel movement). On 5/12/23 at 2:03 PM Staff 4 (LPN) stated Resident 7 had consistent issues with constipation. Staff 4 stated nurses were to offer bowel medication if a resident did not have a bowel movement for three days. On 5/16/23 at 1:45 PM Staff 3 (LPN Resident Care Manager) acknowledged there was no evidence to indicate Resident 7 was offered bowel medication until six days after her/his previous bowel movement. Staff 3 indicated staff were to offer bowel medication three days after a resident's previous bowel movement. Staff 3 was not able to identify a rationale for not offering bowel medication to Resident 7 and stated she expected nurses to document in the clinical record if a medication was offered and refused.

1. Resident 7 has been assessed for any s/sx of bowel blockage. Bowel medications have been reviewed and updated. 2. All residents are at risk for bowel obstruction if proper bowel management is not maintained. All residents will be audited for proper bowel management. 3. Residents bowel medications have been reviewed and updated in the system. 4. Staff meetings will be concluded by 06/15/2023 to review bowel management policies and procedures. 5. The DNS or designee will audit 5 Random residents for bowel management protocol completion weekly times 4 weeks, then monthly x 3. Results will be taken to QAPI monthly By the DNS for root cause analysis and PIP review. to ensure sustained compliance. 6. Date of compliance is 6/16/2023.

Based on interview and record review it was determined the facility failed to provide necessary respiratory care and services including maintaining a policy and procedure for emergency respiratory care and services; completing thorough respiratory assessments; maintenance of equipment and supplies for tracheostomies for 1 of 2 sampled residents (#1) reviewed for tracheostomy (a surgical opening into the windpipe to provide an airway to the lungs). This placed residents at risk for impaired breathing. Findings include: The facility's May 2023 Facility Assessment indicated the facility was able to accept residents who had tracheostomies. The facility's 2001 MED-PASS Tracheostomy Care policy revised 8/2013 did not include: 1. Emergency care including staff training and competency for implementation of emergency interventions, 2. Procedures to follow in the event of adverse reactions to respiratory treatments or interventions, 3. Respiratory assessments including who could conduct each aspect of the assessment, what was contained in an assessment, when and how it was conducted, and documented, 4. Maintenance of equipment, 5. Infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and the use of humidifiers. Resident 1 was admitted to the facility in 4/2023 with diagnoses including: Acute Respiratory Failure with Hypoxia (breathing problems with low oxygen) and a tracheostomy. Progress Notes from 4/2023 through 5/2023 indicated Resident 1 was alert and oriented and able to make her/his needs known. Resident 1 was discharged to the hospital on 5/1/23. Resident 1's Admission Orders stated: Mist to trach (tracheostomy) every shift. Titrate according to amount and consistency of secretions. Suction per resident need. On 4/29/23 at 3:26 PM Staff 6 (RN) noted in Resident 1's Progress Note the inner cannula was changed to one the facility had on-hand, but the new cannula was missing a cap (plug for the trach used so residents can talk and breathe through their nose/mouth instead of through the opening in their neck). On 4/29/23 at 7:01 PM Staff 7 (LPN) noted in the Progress Notes Resident 1 had shortness of breath and difficulty breathing following suctioning which was due to the lack of a cap for the cannula. The physician was notified and supplemental oxygen was ordered. On 4/30/23 at 5:53 AM, a Progress Note by Staff 13 (LPN) indicated a trach cap was obtained at the beginning of night shift. Attempts to contact Staff 13 from 5/15/23 through 5/17/23 were unsuccessful. On 5/15/23 at 9:36 AM Staff 5 (LPN) stated when she cared for Resident 1, the suction machine in Resident 1's room did not work. Staff 3 (LPN Resident Care Manager) was notified and found a different suction machine. On 5/15/23 at 9:51 AM Staff 7 (LPN) stated she worked with Resident 1 and changed the inner cannula to the tracheostomy. She stated it was problematic replacing the new inner cannula because the original cannula had a cap and the replacement did not have a cap. She stated the facility did not have the correct size cannula. She stated she told Staff 2 (DNS) about the lack of a cannula cap and one was obtained later from another facility. In an interview on 5/15/23 at 10:15 AM Staff 6 (RN) stated she could not recall if she auscultated (listened with stethoscope) Resident 1's lungs. A review of Resident 1's Treatment Records from 4/2023 through 5/2023 did not reveal an assessment of the resident's respiratory status before and after suctioning. Resident 1's Treatment Records from 4/2023 through 5/2023 indicated Staff 13 (LPN) did not document Resident 1's respiratory status. On 5/12/23 at 2:02 PM Staff 2 (DNS) stated the facility should have had trach supplies ready for Resident 1. Staff 2 stated she expected the nurses to have a base knowledge of tracheostomy care, including what to assess and document, which was taught in nursing school.

1. Resident 1 is no longer in the facility. 2. All residents with tracheostomies are at risk for respiratory distress if not managed correctly. 3. Currently there are no other residents with a tracheostomy in the facility. 4. The tracheostomy policies and procedures will be revised and updated to reflect required standards of care. 5. Staff meetings will be concluded by 06/15/2023 to review the revised trach policies and procedures. 6. The DNS or designee will audit 2 Random staff for proper trach care and or suctioning protocols weekly times 4 weeks, then monthly x 3. Results will be taken to QAPI by the DNS monthly for root cause analysis and PIP review to ensure sustained compliance. 7. Date of compliance is 6/16/2023.

Based on interview and record review it was determined the facility failed to ensure nursing staff had appropriate competencies and skill sets related to tracheostomy care for 1 of 2 sampled residents (#1) reviewed for tracheostomy (a surgical opening into the windpipe to provide an airway to the lungs). This placed residents at risk for complications of a tracheostomy. Findings include: The facility's May 2023 Facility Assessment indicated the facility was able to accept residents with tracheostomies. The facility's training records indicated four day shift nurses were verbally educated on tracheostomy care between 2/2023 and 4/2023. No other competency documentation was provided. Resident 1 was admitted to the facility 4/2023 with diagnoses including: Acute Respiratory Failure with Hypoxia (breathing problems with low oxygen) and a tracheostomy. Progress Notes from 4/2023 through 5/2023 indicated Resident 1 was alert and oriented and able to make her/his needs known. On 5/12/23 at 11:57 AM Staff 4 (LPN) stated he was uncomfortable taking care of Resident 1 and requested additional training on tracheostomy care when he was assigned to work with Resident 1. Staff 4 stated he requested Staff 3 (LPN Resident Care Manager) accompany him and walk him through suctioning of the tracheostomy. On 5/12/23 at 12:19 PM Staff 3 stated some of the nurses had tracheostomy experience in the past, but nothing recent. She stated some of the RNs could take care of a resident with a tracheostomy. She stated the dayshift nurses were more experienced, she was not sure about the expertise of night shift nurses. On 5/12/23 at 2:02 PM Staff 2 (DNS) stated some of the nurses mentioned they did not feel confident in their skills for tracheostomy care and wanted a refresher course when Resident 1 was admitted. Staff 3 and Staff 2 in-serviced two nurses who were working on the day Resident 1 was admitted. On 5/15/23 at 9:39 AM Staff 5 (LPN) stated she was called in to attend a training on trach care because the facility admitted a resident with a tracheostomy. Staff 5 stated after the in-service she requested additional training because she had not taken care of a resident with a tracheostomy. On 5/12/23 at 2:02 PM Staff 2 (DNS) stated she expected the nurses to have a base knowledge of tracheostomy care, including what to assess and document, which was taught in nursing school. Staff 2 was unable to produce tracheostomy competency records for the nurses. See F695.

1. Resident 1 is no longer in the facility. 2. All residents with tracheostomies are at risk for respiratory distress if staff are not trained per standard of care. 3. Currently there are no other residents with a tracheostomy in the facility. 4. The tracheostomy policies and procedures will be revised and updated to reflect required standards of care. 5. Staff meetings will be concluded by 06/15/2023 to review the revised trach policies and procedures. 6. All nurses will be educated on the new trach policies and procedures. Competencies will be reviewed and return demonstration will be required. Competencies will be added to employee files. 7. The DNS or designee will audit 2 Random staff for proper trach care and or suctioning protocols weekly times 4 weeks, then monthly x 3. Results will be taken to QAPI by the dns monthly for root cause analysis and PIP review to ensure sustained compliance. 8. Date of compliance is 6/16/2023.

OAR 411-085-0360 Abuse

Refer to F600 and F610 ******************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 and F695 ********************* OAR 411-086-0100 Nursing Services: Staffing Refer to F726 *********************

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 12/26/2022 and 01/01/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to ensure a resident had the right to refuse medications for 1 of 3 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk of not having the right to refuse. Findings include: Resident 2 was admitted to the facility in 2022 with diagnoses including stroke. Resident 2's 6/2022 MAR included the order "Ok to disguise medications in food due to medication refusals." On 6/10/22 at 10:52 AM Staff 2 (DNS) stated the order did not allow Resident 2 the right to refuse. Staff 2 stated she would discontinue the order immediately.

Immediate: Order stating ok to disguise medication in food due to medication refusals discontinued immediately for resident #2. Others: Reviewed all other orders to ensure no other resident had an order similar in nature. Systematic: LNs educated on the residents right to be informed and participate in planning/implementation of their care. DNS/Designee to complete new admission audit next working day to ensure appropriateness of orders. Monitor: NHA/Designee to interview 20% of population monthly to ensure residents feel they are informed and participate in planning/implementation of their care. Findings of interviews and admit audits reported at monthly QAPI.

Based on interview and record review it was determined the facility failed to obtain copies of advance directives for 2 of 4 sampled residents (#s 105 and 156) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 105 was admitted to the facility in 5/2022 with diagnoses including chronic kidney disease, heart failure, atrial fibrillation and stroke. The 5/20/22 Admission Agreement indicated Resident 105 completed an advance directive. There was no advance directive located in Resident 105's medical record. On 6/9/22 at 1:20 PM Staff 1 (Administrator) confirmed there was no advance directive in Resident 105's medical record and the family had not been contacted to provide a copy. , 2. Resident 156 admitted to the facility in 5/2022 with diagnoses including a stroke. On 6/8/22 at 3:13 PM the resident stated she/he completed an advance directive while in the hospital and it was sent to the current facility with the rest of her/his paperwork. No advance directive was found in the facility's electronic health record for Resident 156. On 6/9/22 at 1:20 PM Staff 1 (Administrator) verified there was no advanced directive in the resident's medical record.

Immediate: Resident 105 was offered to complete an Advanced Directive. Resident 156 no longer in facility. Others: Ensure all other residents were offered and competed an advanced directive based on resident choice to complete. Systematic: Social services to be educated on importance of reviewing advanced directive with resident upon admission. All residents to be asked regarding advanced directive status on admit and offered to complete one if they wish. Monitor: Medical Records/Designee to audit new admits monthly for advanced directive education and completion as resident desires. Findings reported at monthly QAPI.

Based on interview and record review it was determined the facility failed to provide a written summary of the baseline care plan for 2 of 2 sampled residents (#s 106 and 107) reviewed for new admissions. This placed residents at risk of being uninformed of their plan of care. Findings include: 1. Resident 106 was admitted to the facility in 5/2022 with diagnosis including multiple sclerosis and urinary tract infection. The 5/21/22 Admission MDS revealed Resident 106 had intact cognition. On 6/14/22 at 1:50 PM Resident 106 was shown her/his baseline care plan and stated she/he did not recall reviewing her/his baseline care plan and did not receive a copy of it. On 6/14/22 at 1:17 PM Staff 2 (Interim DNS) and Staff 19 (RNCM) stated the facility had no formal process to review the baseline care plan or to provide copies of the baseline care plan to residents or their representatives. 2. Resident 107 was admitted to the facility in 5/2022 with diagnoses including diabetes, heart failure and chronic kidney disease. The 5/27/22 Admission MDS revealed Resident 107 had intact cognition. On 6/14/22 at 1:51 PM Resident 107 was shown her/his baseline care plan and stated she/he never saw the baseline care plan before and did not receive a copy of it. On 6/14/22 at 1:17 PM Staff 2 and Staff 19 stated the facility had no formal process to review the baseline care plan or to provide copies of the baseline care plan to residents or their representatives.

Immediate: Residents 106 no longer in facility, resident 107 is outside of baseline care plan timeframe. Others: All other residents outside of baseline care plan timeframe. Systematic: IDT Team educated on the importance/need for baseline care plan and need for resident or resident representative, as well as new baseline care plan tool that will replace the previous insufficient version. LNs to be education on importance of initiating baseline care plan on admission and of new tool. DNS/Designee to review all new admission baseline care plans as well as review of the care plan with resident or resident representative next working day. Copy to be provided. Monitor: DNS/Designee to audit 20% of baseline care plans to ensure completion/review and signature of resident or resident representative. Findings reported at monthly QAPI.

Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 3 of 7 sampled residents (#s 105, 107 and 156) reviewed for activities and unnecessary medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 105 was admitted to the facility in 5/2022 with diagnoses including chronic kidney disease, heart failure, atrial fibrillation and stroke. Resident 105's 5/27/22 Admission MDS-Section F: Preferences for Customary Routine and Activities identified her/his most important activities were to listen to music, keep up with the news, do things in groups of people, do their favorite activities, go outside to get fresh air when the weather was good and to participate in religious services or practices. Resident 105's current activity care plan included the following interventions: facility RA/CNA will walk with the resident in the mornings and the social service director or activity director will walk with Resident 105 in the afternoons. Resident 105's care plan did not include activities identified in her/his Admission MDS. In an interview on 6/14/22 at 2:27 PM Staff 2 (Interim DNS) reviewed Resident 105's activity care plan and stated Resident 105 did not walk, she would expect the care plan to reflect the resident's interests and the care plan should have included the identifed activities from the MDS. 2. Resident 107 was admitted to the facility in 5/2022 with diagnoses including heart failure, diabetes and bipolar disorder. Resident 107's 5/27/22 Admission MDS-Section F: Preferences for Customary Routine and Activities identified her/his most important activities were to listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do their favorite activities and go outside to get fresh air when the weather is good. Resident 107's 6/2/22 Activity Assessment identified the resident's activity preferences as crafts, music, walking/wheeling outdoors, watching TV, talking or conversing, cooking, dining out, movies, needlework, painting, quilting and radio. Resident 107's 6/9/22 current activity care plan directed staff to provide the resident with coloring pages/books and colored pencils and encourage the resident to request in-room activities they enjoy. Resident 107's care plan did not include other activities identified in her/his Admission MDS or Activity Assessment. In an interview on 6/14/22 at 2:27 PM Staff 2 reviewed Resident 107's activity care plan and stated preferences identifed on the resident's Admission MDS and Activity Assessment were not included on the care plan and she expected the care plan to be personalized and include those preferences. , 3. Resident 156 was admitted in 5/2022 with diagnoses including stroke. A review of the resident's medical record on 6/14/22 revealed no comprehenensive care plan was developed. On 6/16/22 at 10:54 AM Staff 2 (Interim DNS) confirmed the care plan was not developed in the appropriate amount of time.

Immediate: Resident 105s and 107s activity care plan updated to reflect resident preferences. Resident 156 no longer in facility. Others: Remaining residents audited to ensure comprehensive care plans updated. Systematic: IDT team trained on the importance of comprehensive care plans. DNS/Designee to audit comprehensive care plans following completion of comprehensive MDS. Monitor: DNS/Designee to audit 20% of care plans monthly to ensure comprehensiveness. Findings reported at monthly QAPI.

Based on observation, interview, and record review it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and needs for residents for 2 of 2 sampled residents (#s 105 and 107) reviewed for activities. This placed residents at risk for a lack of psychosocial well-being. Findings include: The facility's Group Programs and Activities Calendar policy, last revised 6/2018, indicated large and small group activities were available in the facility and an activities calendar was completed and maintained in a high-visibility, high traffic area to inform residents, families and staff of the activity opportunities available. 1. Resident 105 was admitted to the facility in 5/2022 with diagnoses including chronic kidney disease, heart failure, atrial fibrillation and stroke. Random observations from 6/8/22 through 6/15/22 between the hours of 8:00 AM and 4:00 PM revealed Resident 105 was in bed with the room dark; occasionally the TV was on. No other activities were observed. The activity calendar in the main hallway was blank with the exception of "payday" and "Father's Day" listed. Resident 105's 5/27/22 Admission MDS-Section F: Preferences for Customary Routine and Activities identified her/his most important activities were to listen to music, keep up with the news, do things in groups of people, do their favorite activities, go outside to get fresh air when the weather was good and to participate in religious services or practices. On 6/9/22 at 2:32 PM and 6/14/22 at 8:36 AM Staff 20 (Activities/Social Services Director) stated she was recently hired as the Activities Director and there was currently no functioning activity program. Staff 20 stated she had no process in place to set up activities and there was no interim activity staff to conduct the program or assist her while she was being trained. On 6/10/22 at 11:07 AM, 11:51 AM and 6/13/22 at 10:59 AM Staff 11 (CNA), Staff 15 (CNA) and Staff 5 (CNA) reported the facility did not currently have an activities program. On 6/14/22 at 11:45 AM Staff 1 (Adminstrator) reported the facility did not have an activities program and Staff 20 would be trained as the activity director once payment was made for the activity training course. 2. Resident 107 was admitted to the facility in 5/2022 with diagnoses including heart failure, diabetes and bipolar disorder. Resident 107's 5/27/22 Admission MDS-Section F: Preferences for Customary Routine and Activities identified her/his most important activities were to listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do their favorite activities and go outside to get fresh air when the weather is good. Resident 107's 6/2/22 Activity Assessment identified the resident's activity preferences as crafts, music, walking/wheeling outdoors, watching TV, talking or conversing, cooking, dining out, movies, needlework, painting, quilting and radio. Random observations from 6/8/22 through 6/15/22 between the hours of 8:00 AM and 4:00 PM revealed Resident 107 was in her/his room, at times coloring pages from a coloring book and occasionally watching TV. No other activities were observed. The activity calendar in the main hallway was blank with the exception of "payday" and "Father's Day" listed. On 6/8/22 at 11:28 AM, 6/13/22 at 8:52 AM, 6/14/22 at 10:48 AM and 6/15/22 at 8:20 AM Resident 107 reported that no activities occurred in the facility during the week or on the weekends. Resident 107 stated she/he was given coloring pages and colored pencils, had colored many pages, was tired of coloring and wanted to do something different. Resident 107 stated a few weeks ago she/he was given a stack of old magazines which she/he read at least twice and had no further interest in reading them again. Resident 107 stated she/he loved crafts and bingo and asked to have a visit with her/his dog but that did not happened. Resident 107 reported she/he just sat in her/his room all day and stated "they just dump you off and leave you here". On 6/9/22 at 2:32 PM and 6/14/22 at 8:36 AM Staff 20 (Activities/Social Services Director) stated she was recently hired as the Activities Director and there was currently no functioning activity program. Staff 20 stated she had no process in place to set up activities and there was no interim activity staff to conduct the program or assist her while she was being trained. On 6/10/22 at 11:07 AM, 11:51 AM and 6/13/22 at 10:59 AM Staff 11 (CNA), Staff 15 (CNA) and Staff 5 (CNA) reported the facility did not currently have an activities program. On 6/14/22 at 11:45 AM Staff 1 (Adminstrator) reported the facility did not have an activities program and Staff 20 would be trained as the activity director once payment was made for the activity training course.

Immediate: Resident 105 & 107 activities preferences initiated. Others: All residents are at risk of being affected by alleged deficient practice. Systematic: OHCA activities course competed by Activities Director. Activities program initiated based on resident preferences. NHA to complete visual observations weekly of activities as they occur. Monitor: NHA to review activity program participation logs monthly for resident participation. Findings reported at monthly QAPI.

Based on interview and record review it was determined the facility failed to follow physician's orders for medication administration for 4 of 5 sampled residents (#s 2, 107, 156 and 157) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: 1.Resident 2 was admitted to the facility in 2022 with diagnoses including constipation. Resident 2's Physician Order Report signed my the physician on 5/2/22 revealed orders for the following PRN bowel care medications: - Milk of Magnesia, to be administered if the resident did not have a bowel movement for three days. - Senna, to be administered first on day three with no bowel movement. Resident 2's 5/10/22 through 6/10/22 bowel record revealed the following date ranges when the resident did not have a bowel movement: - 5/18/22 through 5/20/22. - 6/3/22 through 6/5/22. Resident 2's 5/2022 and 6/2022 MARs revealed the ordered Milk of Magnesia and senna were not administered when the resident did not have a bowel movement for three days. , 2. Resident 107 was admitted to the facility in 5/2022 with diagnoses including heart failure, diabetes and bipolar disorder. a. A 5/20/22 physician's order indicated Resident 107 was prescribed insulin aspart U-100 units solution; subcutaneously at meals; 100 unit/ML per sliding scale as follows: -If blood sugar is 141 to 180, give 1 unit. -If blood sugar is 181 to 220, give 2 units. -If blood sugar is 221 to 260, give 2 units. -If blood sugar is 261 to 300, give 3 units. -If blood sugar is 301 to 340, give 3 units. -If blood sugar is 341 to 380, give 4 units. -If blood sugar is 381 to 420, give 4 units. -If blood sugar is greater than 420, give 5 units. -If blood sugar is greater than 420, call MD. A review of Resident 107's 5/2022 and 6/2022 MARs revealed Resident 107 was not administered insulin aspart U-100 at breakfast (8:00 AM) on 5/23/22 and 5/26/22. A 5/23/22 comment note on Resident 107's MAR indicated Resident 107's blood sugar was not checked prior to breakfast and a 5/26/22 comment note indicated the resident's insulin was not administered due to Resident 107's blood sugar being 175. On 6/13/22 at 3:15 PM Staff 19 (RNCM) reviewed Resident 107's 5/23/22 and 5/26/22 insulin MAR and progress notes and stated the resident was not administered insulin as prescribed by the physician. b. A 5/20/22 physician's order indicated Resident 107 was prescribed ferrous gluconate 324 mg, once a day. A review of Resident 107's 5/2022 and 6/2022 MARs revealed Resident 107 received ferrous gluconate, 324 mg, twice on 6/3/22. On 6/13/22 at 3:15 PM Staff 19 (RNCM) reviewed Resident 107's 6/3/22 ferrous gluconate MAR and stated the resident incorrectly received two doses of ferrous gluconate 6/3/22. On 6/14/22 at 2:42 PM Staff 2 (Interim DNS) was provided with the findings of this investigation and acknowledged the medications were not administered according to physician's orders. , 3. Resident 156 was admitted in 5/2022 with diagnoses including stroke. a. The 6/2022 MAR indicated an order for metformin to be administered twice daily to address the symptoms associated with diabetic polyneuropathy. The MAR indicated the morning dose on 6/2/22 was not administered due to "other." No additional information was located in the resident's clinical record to indicate a rationale for not providing the medication. On 6/16/22 at 10:54 AM Staff 2 (Interim DNS) confirmed the medication should have been administered. b. The 6/2022 MAR indicated Resident 156 had an order for pantoprazole to be administered twice daily before meals to address GI distress. The MAR indicated the morning dose on 6/2/22 was not administered due to "other." No additional information was located in the resident's clinical record to indicate a rationale for not providing the medication. On 6/16/22 at 10:54 AM Staff 2 (Interim DNS) confirmed the medication should have been administered. She reported there should be documentation from the nurse clarifying the reason the dose was not administered. 4. Resident 157 was admitted to the facility in 5/2022 with diagnoses including diabetes. The 6/2022 MAR indicated Resident 157 had an order for omeprazole to be administered once each day. The MAR indicated she/he received one dose in the morning and one dose in the evening on 6/3/22. On 6/15/22 at 3:39 PM Staff 19 (RNCM) confirmed the medication error and reported the order was revised after the morning dose on 6/3/22 to allow for evening administration of the medication. She reported when an order was updated, the previous administration on that day was no longer visible to the administering nurse.

Immediate: Residents 2 and 107 had a medication error form completed, and notifications made to representative/MD as warranted. Resident 156, and 157 no longer in facility. Others: All residents are at risk of being affected by alleged deficient practice. All additional residents in house had MARs reviewed for last 7 days to ensure physicians orders for medication administration was followed. Corrections as needed. Systematic: LNs to be trained on requirement that physicians orders for medication administration be followed. Omnicare medication administration guide to be used for education and competencies. DNS/Designee to review MAR/TAR weekly to ensure physicians orders for medication administration are followed, corrections as needed. Medication pass observation completed on each nurse monthly to ensure on-going competency. Monitor: DNS/Designee to report findings of MAR/TAR audits and medication pass observations at monthly QAPI.

Based on interview and record review, it was determined the facility failed to ensure nursing staff received and demonstrated the appropriate competencies and skills to provide nursing services to assure resident safety and maintain highest practicable physical, mental, and psychosocial well-being of each resident for 13 of 13 staff (#s 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: The facility's Competency of Nursing Staff policy, last revised 5/2019, indicated the following: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by the State law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency based development and training program: and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care. On 6/13/22 at 12:15 PM, nursing staff training requirements were reviewed to ensure licensed nursing staff had the specific competencies and skills sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care and nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through resident assessments and described in the plan of care. On 6/10/22 at 12:58 PM Staff 1 (Administrator) reported when new staff were hired, they completed a packet of orientation materials and then were assigned to the floor with an experienced nursing staff member until they were sure the staff member was capable of performing all tasks. Staff 1 reported the experienced staff member provided him with feedback and, based on the feedback, it was determined if the newly hired staff member was competent to perform their job duties. Staff 1 reported they did not utilize any type of formal competency measures or checklists. Staff 1 stated he was not aware of any routine competencies being completed with current staff. On 6/10/22 at 11:03 AM, 6/13/22 at 8:30 AM and 6/13/22 at 10:49 AM Staff 11 (CNA), Staff 6 (RN) and Staff 5 (CNA) reported they did not remember being assessed for competencies to perform their job duties. On 6/13/22 at 12:15 PM Staff 1 and Staff 2 (Interim DNS) were asked to provide documentation of all licensed nursing staff including documentation indicating all staff were able to exhibit competencies required for their job duties. On 6/13/22 at 1:27 PM Staff 1 stated they were unable to provide any documentation indicating nursing staff displayed specific competencies, skill sets and techniques necessary to care for residents. Refer to F759 and F880.

Immediate: Facility has initiated a competency program designed to meet the needs of current residents. Others: All residents are at risk of being affected by alleged deficient practice. Systematic: DNS/NHA/designee to implement a competency plan for all nursing staff to ensure all staff are competent and have the training required to provide correct care to the residents. Competencies shall be completed on hire, as well as annually. Competencies shall also be done based on facility/resident needs. Monitor: DNS/HR/Designee to audit new hires for completion of competencies as well as tracking on annual competencies monthly. Findings reported at monthly QAPI.

Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) and failed to complete nurse aide training performance reviews every 12 months and provide regular in-service training based on the outcome of these reviews for 10 of 10 CNAs (#s 5, 7, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of the facility's staff training records for CNAs employed over one year revealed the following: -Staff 5 (CNA), hired 1/7/21, had no performance review and no documentation they completed 12 hours of in-service training. -Staff 7 (CNA), hired 11/1/20, had no performance review and no documentation they completed 12 hours of in-service training. -Staff 9 (CNA), hired 12/2/20, had no performance review and no documentation they completed 12 hours of in-service training. -Staff 10 (CNA), hired 8/17/20, had no performance review and no documentation they completed 12 hours of in-service training. -Staff 11 (CNA), hired 7/11/17, had no performance review and no documentation they completed 12 hours of in-service training. -Staff 12 (CNA), hired 5/8/12, had no performance review and no documentation they completed 12 hours of in-service training -Staff 13 (CNA), hired 10/14/09, had no performance review and no documentation they completed 12 hours of in-service training. -Staff 14 (CNA), hired 6/7/12, had no performance review and no documentation they completed 12 hours of in-service training. -Staff 15 (CNA), hired 1/16/21, had no performance review and no documentation they completed 12 hours of in-service training. -Staff 16 (CNA), hired 9/4/20, had no performance review and no documentation they completed 12 hours of in-service training. On 6/13/22 at 1:27 PM, Staff 1 (Administrator) acknowledged the facility did not have a system in place to track nurse aide in-service training hours and did not complete annual performance reviews.

Immediate: Facility has initiated a performance review program designed to meet the needs of current residents. Others: All residents are at risk of being affected by alleged deficient practice. Systematic: Nurse aides to be trained on requirement of 12 in-services hours annually minimum. DNS to implement an annual performance review program as well as implementation of a system to track the 12 required in-service hours for nurse aides. Monitor: HR/Designee to audit tracking on nurse aide in-service hours as well as annual reviews quarterly. Findings reported at monthly QAPI.

Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 3 of 7 residents (#s 106, 107 and 156) reviewed for medication administration. The facility's medication administration error rate was 35%. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 106 was admitted to the facility in 2022 with diagnoses including stroke. Resident 106's current physician's orders included the following medications that were ordered to be administered between 6:00 AM and 10:00 AM: - aspirin (pain reliever and blood thinner) - vitamin D3 (supplement) - fludrocortisone (steroid) - levetiracetam (anticonvulsant) - magnesium oxide (supplement) - polyethylene glycol (stool softener) Resident 106's current physician's orders included the medication Eliquis (anticoagulant) that was ordered to be administered at 8:00 AM. On 6/13/22 at 12:01 PM Staff 6 (RN) was observed to administer Resident 106's aspirin, vitamin D3, fludrocortisone, levetiracetam, magnesium oxide, polyethylene glycol and Eliquis. On 6/13/22 at 1:39 PM Staff 2 (DNS) stated medications should be administered within 1 hour of their ordered administration times. 2. Resident 107 was admitted to the facility in 2022 with diagnoses including diabetes. Resident 107's current physician's orders included insulin aspart 10 units (injectable medication for treating high blood sugar). On 6/14/22 at 11:42 AM Staff 17 (Agency RN) administered insulin aspart to Resident 107 using an insulin pen. Staff 17 did not prime the pen first to remove air from the needle. Staff 17 confirmed she did not prime the pen and stated she did not prime the pen because she did not see any air in it. The Surveyor suggested Staff 17 check the insulin pen manufacturers instructions, which she did not do. On 6/14/22 at 12:15 PM Staff 19 (RNCM) confirmed the correct procedure was to prime the insulin pen prior to administering the insulin. 3. Resident 156 was admitted to the facility in 2022 with diagnoses including diabetes. Resident 156's current physician's orders included insulin aspart per sliding scale (injectable medication for treating high blood sugar). On 6/14/22 at 11:52 AM Staff 17 (Agency RN) administered insulin aspart to Resident 156 using an insulin pen. Staff 17 did not prime the pen first to remove air from the needle. Staff 17 confirmed she did not prime the pen and stated she did not prime the pen because she did not see any air in it. The Surveyor again suggested Staff 17 check the insulin pen manufacturers instructions, which she did not do. On 6/14/22 at 12:15 PM Staff 19 (RNCM) confirmed the correct procedure was to prime the insulin pen prior to administering the insulin.

Immediate: Resident 106/156 no longer in facility. Education provided to LNs regarding resident 107s insulin and need to prime insulin pen per manufacturer's instructions. Others: All residents are at risk of being affected by alleged deficient practice. Systematic: LNs to be educated on proper medication pass requirements. Omnicare medication administration guide to be used for education and competencies. DNS/designee to complete medication pass observation monthly with each nurse to ensure med pass is free of med errors. Monitor: DNS/Designee to report findings of medication pass observations at monthly QAPI

Based on observation, interview and record review it was determined the facility failed to properly disinfect a glucometer between resident uses for 1 of 2 sampled residents (#107) reviewed for CBG monitoring. This failure, which was determined to be immediate jeopardy, placed Residents 156, 2, 104 and 155 at risk for viral hepatitis C infection. Findings include: On 6/10/22 at 12:38 PM Staff 3 (RN) used a glucometer (a device used to check CBG levels from a blood sample) from the treatment cart to check Resident 107's CBG. Staff 3 then wiped the front of the glucometer with an alcohol wipe and placed the glucometer in the front center of the top drawer of the treatment cart. On 6/10/22 at 1:00 PM Staff 3 removed the same glucometer from the treatment cart and prepared to enter Resident 156's room to check the resident's CBG. The Surveyor stopped Staff 3 from entering the room and asked her what the facility's policy and procedure was for disinfecting glucometers. Staff 3 stated she did not know. At the Surveyors request, Staff 3 then asked Staff 2 (DNS) what the correct procedure was for disinfecting glucometers between use. Staff 2 stated there were disinfectant wipes on the treatment cart for disinfecting the glucometers. The surveyor, Staff 2 and Staff 3 returned to the cart and verified the disinfectant wipes were available on the treatment cart. Staff 2 was asked to provide a list of residents who have CBGs checked and if any of them had a bloodborne infection. Staff 2 was requested by the Surveyor to cease all resident CBG checks at this time. Staff 2 immediately removed all seven used glucometers from the two treatment carts for disposal. Staff 2 then brought six brand new unused glucometers from storage for individual resident use. Staff 2 stated the glucometers would be labeled for each resident and stored in separate bags. On 6/10/22 at 1:45 PM The facility provided a list of all residents in the facility who had their CBG's checked. The list indicated Resident 107 had viral hepatitis C. On 6/10/22 at 2:39 PM Staff 1 (Administrator) was notified of the immediate jeopardy situation and was provided with a copy of the immediate jeopardy template. An immediate plan of correction was requested. On 6/10/22 at 4:03 PM Staff 1 and Staff 2 (DNS) provided a copy of the glucometer manufacturers disinfection instructions, demonstrated the manufacturers recommended disinfection cleaning wipes were available in the facility and the wipes were labeled with the correct contact time. Staff 2 provided copies of licensed nurse in-servicing materials related to glucometer disinfecting and a roster which indicted licensed nurse staff currently in the facility competed the education. On 6/10/22 at 4:11 PM Staff 1 submitted an acceptable plan of correction which included the following: Immediate: - All CBG's stopped, nurses in the building trained on policy and proper protocol as well as demonstrating competency, as well as education on the correct germicidal product to be used for cleaning the CBG machine, along with dwell times. - All open CBG machines have been pulled and discarded. New individualized CBG machines have been assigned to each resident and labeled with their name and placed in individualized bag. - RNCM has assumed charge roll of the floor and is educating RN while working side by side. - Documentation to be provided showing the germicidal product meets manufacturer's requirements for disinfection of CBG machine. Ongoing: - Resident physicians notified and obtained orders for bloodborne pathogen testing. - Blood draws ordered for residents who received CBG testing. - All remaining nurses to be trained before next working shift on proper protocol on CBG process, as well as education on the correct germicidal product to be used for cleaning the CBG machine, along with dwell times. Systemic Changes: - Germicidal product to be clearly labeled with dwell time. - DNS/RNCM or designee will perform CBG competencies all current licensed nurses employed and will conduct CBG competency for all new hires prior to end of orientation period. Monitoring: - DNS/RNCM or designee, to complete random weekly checks on 50% of residents receiving CBG testing to ensure compliance with correct CBG administration as well as monitoring of technique and ensuring correct cleaning protocols are being followed, corrections as needed. - DNS/RNCM or designee to report findings at Monthly QAPI. On 6/10/22 at 4:17 PM Staff 1 was notified the immediacy was removed and resident CBG testing could resume. ,

Immediate: All CBGs stopped, nurses in the building trained on policy and proper protocol as well as demonstrating competency, as well as education on the correct germicidal product to be used for cleaning the CBG machine, along with dwell times. All open CBG machines have been pulled and discarded. New individualized CBG machines have been assigned to each resident and labeled with their name and placed in individualized bag. RCM has assumed charge roll of the floor and is educating RN while working side by side. Documentation to be provided showing the germicidal product meets manufacturer's requirements for disinfection of CBG machine. Ongoing: Resident physicians notified and obtained orders for blood bourn pathogen testing. Blood draws ordered for residents who received CBG testing. All remaining nurses to be trained before next working shift on proper protocol on CBG process, as well as education on the correct germicidal product to be used for cleaning the CBG machine, along with dwell times. Systemic Changes: Germicidal product to be clearly labeled with dwell time. DNS/RCM or designee will perform CBG competencies all current licensed nurses employed and will conduct CBG competency for all new hires prior to end of orientation period. Monitoring: DNS/RCM or designee, to complete random weekly checks on 50% of residents receiving CBG testing to ensure compliance with correct CBG administration as well as monitoring of technique and ensuring correct cleaning protocols are being followed, corrections as needed. DNS/RCM or designee to report findings at Monthly QAPI.

Based on interview and record review it was determined the facility failed to provide education regarding the benefits and potential side effects associated with receiving the pneumococcal vaccination for 3 of 5 sampled residents (#s 3, 155 and 156) reviewed for vaccinations. This placed residents at risk of not being aware of healthcare options. Findings include: 1. Resident 3 was admitted in 5/2022 with diagnoses including one-sided weakness. There was no documentation of her/him receiving information from the facility regarding the benefits and potential side effects related to the pneumococcal vaccine or if the resident had received the pneumococcal vaccine. On 6/14/22 at 12:16 PM Staff 2 (Interim DNS) stated she was unaware of Resident 3's pneumococcal vaccination status and had not discussed this with the resident. 2. Resident 155 was admitted in 6/2022 with diagnoses including chronic kidney disease. There was no documentation of the facility staff offering her/him the pneumococcal vaccines or providing information related to their benefits and potential side effects. On 6/14/22 at 10:27 AM Resident 155 stated she/he "just got over pneumonia" and the facility staff did not discuss the vaccine with her/him. On 6/14/22 at 12:19 PM, Staff 2 (Interim DNS) confirmed she had not discussed or offered the pneumococcal vaccine with Resident 155. 3. Resident 156 admitted to the facility in 5/2022 with diagnoses including a stroke. The resident stated the facility staff had not asked if she/he had received the pneumococcal vaccine previously and had not provided information regarding the pneumococcal vaccine, its benefits, or potential side effects with her/him. There was no documentation in the resident's medical record of the resident receiving the pneumococcal vaccine or education related to the benefits or potential side effects. On 6/14/22 at 12:19 PM, Staff 2 (Interim DNS) stated she had not discussed or offered the pneumococcal vaccine with Resident 156.

Immediate: Resident 3 offered pneumococcal vaccine, discussing its benefits or potential side effects with him/her. Resident 155, and 156 no longer in facility. Others: All remaining residents in facility audited for pneumococcal vaccination. Those who have not received the vaccine were offered pneumococcal vaccine, discussing its benefits and/or potential side effects with him/her. Systematic: All new admissions to be reviewed for pneumococcal vaccination, when medically indicated offer the vaccine within 30 days of admission. DNS/Designee to complete audit of all new admits weekly determining need for pneumococcal vaccine. Monitor: Medical Records/Designee to audit monthly for new admission pneumococcal vaccinations. Findings reported at monthly QAPI.

Based on interview and record review it was determined the facility failed to provide education regarding the benefits, risks, and potential side effects associated, and failed to provide the opportunity to accept or decline COVID-19 vaccinations for 2 of 5 sampled residents (#s 3 and 157) reviewed for vaccinations. This placed residents at risk for making uninformed healthcare decisions. Findings include: 1. Resident 3 was admitted in 5/2022. There was no documentation of her/him receiving information from the facility regarding the benefits and potential side effects related to the COVID-19 vaccine. On 6/15/22 at 1:07 PM Staff 2 (Interim DNS) confirmed she did not yet offer the COVID-19 vaccine to the resident or provide her/him with education related to the risks, benefits, and potential side effects associated with receiving the vaccine. 2. Resident 157 was admitted in 5/2022 with diagnoses including diabetes. No evidence was found in the facility's electronic health record indicating Resident 157's COVID-19 vaccination status. On 6/15/22 at 10:14 AM Resident 157 reported the facility did not discuss a COVID-19 vaccination with her/him. She/he stated she/he received both doses plus one booster of the vaccine prior to admission and that she/he kept a vaccination card with her/his personal belongings. On 6/15/22 at 1:05 PM, Staff 2 (Interim DNS) stated she did not document any communication with Resident 157 related to her/his COVID-19 vaccination status.

Immediate: Offer vaccine to resident 3, discussing risks versus benefits. Resident 157 no longer in facility. Others: Covid vaccination status of all other residents reviewed to ensure they were up to date with vaccines. Those who were eligible for boosters we offered, risks versus benefits explained. Systematic: All new admissions to be reviewed for covid-19 vaccination. DNS/Designee to interview all new residents regarding vaccination status if not reflected in their medical record. DNS/Designee to track vaccination status and booster eligibility. Monitor: Medical Records/Designee to audit monthly for new admission covid-19 vaccinations. Findings reported at monthly QAPI.

OAR 411-085-0310 Residents' Rights: Generally

Refer to F552 *************** OAR 411-086-0040 Admission of Residents Refer to F578, F655 *************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F656 *************** OAR 411-086-0230 Activity Services Refer to F679 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F684 *************** OAR 411-086-0100 Nursing Services: Staffing Refer to F726 *************** OAR 411-086-0310 Employee Orientation and In-Service Training Refer to F730 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F759 *************** OAR 411-086-0330 Infection Control and Universal Precautions Refer to F880 *************** OAR 411-086-0140 Nursing Services: Problem and Resolution and Preventive Care Refer to F883, F887 ***************

Based on interview and record review it was determined the facility failed to allow a resident to go outside for 1 of 3 sampled residents (#29) reviewed for residents right to leave the facility. This placed residents at risk for anxiety. Findings include: Resident 29 was admitted to the facility in 2022 with diagnoses including chronic lung disease. Resident 29's Clinical Admissions form indicated she/he was able to make needs known and had a good long term and short term memory. A 2/4/22 Progress Note indicated Resident 29 reported rapid breathing. The resident was administered medication which was not effective. The physician was notified and new medication orders were received, implemented and were effective. On 2/8/22 Resident 29 stated she/he had chronic breathing issues. On 2/4/22 she/he spent much of the day at physician appointments, was exhausted and anxious. Resident 29 indicated when anxious, she/he needed to go outside for fresh air, otherwise she/he felt like she/he was suffocating. Resident 29 stated on 2/4/22 she/he asked staff to let her/him go outside and the staff denied her/his request. Resident 29 indicated the facility called her/his physician, obtained new medication orders and her/his breathing improved. On 2/10/22 at 11:12 AM Staff 12 (LPN) stated the facility had an outside patio the residents could utilize. At times on night shift, after 8:00 PM, residents were not allowed to go outside by the front entrance because there was not enough staff to watch the residents. The resident's always had access to the back patio. On 2/11/22 at 1:45 PM Staff 17 (CNA) stated on 2/4/22 Resident 29 asked to go outside but there was not enough staff to assist the resident. Staff 17 indicated she took the resident to the nurses station and once the resident's room cooled down the resident seemed better. On 2/8/22 Staff 1 (Chief Operating Officer) stated all residents were allowed to go outside, had a right to leave the building and staff were to assist the residents as needed.

Immediate: Resident (29) is no longer in the facility. Others: Audit/Interview completed on current residents in house to ensure self-determination is being achieved. If areas of concern are found, facility will investigate and work with resident for resolution. Resolution will be document in resident record. Systematic: Facility staff to be trained on the importance of self-determination and right of choice. Monitoring: NHA, and or Designee to interview 10% of facility population each month regarding self-determination, and report interview findings at monthly QAPI.

Based on interview and record review it was determined the facility failed to ensure residents' responsible party or physician were notified of a fall with injury, low oxygen saturation levels, abnormal blood pressures, weight loss, poor oral intake, treatment refusals or omissions of medications and treatments for 6 of 13 sampled residents (#s 1, 10, 12, 14, 15 and 22) reviewed for leg wraps, change in condition, eating assistance, pain and pressure ulcers. This placed residents' families and physicians at risk for lack of information related to residents' health status and worsening health conditions. Findings include: 1. Resident 12 was admitted to the facility in 2021 with diagnoses including dementia. A 6/9/21 Fall report and Progress Note created by Witness 1 (Former RN) indicated Resident 12 was found on the ground at 5:38 AM. The report indicated the resident's representative was not notified of the fall. On 2/10/22 at 9:00 AM and Witness 3 (Spouse) indicated she/he was not notified of the resident's fall. On 2/11/22 at 10:17 AM Witness 2 (Family) indicated he was not notified of Resident 12's fall. On 2/16/22 at 11:45 AM Staff 3 (RNCM) stated the documentation indicated the resident's physician was notified of the fall but there was no family notification. 2. Resident 15 was admitted to the facility in 2021 with diagnoses including COVID-19. Resident 15's January 2021 Vital Signs revealed her/his oxygen saturation levels from 1/20/21 through 1/23/21 remained above 91 percent (normal range-95% or higher if no diagnosis of chronic lung disease). Progress Notes indicated on 1/20/21 Resident 15 informed the facility she/he did not want to be followed by the facility physician. A 1/24/21 at 11:23 PM note by Staff 4 (LPN) indicated the resident's oxygen saturation level was 80% on six liters of oxygen. The resident's oxygen saturation level increased with deep breathing. When the resident did not take deep breaths the oxygen level dropped to the low 80's. A breathing treatment was provided and was not effective to help the resident's oxygen saturation levels. The resident was instructed to continue to deep breathe. A 1/26/21 at 8:28 AM note by Staff 6 (RN) indicated the resident's oxygen saturation level was 85% on seven liters of oxygen. The resident's lungs were clear and the resident denied shortness of breath. The resident's oxygen levels increased if the resident did not move or talk. The note indicated the resident was to be monitored every four hours. There was no documentation to indicate the resident's physician was notified of the resident's low oxygen saturation levels which started on 1/24/21. On 2/11/22 at 13:41 PM Staff 4 stated if a resident's oxygen saturation was below 90% the physician was to be notified. Staff 4 did not recall Resident 15. On 2/25/22 at 7:49 AM Staff 6 stated if a resident was administered oxygen or if the oxygen had to be increased, the resident's physician was to be notified. Staff 6 also stated oxygen saturation levels should ideally be above 92%. Staff 6 stated she did not recall Resident 15 but indicated the resident required more oxygen than normal. Staff 6 thought she likely called the physician on both days the oxygen level was low but did not document the notification. A request was made to Staff 6 to provide documentation to verify the resident's physician was notified. No additional information was provided. On 2/25/22 at 8:09 AM Witness 4 (Health Plan Coordinator) stated she worked at Resident 15's physician's office, reviewed Resident 15's record and did not see notes to indicate the facility called the physician on 1/24/21 to report low oxygen saturation levels. Witness 4 stated the resident called the physician's office on 1/26/21 and reported her/his oxygen levels were low. The facility did not report the resident's low oxygen saturation levels were low until 1/27/21. On 2/16/22 at 11:45 PM Staff 23 (RNCM) stated staff should have called the resident's physician when the oxygen saturation levels were in the 80's. 3. Resident 10 was admitted to the facility in 2021 with diagnoses including dementia. The resident's Face Sheet indicated Witness 7 (Complainant) was the resident's Health Care Power of Attorney. A 7/1/21 Progress Note indicated Resident 10 was admitted to the facility and was too lethargic to sign consent forms. Witness 7 provided consent. Resident 10's undated Kardex (CNA guide to resident specific care) revealed Resident 10 required 1 to 1 assist to eat. A Breakfast Intake report for 7/2021 revealed staff documented 10 out of 17 meals. The resident was documented to not eat breakfast on six days, ate 1-25% on three days and 26-50% on one day. A Lunch Intake report for 7/2021 revealed staff documented 10 out of 17 meals. The resident was documented to not eat lunch on five days and ate 1-25 % on five days. A Dinner Intake report for 7/2021 revealed staff documented 9 out of 17 meals. The resident was documented to not eat for three meals and 1-25 % for five meals. Resident 10's 7/2021 Fluids log indicated she/he drank 90-260 cc of fluids each day through 7/11/21. 7/2021 Progress Notes and Daily Skilled Nursing notes did not include notification to the resident's family or physician related to Resident 10's lack of oral intake. A 7/26/21 Intake revealed Witness 7 (Complainant) reported Resident 10 did not eat while in the facility, the facility staff did not notify her of the poor intakes and she was not able to assist with Resident 10's situation. On 2/16/22 at 11:45 AM and 2/28/22 at 3:25 PM Staff 3 (RNCM) acknowledged Resident 10 did not eat or drink well and often the intake was less than 50%, Staff 3 also indicated she would look for documentation the physician and family were notified of the resident's lack of oral intake. No additional information was provided. Refer to F692, example 1. , 4. Resident 1 was admitted to the facility in 11/2021 with diagnoses including COVID-19, nutritional deficiency and high blood pressure. a. A review of Resident 1's weight record revealed on 11/10/21 the resident's weight was 139.2 pounds. On 11/17/21 the resident's weight was 128.6. The facility's electronic medical record flagged the 11/17/21 weight as outside the acceptable range for weight change. This was a 7.6% body weight loss over seven days. A review of Resident 1's clinical record revealed no indication Staff 20 (RD) or the resident's physician were notified of the weight loss identified on 11/17/21. A review of Resident 1's food intake record from 11/10/21 through 11/20/21 revealed overall poor food intake including: - Seven out of ten breakfast intakes of 0-25% consumed. - Seven out of ten lunch intakes of 0-25% consumed. - Seven out of ten dinner intakes of 0-50% consumed. An RD assessment dated 11/19/21 indicated the resident had a severe weight loss and the resident was at increased nutritional risk due to poor intake and weight loss. On 2/25/22 at 12:00 PM Staff 20 (RD) confirmed Resident 1's weights, weight loss and poor intake. Staff 20 stated she would expect the facility to assess the resident and implement appropriate interventions based on the resident's documented poor intake, as well as notify her and the resident's physician. b. A review of Resident 1's 11/2021 vital signs record revealed the following abnormal blood pressure (BP) and O2 sats readings: - On 11/10/21 at 4:50 PM the resident's BP was 167/85 (normal is 120/80) - On 11/11/21 at 3:05 PM the resident's BP was 74/40 - On 11/12/21 at 12:51 AM the resident's BP was 85/53 - On 11/12/21 at 3:36 PM the resident's BP was 105/47 - On 11/13/21 at 4:47 PM the resident's BP was 161/73 - On 11/13/21 at 10:55 PM the resident's BP was 121/48 - On 11/15/21 at 11:25 PM the resident's BP was 162/71 - On 11/16/21 at 2:54 PM the resident's BP was 199/92 - On 11/18/21 at 6:42 AM the resident's O2 sats was 87% (normal is 95% to 100%) - On 11/19/21 at 3:15 PM the resident's BP was 184/77 A review of Resident 1's 11/10/21 through 11/19/21 Progress Notes revealed no notifications to the physician or family related to the abnormal vital signs. On 2/16/22 at 10:07 AM Staff 7 (DNS) verified Resident 1's physician and family were not notified. Refer to F-684 example 3 and F-692 example 3 , 5. Resident 22 admitted to the facility on 1/2022 with diagnoses including dementia, COVID-19 and a chronic pressure ulcer. The 1/6/22 Admission orders included the following orders: -Pressure ulcer wound care to be completed daily and as needed. -Protein gel (nutritional supplement) 20 ml in 120 ml in juice daily. -Loratadine (allergy medication) daily. -Omeprazole (treats reflux) bid before meals. -Senna syrup (stool softener) bid. A January 2022 TARs revealed Resident 22 refused wound treatments on January 7, 19, 11, 12 and 14. The January 2022 MARs indicated the following: - Loratadine: documented as not administered/drug unavailable on January 7, 8, 13, 14, 15, 16, 17. - Omeprazole: administered late on January 8, 15 and 16 and documented as unavailable/not administered on January 18, 19 (both administrations) and 20 (both administrations). -Protein gel: documented as unavailable on January 7, 8, 9, 10 and 11. -Senna syrup: documented as unavailable on January 15 (day), 19 (day and evening), 20 (day) and 21 (day). The medical record revealed the physician was not notified of the missed doses of loratadine, omeprazole, protein gel and Senna syrup. There was no evidence in the medical record the family or physician were notified of the treatment refusals until 1/19/22. On 2/14/22 at 9:09 AM Staff 7 (DNS) verified the wound care, loratadine, omeprazole, protein gel and Senna syrup were not administered as ordered and the physician was not notified of the missed medication refusals and not notified of the treatment refusals until 1/19/22. 6. Resident 14 admitted to the facility in 4/2021 with diagnoses including diabetes and Prader-Willi syndrome (a genetic disorder which affects many parts of the body and growth). The 4/15/21 Admission Orders included the following orders: -Dilute one part vinegar with two parts water in spray bottle, clean folds with mixture, dry well, apply other creams and powders bid for skin care. -Hibiclens 4% (antiseptic soap) topical once a day on Sunday, Wednesday and Friday for skin impairment. -Proctozone-HC (steroid) cream bid. The April 2021 and May 2021 TARs revealed the following missed administrations: - Vinegar: Not completed from 4/15/21 through discharge on 5/4/21. - Hibiclens: not completed on April 16, 21, 23, 25 and May 2. -Proctozone-HC: Not completed on April 15, 16 (both doses) and 17 (both doses). There was no evidence in the medical record the physician was notified of the missed treatments of the vinegar, Hibiclens or Proctozone-HC. On 2/14/22 at 8:48 AM Staff 7 (DNS) verified the vinegar, Hibiclens and Proctozone was not administered as ordered and the physician was not notified of the missed doses.

Immediate: Residents (1,10,12,14,15,22) are no longer in the facility. Others: Audit records of current residents in house to ensure proper notifications have been made to MD and resident representatives. Systematic: LNs to be educated on requirement of notifying MD and resident representative for the following items: Accident that results in injury, significant change in physical, mental, of psychosocial status, low oxygen saturation levels, abnormal blood pressures, weight loss, poor oral intake, treatment refusals or omissions of medications and treatments. RCM/DNS to review prior days chart documentation, next working day, to ensure required notifications are made. Corrections will be made as found. Monitoring: DNS, and or designee to audit 10% of facility population each month to ensure proper notifications are being made to MD and representatives. Findings will be reported at monthly QAPI.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 residents (#7) reviewed for abuse. This placed residents at risk for physical and psychosocial harm. Findings include: Resident 7 was admitted to the facility in 9/2021 with chronic obstructive pulmonary disease (lung disease making it difficult to breathe) and acute respiratory disease. Resident 7's 9/1/21 Annual MDS revealed a BIMS score of 15 (no cognitive impairment). Resident 39 was admitted to the facility in 8/2021 with diagnoses including acute respiratory disease and major depressive disorder. Resident 39's 9/3/21 Admission MDS revealed Resident 39 was documented as having memory problems and physical behaviors effecting others. An 8/29/21 progress note indicated staff were aware Resident 39 wandered into resident rooms, was moved to a different room, and continued to wander into resident rooms. The same progress note indicated Resident 39 had been physically aggressive with staff. A 9/2/21 FRI indicated Resident 7 was heard yelling "Get her/him out of here" at Resident 39. Staff 11 (LPN) entered the room, stopped Resident 39 from yanking Resident 7 out of bed. Resident 39 was escorted out of the room. The 9/1/21 Facility Abuse Investigation indicated Resident 39 was found in Resident 7's room. Resident 39 grabbed Resident 7 by the ankles, yanked repeatedly and attempted to pull Resident 7 out of bed. Resident 7 flailed her/his legs and screamed at Resident 39 and for staff assistance. Staff 11 intervened and removed Resident 39 from the room. Resident 39 was interviewed the next day and stated she/he had no recollection of the event. Resident 7 stated she/he was kicking, screaming, and was very scared when the incident occurred. Resident 7 discharged eight days after the incident occurred. A progress note dated 9/2/21 indicated she/he was assessed for injury. No documentation of further monitoring, or assessment for latent injuries or lingering emotional distress was found. On 2/17/22 at 1:37 PM , Staff 7 (DNS) confirmed the incident between Residents 7 and 39 occurred.

Immediate: Resident (7) is no longer in the facility. Others: Interview current residents who are appropriate to be interviewed, and skin assessment for those who cannot be interviewed. No current residents with physical behaviors effecting others. Systematic: Facility staff to be educated on abuse prevention, types of abuse, and documentation following an abuse allegation. Facility initiating alert charting through EHR system. LNs to be educated on preventative intervention measures to be initiated when a resident admits with physicals behaviors effecting others or initiation of physical behaviors effecting others. Kardex to be updated with preventative interventions for communication to other staff. Monitoring: RCM/Designee to review progress notes looking for changes in behavior or potential escalation of behavior next working day. Changes to be made to plan of care if changes notes or interventions become ineffective. Report finding at monthly QAPI.

Based on interview and record review it was determined the facility failed to report an allegation of abuse to the State Agency within the required timeframe for 1 of 3 sampled residents (#7) reviewed for abuse. This placed residents at risk for continued abuse. Findings include: Resident 7 admitted to the facility in 8/2021 with diagnoses including COVID-19. The 9/1/21 BIMs (cognitive assessment) indicated Resident 7 was not cognitively impairment. The 9/1/21 Facility Abuse Investigation indicated Resident 39 was found in Resident 7's room. Resident 39 grabbed Resident 7 by the ankles, yanked repeatedly and attempted to pull Resident 7 out of bed. Resident 7 flailed her/his legs and screamed at Resident 39 and for staff assistance. The 9/1/21 abuse investigation report further indicated the incident occurred at 9:00 PM on 9/1/21. The 9/2/21 FRI was submitted to the State Agency at 9:00 AM on 9/2/21, reported the incident occurred on 9/1/21. On 2/17/22 at 1:37 PM, Staff 7 (DNS) confirmed the incident between Residents 39 and 7 was reported the next day.

Immediate: Resident (7) is no longer in the facility. Current system of reviewing progress notes/facility events working in catching the unreported abuse. Others: No current allegations of abuse to report at this time. Systematic: LNs to be educated on the time requirements of reporting abuse. LNs reeducated on after-hours system (FRI Binder) should the need arise for an FRI report to be submitted when NHA/designee is not in the facility. Monitoring: NHA and or designee to review FRI reports monthly to ensure timely submissions of FRI Reports. Findings of audit to be reported at monthly QAPI.

Based on interview and record review it was determined the facility failed to thoroughly investigate an allegation of abuse for 1 of 4 sampled residents (#7) reviewed for abuse. This placed residents at risk for inaccurate abuse determinations. Findings include: An 8/29/21 Progress Note indicated Resident 39 was observed wandering throughout the facility with and without clothing on. The same progress notes further indicated Resident 39 had gone into occupied rooms, and grabbed female staff aggressively. The 9/1/21 Facility Abuse Investigation indicated Resident 39 was found in Resident 7's room. Resident 39 grabbed Resident 7 by the ankles, yanked repeatedly and attempted to pull Resident 7 out of bed. Resident 7 flailed her/his legs and screamed at Resident 39 and for staff assistance. The 9/1/21 Resident to Resident Altercation report included a summary of the incident, alleged perpetrator interview, alleged victim interview, one staff interview, and a conclusion statement. The report did not determine the root cause and did not identify previous behaviors of Resident 39. There were no additional interviews of staff who were familiar with the incident. On 2/17/22 at 2:21 PM Staff 4 (Administrator) confirmed the investigation had limited staff interviews, could not determine a root cause, and did not identify previous behaviors which impacted both residents and staff.

Immediate: Resident (7) is no longer in the facility. Others: No current open FRI investigation. Systematic: Educate IDT team on how to investigate and determine root cause analysis. Investigation tool to be implemented to guide the investigation thoroughness. Monitoring: IDT team will review recent investigations at monthly QAPI to ensure a thorough investigation was completed including root cause analysis.

Based on interview and record review it was determined the facility failed to comprehensively assess a resident's ADL and nutritional status for 1 of 4 sampled residents (#2) reviewed for weight loss. This placed residents at risk for unmet nutritional needs and lack of eating assistance. Findings include: Resident 2 admitted to the facility 10/2021 with diagnoses including diabetes and stroke. A 10/4/21 admission note indicated Resident 2 admitted to the facility with left sided weakness due to stroke. A 10/4/21 Physician Orders revealed a diet order for mechanical soft diet and thickened liquids. A 10/11/21 Admission MDS revealed Resident 2 had unplanned weight loss and required one person supervision with eating. The Nutritional Assessment CAA did not include an analysis of Resident 2's nutritional risk. It did not include Resident 2's recent stroke with left sided impairment, unplanned weight loss or the mechanically altered diet and thickened liquids she/he was ordered. The ADL CAA did not analyze Resident 2's need for eating assistance due to her/his left sided weakness. Both CAAs were not comprehensive. On 2/15/22 at 1:48 PM Staff 7 (DNS) acknowledged the Admission Nutritional CAA and the Admission ADL CAA were not comprehensive assessments of Resident 2's nutritional and ADL status.

Immediate: Resident (2) is no longer in facility. Others: Facility will audit current residents with trigger ADL and nutrition CAAs to ensure the CAA is comprehensive. If a problem is noted, facility will add an addendum progress note. Systematic: Corporate RN consultant to educate RCM on comprehensiveness of CAA assessments. RCM to attend online MDS training. DNS or designee to review triggered ADL and Nutrition CAA's for next 90 days prior to assessment submission, to ensure comprehensiveness of the CAA. Monitoring: RN Consultant and or designee will audit 10% of triggered ADL and Nutrition CAAs monthly to ensure the CAA is comprehensive. Findings to be reported at monthly QAPI to ensure sustained compliance.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 2 of 8 sampled residents (#s 3 and 7) reviewed for dehydration and discharge. This placed residents at risk for unmet discharge needs. Findings include: 1. Resident 3 admitted to the facility in 1/2021 with diagnoses including COVID-19 and heart failure. The resident discharged as planned on 1/30/21. Resident 3's medical record revealed no evidence a discharge summary was completed. On 2/23/22 at 10:17 AM Staff 4 (Administrator) stated he was unable to locate a discharge summary for the resident. 2. Resident 7 admitted to the facility in 8/2021 with diagnoses including COVID-19. The resident discharged as planned on 9/10/21. Resident 7's medical record revealed no evidence a discharge summary was completed. On 2/23/22 at 10:17 AM Staff 4 (Administrator) stated he was unable to locate a discharge summary for the resident.

Immediate: Residents (3,7) no longer in facility. Others: Facility completed an audit of discharges back to 3/1/2022, to ensure discharge summaries were completed. Corrections made as needed. Systematic: IDT team to be educated on importance of discharge summary process and requirement for completion. Medical records will monitor and track for timely completion. Monitoring: DNS and or designee will audit 10% of discharge summarys monthly and report audit findings at monthly QAPI.

Based on interview and record review it was determined the facility failed to ensure a resident received scheduled showers for 1 of 3 sampled residents (#9) reviewed for grooming. This placed residents at risk for poor hygiene. Findings include: Resident 9 was admitted to the facility 7/19/21 with diagnoses including dementia. An undated Kardex (CNA guide for resident specific care) indicated the resident required the assistance of one person for bathing and showers were scheduled for Tuesday and Friday evening shifts. Resident 9's 7/2021 and 8/2021 bathing record indicated the resident refused one shower on 7/20/21. The resident missed three opportunities for showers (7/23/21, 7/27/21 and 7/30/21) prior to discharge on 8/3/21. On 2/15/22 at 10:12 AM Staff 15 (CNA) stated residents were scheduled to have two showers a week. If a resident was scheduled for a shower, staff were to make multiple attempts to provide a shower. If the resident refused the nurse was informed and the nurse attempted to encourage the resident to shower. If the resident continued to refuse it was documented as a refusal in the resident's record. On 2/16/22 at 11:45 AM Staff 3 (RNCM) indicated residents were to be offered a shower at least twice a week. Staff 3 acknowledged Resident 9 was offered a shower on 7/20/21 but no additional showers were documented as offered. A request was made to Staff 3 to provide documentation to indicate Resident 9 was offered showers after 7/20/21. No additional information was provided.

Immediate: Resident (9) is no longer in the facility. Others: Shower audit to be completed for 7 days to ensure twice weekly showers were given as residents allow. Follow up as needed. Systematic: LNs and CNAs to be educated on importance of showers and correct documentation. Shower schedule to be added to TAR to ensure completion of showers per schedule. Monitoring: DNS and or designee to audit 10% of residents TARs for shower completion weekly. Report findings at monthly QAPI.

Based on interview and record review it was determined the facility failed to administer medication and complete treatments according to physician's order, failed to monitor a resident's venous access port and failed to monitor for a change of condition for 5 of 10 sampled residents (#1, 12, 14, 20 and 22) reviewed for change in condition, physicians orders, venous access ports and unsafe medication system. This placed residents at risk for reduced medication efficacy, worsening skin conditions, lack of treatment for a change of condition and unidentified complications. Findings include: 1. Resident 22 admitted to the facility in 1/2022 with diagnoses of dementia and COVID-19. Resident 22's 1/6/22 Admission Orders included the following: -Loratadine (allergy medication) daily. -Omeprazole (reflux medication) bid before meals. -Protein gel daily. -Senna syrup (stool softener) bid. The resident's January 2022 MARs indicated the following: - Loratadine: documented as not administered/drug unavailable on January 7, 8, 13, 14, 15, 16, 17. - Omeprazole: administered late on January 8, 15 and 16 and documented as unavailable/not administered on January 18, 19 (both administrations) and 20 (both administrations). -Protein Gel: documented as unavailable on January 7, 8, 9, 10 and 11. -Senna syrup: documented as unavailable on January 15 (day), 19 (day and evening), 20 (day) and 21 (day). The medical record revealed the physician was not notified of the missed doses of loratadine, omeprazole, protein gel and senna syrup. On 2/14/22 at 9:09 AM Staff 7 (DNS) verified loratadine, omeprazole, protein gel and senna syrup were not administered as ordered and the physician was not notified of the missed doses. 2. Resident 14 admitted to the facility in 4/2021 with diagnoses including diabetes and Prader-Willi syndrome (a genetic disorder which affects many parts of the body and growth). Resident 14's 4/15/21 Admission Orders included the following orders: -Dilute one part vinegar with two parts water in spray bottle, clean folds with mixture, dry well, apply other creams and powders bid for skin care. -Hibiclens 4% (antiseptic soap) topical once a day on Wednesday, Friday and Sunday for skin impairment. -Proctozone-HC (steroid) cream bid. The resident's April 2021 and May 2021 TARs revealed the following missed administrations: - Vinegar: Not completed from 4/15/21 through discharge on 5/4/21. - Hibiclens: not completed on April 16, 21, 23, 25 and May 2. -Proctozone-HC: Not completed on April 15, 16 (both doses) and 17 (both doses). There was no evidence in the medical record the physician was notified of the missed treatments of the vinegar, Hibiclens or Proctozone-HC. On 2/8/21 at 10:58 AM Witness 8 (Assisted Living Nurse) stated the vinegar skin treatments worked well for Resident 14 because it suppressed the candida (fungal) growth. Witness 8 stated if the vinegar treatment was not completed Resident 14 would begin to have skin problems. On 2/14/22 at 8:48 AM Staff 7 (DNS) verified the vinegar, Hibiclens and Proctozone was not administered as ordered. , 3. Resident 1 was admitted to the facility in 11/2021 with diagnoses including depression, insomnia, COVID-19 and COPD (chronic obstructive pulmonary disorder causes inflammation of the lungs which obstructs airflow). a. A review of Resident 1's 11/2021 MAR revealed the resident was ordered tramadol (pain medication) 50 mg, one tablet, four times a day. On 11/13/21 at 9:58 AM and 2:50 PM an unidentified "Agency Nurse" indicated the tramadol was administered late because the drug was unavailable and a half tab (25 mg) was administered to the resident. A review of Resident 1's 11/2021 Progress Notes revealed no indication the pharmacy was notified regarding the supply of trazadone or a request to the physician to administer a half tablet instead of a full tablet. A review of Resident 1's 11/2021 physician's orders revealed no order for the administration of a half tablet instead of a full tablet of tramadol. On 2/16/22 at 10:07 AM the administration of a half tablet of trazadone to Resident 1 was discussed with Staff 7 (DNS) who verified it was not appropriate to administer a half tablet when the order was for a full tablet. b. A review of Resident 1's Progress Note revealed a note on 11/20/21 which indicated the resident's condition declined since admission to the facility and was not willing to keep oxygen [tubing used to deliver oxygen] in place. The note failed to indicate specifically how the resident's condition had declined. The Progress Notes failed to indicate the date and a rationale for when the oxygen therapy was first initiated or that the resident's family and physician were notified. Resident 1's 11/2021 physician's orders revealed no order for oxygen therapy. On 2/16/22 at 10:07 AM the administration of oxygen therapy with no physician's order for Resident 1 was discussed with Staff 7 (DNS). Staff 7 stated the facility had standing orders for the use of oxygen therapy to residents. Staff 7 stated the expectation was for a nurse to assess the resident and document the assessment and rationale for initiating oxygen therapy. The standing order was then placed on the resident's orders in the electronic medical record. Staff 7 reviewed Resident 1's clinical record but could not find a date or rationale for when oxygen therapy was initiated. c. A review of Resident 1's 11/2021 vital signs record revealed the following abnormal blood pressure (BP) and O2 sats readings: - On 11/10/21 at 4:50 PM the resident's BP was 167/85 (normal is 120/80) - On 11/11/21 at 3:05 PM the resident's BP was 74/40 - On 11/12/21 at 12:51 AM the resident's BP was 85/53 - On 11/12/21 at 3:36 PM the resident's BP was 105/47 - On 11/13/21 at 4:47 PM the resident's BP was 161/73 - On 11/13/21 at 10:55 PM the resident's BP was 121/48 - On 11/15/21 at 11:25 PM the resident's BP was 162/71 - On 11/16/21 at 2:54 PM the resident's BP was 199/92 - On 11/18/21 at 6:42 AM the resident's O2 sats was 87% (normal is 95% to 100%) - On 11/19/21 at 3:15 PM the resident's BP was 184/77 A review of Resident 1's 11/10/21 through 11/19/21 Progress Notes revealed no nursing assessments, re-checks to verify the readings, notifications to the physician or family related to the abnormal vital signs. On 2/16/22 at 10:07 AM Staff 7 (DNS) stated abnormal vital signs should be rechecked and the resident should be assessed. Staff 7 verified Resident 1's vital signs were not rechecked and there were no assessments. Staff 7 verified Resident 1's physician and family were not notified. 4. Resident 20 was admitted to the facility in 2020 with diagnoses including fracture. A review of Resident 20's 1/22/20 hospital History & Physical revealed the resident had a left upper chest implanted port. No anticoagulant injections were ordered or provided to maintain the port. No discharge orders were given to the facility by the hospital for monitoring or maintenance of the port. A Progress Note dated 3/12/20 indicated an un-named Resident Care Manager, Nurse Practitioner and Charge Nurse "looked" at Resident 20's left chest port. The resident asked if the port would be flushed or not. The note failed to indicate what prompted staff to look at the port and did not document an assessment of the port. The note failed to indicate a response to the resident's question regarding flushing the port. A Physician Progress Note dated 3/18/20 revealed Resident 20 had a left upper chest port covered by skin with scar tissue and, "[the port] does not look accessible anymore, and therefore heparin (blood thinner) flushes would not be helpful, [the resident] is requesting heparin flushes as [the resident] had before when [the resident] was in the hospital. Patient does not remember under whose direction the port was put in ....We will continue to monitor for now." A review of Resident 20's 3/2020 and 4/2020 Physician's Orders, Progress Notes and TARs revealed no indication the resident's port was monitored. On 2/11/22 at 10:26 AM Staff 7 (DNS) stated the facility was not aware of the physician's instructions to monitor the resident's port because physician's notes were sent directly to medical records and were not reviewed by nursing. , 5. Resident 12 was admitted to the facility in 2021 with diagnoses including dementia. A 6/9/21 Progress Note at 5:54 AM indicated the resident had an unwitnessed fall and sustained a laceration to the right eyebrow. The note indicated neurological assessments (monitors a resident for adverse effects related to an actual or potential head injury) were started. The 6/9/21 at 11:31 AM note did not indicate the resident was assessed for latent injuries from the fall. There was no documentation related to the resident's condition after she/he fell until 6/10/21 at 8:56 AM which indicated the resident was sent to the hospital emergency department due to a change in cognition. The resident's clinical record did not include neurological assessments. On 2/16/22 at 11:45 AM Staff 3 (RNCM) indicated staff were to perform scheduled neurological checks after a resident fell. The completed document was to be submitted to the RNCM and then the document was to be scanned into the resident's record. Staff 3 indicated at times the neurological assessment sheets were initiated but not completed. A request was made to Staff 3 to provide documentation Resident 12 was monitored for a change in condition from 6/9/21 at 5:54 AM through 6/10/21 when Resident 12 was discharged to the hospital for evaluation. No additional information was provided. Resident 12's 6/10/21 hospital Emergency Department dictation indicated the resident arrived to the Emergency Room and was "overall nontoxic-appearing" and her/his vital signs were stable. The resident was weak and oriented to self. The resident's head scan did not reveal new trauma or bleeding. Refer to F689.

Immediate: Residents (1,12,14,20,22) are no longer in facility. Others: Current residents have the potential to be affected by the alleged deficient practice. Facility currently has no residents a with venous access port. Systematic: LNs to be educated on importance of proper medication and treatment administration and documentation, as well as what to do when medications/supplies are unavailable. LNs to be educated on the change of condition process. LNs to be educated on procedure for venous access ports. LNs to be educated on 24-hour report and alert charting system. RCM and or designee to audit MAR/TAR to ensure no missed administrations or unavailable items. RCM and or designee to review progress next working day for any change of conditions to process was correctly followed. Corrections as needed. 24-hour report and alert charting system will communicate changes of condition and need for ongoing monitoring. Monitoring: DNS and or designee to audit 10% of current residents medical records weekly for the following items: proper medication and treatment administration, documentation, availability of supplies, change of condition, 24 hour report and alert charting. Findings to be reported at monthly QAPI to ensure sustained compliance.

Based on interview and record review it was determined the facility failed to ensure a resident received the necessary treatment and services to prevent infection and the worsening of a Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) for 1 of 3 sampled residents (#22) reviewed for pressure ulcers. This failure, which was determined to be immediate jeopardy, resulted in worsening of Resident 22's pressure ulcer and subsequent transfer to the hospital where the resident died from complications related to the worsening of the pressure ulcer. Findings include: Resident 22 admitted to the facility on 1/6/22 with diagnoses including dementia, COVID-19 and a chronic Stage 4 pressure ulcer. Resident 22's 1/3/22 Skin and Wound Evaluation from the resident's previous facility assessed the Stage 4 pressure ulcer to measure 1.9 cm x 2.0 cm (no depth was documented) with 90% epithelial tissue (tissue that forms the outer covering of skin) and no evidence of infection. No exudate (drainage) or odor was present, the wound edges were attached and the surrounding tissue was normal with no indurating (abnormal hardening of the tissue) or edema (swelling). The peri-wound (skin around the ulcer) was normal and the resident denied pain. The wound was determined to be stable but slow to heal. Resident 22's 1/6/22 Admission Transfer assessment revealed the resident had a Stage 4 pressure ulcer to the coccyx. [A comprehensive wound assessment was not completed.] A 1/7/22 Care Plan indicated Resident 22 was at risk for skin breakdown related to an existing pressure injury and changes in mobility and ADLs which were further complicated by the COVID-19 viral infection. Interventions included repositioning the resident every two hours. There was no documentation in the medical record repositioning every two hours occurred. The resident's 1/6/22 Admission orders included the following orders: -Stage 4 pressure ulcer wound care: cleanse with normal saline (NS), apply skin prep to the peri-wound, apply collagen to the wound base (mix NS with collagen powder to create paste) and then gently fill the remaining ulcer with calcium alginate and cover with a foam bordered dressing. Change daily and as needed. -Protein gel: 20 ml in 120 ml in juice daily (nutritional supplement). The January 2022 TARs revealed Resident 22 refused wound treatments on January 7, 8, 10, 11, 12 and 14. (A 1/8/22 Progress Note revealed the wound treatment was completed.) There was no evidence in the medical record the facility staff provided encouragement or education to the resident or family related to the treatment refusals. There was no evidence in the medical record the family or physician were notified of the refusals until 1/19/22. A January 2022 MARs revealed Resident 22 did not receive the prescribed protein gel on January 7, 8, 9, 10 and 11. There was no evidence in the medical record the physician was notified the protein gel was not administered. A 1/13/22 Wound Management assessment indicated the resident's wound measured 3.2 cm x 3 cm x 2.7 cm with light serosanguineous (light pink/red, thin and water-like) exudate and no odor. Undermining (wounds that extend under the skin) was 9.7 cm with no tunneling (channels formed beneath the skin). Granulation tissue (new tissue) was present, wound edges were rolled under and thickened and the surrounding skin was dry, thin and scaling. The wound was determined to be stable. [The assessment failed to identify the wound had worsened since admission.] A 1/15/22 Progress Note revealed the resident's wound did not have odor and did not have signs of infection. The wound was painful to touch. A 1/18/22 Nutritional Assessment revealed Resident 22 should continue her/his current diet, add NEM (nutritionally enhanced meals), add 120 ml of "2 cal" (nutritional health shake) five times a day, provide a multivitamin with minerals to the evening mediation pass and notify the RD PRN. [The assessment did not include the resident only consumed mandarin oranges, bananas and drank milk for two meals daily.] There was no evidence in the medical records the RD recommendations were initiated and followed. The 1/19/22 Wound Management assessment indicated the wound measured 4 cm x 3.4 cm x 2.8 cm with light seropurulent (mixture of serum and pus) drainage. A strong, foul odor was present. There was 2 cm of undermining of the entire wound and 4 cm of tunneling from one to five o'clock present. The wound was assessed to have declined. The 1/21/22 Wound Management assessment indicated the wound measured 4 cm x 3.4 cm x 2.8 cm with moderate seropurulent drainage. Odor was present, undermining was 4.5 cm and tunneling was 5 cm. The wound was assessed to have declined. Additionally a second wound was identified as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (moist, devitalized tissue) and/or eschar (dead tissue) adjacent to the Stage 4 pressure ulcer. There was no evidence in the medical record her/his physician physically assessed the Stage 4 pressure ulcer. The 1/21/22 Progress note revealed Resident 22 transferred back to her/his prior long-term care facility. On 1/21/22 the receiving facility completed a Skin and Wound evaluation which assessed the Stage 4 pressure ulcer to measure 9.6 cm x 8.7 cm (no depth identified). The wound bed had eschar and there was evidence of infection which included increased pain, redness/inflammation and a strong odor. The surrounding tissue had black/blue discoloration and erythema (redness), the peri-wound skin temperature was warm and the resident complained of intermittent pain. The resident's 1/23/22 Hospital records revealed Resident 22 was found to be unresponsive the morning of 1/22/22 and was transferred to the hospital. The resident was identified to be in multi-organ failure due to chronic infection and admitted to the intensive care unit. On 1/23/22 Resident 22 died. The principal cause of death was septic shock present for days due to the sacral decubitus (pressure) ulcer and UTI. On 2/14/22 at 9:09 AM Staff 7 (DNS) verified the Stage 4 pressure ulcer was identified but not assessed on admission, verified both the wound care and protein gel were not completed per physician orders and the facility did not notify the physician or the family of the treatment refusals until 1/19/22. Staff 7 further stated the facility did not accommodate Resident 22's specific food preference, did not follow the RD recommendations, did not document care plan turning interventions and verified the physician did not visually assess the wounds during Resident 22's stay at the facility. On 2/23/22 at 9:27 AM Staff 20 (RD) acknowledged she was unaware of Resident 22's food preferences, likes and dislikes and was unaware Resident 22 only ate mandarin oranges, bananas and milk twice a day. Staff 20 stated she would have recommended other dietary interventions had she known of Resident 22's food preferences. Staff 20 acknowledged the 1/18/22 Nutritional Assessment was not a comprehensive assessment. On 3/1/22 at 10:05 AM Staff 3 (RNCM) acknowledged the Stage 4 pressure ulcer worsened at the time of the 1/13/22 assessment. Staff 3 stated she knew little of the wound prior to 1/13/22 when a nurse approached her regarding the frequent refusals of care. She then observed and thoroughly cleaned the wound. Staff 3 stated the nurses were complacent with the resident treatment refusals and did not provide strong encouragement or education. Additionally, Staff 3 stated the wound treatments were not completed as prescribed. Staff 3 stated on 1/19/22 she pulled out a dressing from the wound that was not the prescribed treatment and found the wound had deteriorated. Staff 3 further stated the second wound documented on 1/19/22 was a continuation of the Stage 4 pressure ulcer and not a separate wound. On 3/1/22 at 1:26 PM Staff 2 (Administrator) and Staff 3 (RNCM) were notified of the immediate jeopardy (IJ) and provided a copy of the IJ template related to the facility's failure to ensure a resident received the necessary treatment and services to prevent infection and the worsening of a Stage 4 pressure ulcer. An immediate plan of correction (POC) was requested. On 3/1/22 at 4:10 PM the submitted POC was approved. The IJ Immediacy Removal Plan included: -Immediately 1. Identification of all pressure ulcers -Ongoing 2. Verify assessments of all pressure ulcers are up to date 3. Verify current assessments are up to date with accurate measurements 4. All identified pressure ulcer care plans reviewed and updated to ensure they cover nutrition, treatment and positioning. 5. RNCM will review RD recommendations of all current residents. 6. RNCM will follow up on all RD recommendations to ensure recommendations are being implemented as recommended. 7. Residents who are refusing care and services will be provided risk versus benefit education upon refusal. The nurse will try to negotiate a reasonable alternative. If the resident continues to refuse after the risk benefit, a reapproach will be attempted prior to the end of the shift. In the event the nurse is unsuccessful and the resident continues to refuse service the facility will notify the family and physician that day. 8. Care plans will be updated as appropriate. -Systematic Changes 1. RNCM will conduct admission audits following day after admit to ensure skin issues are appropriately documented and interventions are in place. 2. Residents who are refusing care and services will be provided risk and benefit education upon refusal. The nurse will listen to why the resident is refusing to help seek/negotiate a reasonable alternative. If the resident continues to refuse after risk and benefit, a reapproach will be attempted prior to end of shift. In the event the nurse is unsuccessful and the resident continues to refuse service the facility will notify the family and physician the same day. 3. Educate the nurses starting 3/1/22 with nurses on staff and educate them prior to the start of the nurses next shift. a. RD recommendations b. Wound assessments and documentation c. Notification of family d. Notification of physician e. RN assessment anytime a wound is declining. f. Location of supplies g. Following physician orders h. Importance of documentation, if it is not documented it is not done. -Monitoring 4. RNCM to do wound rounds once a week to verify wound status, documentation and interventions are in place. 5. DNS or designee will audit pressure/injuries every week and report to monthly QAPI (Quality Assurance and Performance Improvement) to ensure ongoing compliance. 6. DNS or designee will audit RD recommendations every week and report to monthly QAPI to ensure ongoing compliance. 7. DNS or designee will audit MAR/TAR for refusal/not available every week and report to monthly QAPI to ensure ongoing compliance. 8. DNS or designee will audit for refusal of care every week and report to monthly QAPI to ensure ongoing compliance. 9. Audits will continue for at least three months and be re-evaluated at QAPI if auditing can be titrated to twice a month intervals, monthly intervals or no longer needed. On 3/2/22 at 4:26 PM Staff 2 (Administrator) and Staff 24 (Corporate RN) were notified the immediacy was removed based on observations, staff interviews and record review that the IJ removal plan was fully implemented.

Immediate: Resident (22) no longer in the Facility Others: 1) All other residents assessed to ensure no worsening of pressure ulcers. 2) Verify assessments of all pressure ulcer are up to date 3) Verify current assessment are up to date with accurate measurements 4) All identified pressures ulcers care plan reviewed and updated to ensure they cover a. Nutrition b. Treatment c. Positioning 5) RCM will review registered dietician recommendations of all current residents. 6) RCM will follow up on all Registered Dietician recommendations to ensure recommendations are being implemented as recommended 7) Resident who are refusing care / services, will be provide risk/benefit education upon refusal. Nurse will try to negotiate a reasonable alternative. If resident continues to refuse after risk/benefit, a reapproach will be attempted prior to end of shift. In the event the nurse unsuccessful and Resident continues to refuse service the facility will notify family and physician that day.  Daily 8) Care Plans will be updated as appropriate. Systematic 1) RCM will conduct admission audits following day after admit to ensure skin issues are appropriate documented and interventions are in place. 2) Resident who are refusing care / services, will be provide risk/benefit education upon refusal. Nurse will listen to why resident is refusing to help seek/negotiate a reasonable alternative. If resident continues to refuse after risk/benefit, a reapproach will be attempted prior to end of shift. In the event the nurse unsuccessful and Resident continues to refuse service the facility will notify family and physician that day.  Daily 3) Educate nurses starting today with nurses on staff and educate prior to start of nurses next shift. a. Registered Dietician recommendations b. Wound assessments and documentation c. Notification of family d. Notification of physician e. RN assessment anytime a wound is declining f. Location of supplies g. Following Physician orders Importance of documentation if its not documented its not done. Monitoring: 4) RCM to do wound rounds once a week to verify wound status, and documentation and interventions are in place. 5) DNS or designee will audit pressure/ injuries every week and report to at monthly QAPI to ensure ongoing compliance 6) DNS or designee will audit RD recommendations every week and report to at monthly QAPI to ensure ongoing compliance. 7) DNS or designee will audit MAR / TAR for refusal / not available every week and report to at monthly QAPI to ensure ongoing compliance. 8) DNS or designee will audit for refusal of care every week and report to at monthly QAPI to ensure ongoing compliance. 9) Audits will continue for at least 3 months and be re-evaluated at QAPI if auditing can be titrated to twice a month interval, monthly intervals or no longer needed.

Based on interview and record review it was determined the facility failed to ensure fall prevention interventions were identified and implemented for a resident assessed to be at high risk for falls for 1 of 3 sampled residents (#12) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 12 was admitted to the facility 6/8/21 with diagnoses including dementia. A 6/8/21 hospital Care Management Care Facility Admission Orders indicated Resident 12 was at risk for falls, used a front wheeled walker and required one person moderate assist to walk. A facility Admission Fall Risk Assessment completed on 6/8/21 at 3:57 PM indicated the resident was at high risk for falls due to factors including the resident was disoriented and had one or two falls in the last three months. There were no interventions listed in the plan of care section of the form. A 6/9/21 Fall report indicated Resident 12 had an unwitnessed fall on 6/9/21 at 5:38 AM. The resident was found sitting on the left side of the bed trying to "get back up". The resident was last seen resting in bed at 4:00 AM, one and one half hours after prior to the fall. The resident was assessed to have an abrasion and laceration. The contributing factor for the fall was identified to be related to the resident's cognitive impairment. Interventions put in place to prevent future falls were frequent checks, fall mat and the bed was to be lowered to the ground. A 6/9/21 at 5:54 AM Progress Note indicated the resident was found on the ground, denied pain and had blood on the right brow with a small laceration. The bed was lowered and the day shift staff were to find fall mats for the resident's room. The undated Kardex (CNA guide for resident specific care) indicated Resident 12 was at risk for falls. Interventions included mats and bed in lowest position. These interventions were identified on the 6/9/21 Fall report to be added after the fall. There were no additional interventions on the Kardex related to falls. An undated Resident Census (list of rooms Resident 12 resided) indicated the resident was in Room 313 (end of hall further from nurse's station) on 6/8/21 and on 6/9/21 was moved to room 302 (near nurses' station). On 2/14/22 at 10:15 AM Staff 13 (CNA) indicated she did not recall Resident 12. If a resident was at risk for falls the nurse would notify staff of the risk. Interventions to prevent falls were located on the Kardex. Interventions could include mats on the floor by the bed, frequent checks and to keep the bed in low position. The staff had access to mats and could be placed upon a resident's admission to the facility. Staff 13 stated room 313 was at the end of the hall and room 302 was near the nurses' station. On 2/14/22 at 10:29 AM Staff 14 (CNA) stated he did not recall Resident 12. If a resident was identified as a fall risk, the nurses notified staff and interventions were placed on the Kardex. Some interventions could be mats at the bedside, bed in low position and to keep the call light be the resident. On 2/16/22 at 11:45 AM Staff 3 (RNCM) indicated if a resident was assessed to be at risk for falls, interventions were to be implemented. Staff 3 indicated at times it was difficult to implement interventions on the first day a resident was in the facility. Staff 3 acknowledged Resident 12 was assessed to be at risk for falls when she/he was admitted to the facility and interventions were implemented after the fall. On 2/17/22 at 9:25 AM Staff 7 (DNS) indicated the resident was assessed on admission to be a high risk for falls and no interventions were implemented after the assessment was completed. A 6/10/21 hospital Emergency Department dictation indicated Resident 12 fell at the facility had a "very slight" laceration about the right eyebrow which was treated at the facility with Steri-Strips (thin adhesive bandages) and a Band-Aid. The laceration did not have active bleeding, swelling or purulence.

Immediate: Resident (12) no longer in facility Others: Review current residents fall risk assessments and ensure effective interventions are in place. Corrections as needed. Systematic: Educate LNs and CNAs on the importance of implementing preventative interventions once a resident has been assessed as a fall risk. Admitting nurse to compete fall risk assessment and implement interventions as needed. RCM/designee to compete admission audit next working day to verify assessment was completed with interventions implemented. Monitoring: DNS and or designee to audit 10% of fall risk assessments and interventions weekly for implementation. Report findings of audit at monthly QAPI meeting.

Based on interview and record review it was determined the facility failed to provide supra-pubic (SP, tube which drains from the bladder) catheter care for 1 of 3 sampled residents (#22) reviewed for catheters. This resulted in Resident 22 developing a UTI with sepsis. Findings include: Resident 22 admitted to the facility on 1/6/22 with diagnoses including dementia, neurogenic bladder (bladder does not function normally due to nerve damage) and a history of UTIs. Resident 22 discharged on 1/21/22 to a long-term care facility. The 1/6/22 Admission Orders included the following SP catheter care orders: -Irrigate the SP catheter with 30 ml of normal saline every shift. From 1/6/22 through 1/21/22 this was documented as refused seven times. -Apply dimethicone (barrier cream) and split sponge every shift. From 1/6/22 through 1/21/22 this was documented as refused six times. There was no evidence in the medical record the resident was provided risk versus benefit education related to the treatment refusals. There was no evidence in the medical record Resident 22's family or physician was notified about the refusals. Hospital records dated 1/23/22 revealed Resident 22 was transferred to the hospital the day after she/he discharged from the facility and diagnosed with septic shock (full body infection) due to UTI and decubitus ulcer. Resident 22 died in the hospital on 1/23/22. On 2/14/22 at 9:04 AM Staff 16 (CNA) stated Resident 22 frequently refused care and services especially personal hygiene. On 2/14/22 at 9:09 AM Staff 7 (DNS) verified Resident 22 refused the irrigation of the SP catheter and barrier cream and change, and the facility did not educate the resident of the risks and benefits of the refusals or contact the family and physician of the refusals.

Immediate: Resident (22) is no longer in facility. Others: Current residents with catheters will be audited to be sure care is completed as ordered. Education and notifications to be made as needed for noncompliance/refusals of care. Systematic: LNs to be educated on providing catheter care as ordered, and the importance of education of risks of refusals. As well as notification to responsible party and provider for said noncompliance. RCM/designee to audit refusals of catheter care next working day for completion of catheter care, or notification/education of refused care. Corrections as needed. Monitoring: DNS and/or designee to audit refusals of care weekly and report findings at monthly QAPI.

Based on interview and record review it was determined the facility failed to promptly verify weights, identify and assess when residents' nutritional and hydration intake was less than the residents required needs and/or had an unintended severe weight loss for 6 of 12 sampled residents (#s 1, 2, 9, 10, 22 and 35) reviewed for change in condition, dehydration, weight loss, eating assistance and change in condition. This failure resulted in an unintended severe weight loss for Resident #s 1 and 35, worsening wounds contributing to her/his death for Resident 22 and dehydration for Resident 10. Findings include: 1. Resident 10 was admitted to the facility in 2021 with diagnoses including dementia and COVID-19. A 7/1/21 Progress Note indicated Resident 10 was admitted to the facility and was too lethargic to sign consent forms. Resident 10's undated Kardex (CNA guide to resident specific care) revealed Resident 10 required 1 to 1 assist to eat. A Breakfast Intake report for 7/2021 revealed staff documented 10 out of 17 meals. The resident was documented to not eat breakfast on six days, ate 1-25% on three days and 26-50% on one day. A Lunch Intake report for 7/2021 revealed staff documented 10 out of 17 meals. The resident was documented to not eat lunch on five days and ate 1-25 % on five days. A Dinner Intake report for 7/2021 revealed staff documented 9 out of 17 meals. The resident was documented to not eat for three meals and 1-25 % for five meals. Resident 10's 7/2021 Fluids log indicated she/he drank 90-260 cc of fluids each day through 7/11/21. A 7/2021 Supplements Intake form indicated the resident did not receive any supplements even when the resident ate less than 25%. A 7/2021 AM Snack form revealed the resident was not offered snacks. A 7/2021 Bedtime Intake form revealed the resident was not offered snacks. A 7/11/21 Nutritional Assessment indicated the resident's current intake met 25% or less of her/his estimated needs, required 2250 cc of fluids each day and consumed less than 1000 cc per day. Staff were to offer fluids with medication pass and add a fruit based nutritional supplement BID. A 7/2021 Progress Notes and Daily Skilled Nursing notes did not have an assessment of the resident's lack of oral intake, notification to the resident's family and physician or what interventions the facility would implement to help the resident improve her/his intake. Resident 10's 7/2021 Fluids log revealed the amount of fluids consumed increased after the RD recommendation was made for staff to offer the resident additional fluids, but continued to be less than the resident's 2250 cc daily need. The resident's 7/2021 TAR revealed the resident was offered and took up to 120 cc of fluid with each medication pass after the RD recommendations. Resident 10's record did not have documentation to indicate the fruit supplement was started. On 2/15/21 at 5:20 PM Staff 16 (CNA) stated if a resident did not eat her/his meal, the resident could be offered an alternative meal, a snack and or a nutritional supplement. If the resident refused the nurse was notified. The nurse was to check with the resident. On 2/22/22 at 10:21 AM Staff 6 (RN) reviewed Resident 10's record and acknowledged the resident did not eat or drink well. Staff should let the physician know if a resident was not eating or drinking after two to three days of not eating and/or drinking. If needed staff could administer intravenous fluids (fluids administered via a vein) or clysis (fluids administered under the skin). A 7/14/21 Office Visit form indicated Resident 10 was assessed in the facility by the facility physician. The physician assessment revealed the resident was admitted with COVID-19 infection, had fair skin turgor (elasticity of the skin which could be an indication of hydration status) and did not have increased symptoms related to COVID-19. There was no assessment specific to the resident's lack of oral intake of food and fluids. Resident 10's weight on 7/8/21 was 199 pounds and was 197 pounds on 7/15/21. On 2/16/22 at 11:45 AM Staff 3 (RNCM) acknowledged Resident 10 did not eat or drink well and often the intake was less than 50% and the resident was not offered supplements when her/his intake was less than 50%. Staff 3 indicated if a snack or supplement was provided the staff documented the amount consumed in the resident's record. Staff 3 acknowledged the resident was not documented to have snacks. Staff 3 also indicated she would look for documentation the physician was notified of the resident's lack of oral intake. No additional information was provided. On 2/24/22 at 10:00 AM Staff 7 (DNS) stated during COVID-19 the RD assessed residents via virtual visits and record review. The RD wrote a report and then sent it to the facility the next day. The RD recommendations were to be implemented the same day the facility received the recommendation. Staff 7 stated the Staff 19 (Dietary Manager) and RNCM were to work together to get the recommendations in place. Staff were to offer a supplement or snacks if a resident ate less than or equal to 50 percent the meal and they were to document when snacks and supplements were offered. The nurses should assess the resident and monitor the resident if the resident consistently did not eat. Staff 7 acknowledged the resident had decreased food and fluid intake and there was no documentation of snacks or supplements provided. A request was made to Staff 7 to provide documentation the facility assessed the resident and offered additional food and/or fluids to the resident. No additional information was provided. Resident 10's 7/19/21 hospital History and Physical indicated the resident was admitted to the hospital and was "nearly" obtunded (slowed responses to stimulation and drowsy between sleep states). The resident had worsening oral intake "resulting in dehydration". Resident 10 was assessed to have a free water deficit of approximately 2.4 liters. Resident 10 was administered one liter of intravenous fluids in the emergency department. On 2/25/22 at 12:35 PM Staff 20 (RD) reviewed the resident's record and acknowledged the resident had multiple days of poor fluid and oral intake. Staff did not add the fruit based supplement per recommendation. Staff 20 stated the resident's poor fluid intake, prior to her RD assessment, contributed to the resident's diagnoses of dehydration. Staff 20 stated the resident was likely deficient in fluids from multiple days of poor fluid intake. 2. Resident 9 was admitted to the facility 7/19/21 with diagnoses including dementia and respiratory illness. Resident 9's 7/29/21 Nutritional Assessment by the RD indicated the resident's weight on 7/20/21 was 81 pounds and was 83 pounds on 7/26/21. The resident had variable acceptance of meals with an average intake of 50%. The assessment also indicated the resident fluid intake required to meet needs was at least 1100 cc and the resident usually drank less than 1000 cc a day. The recommendation included NEMs (nutritionally enhanced meals-adding high fat foods such as butter and sauces to foods) and staff were to encourage fluids during medication pass. The resident's Active Orders report did not include NEMs and/or an order for staff to provide extra fluids during medication pass. On 2/16/22 at 11:45 AM and on 2/22/21 at 3:36 PM Staff 3 (RNCM) indicated she and the dietary manager were to work together to ensure the Staff 20 (RD) recommendations were implemented. Staff 3 indicated she reviewed Resident 9's Nutritional Assessment and acknowledged the RD recommendation was to add NEMs and to encourage fluids during medication pass. NEMs would be documented as a dietary order. Staff 3 stated when the RD recommended fluids be added with medication pass the recommendation was to be put on the MAR for at least BID fluid administration and to document the amount of fluids consumed. A request was made to Staff 3 to provide documentation NEMs and additional fluids were implemented for the resident after the 7/29/21 RD assessment. No additional information was provided. Resident 9 was discharged on 8/3/21, five days after the RD assessment, and no additional weights were in there resident's record after 7/26/21. The 8/16/21 hospital Discharge summary did not include the diagnosis of dehydration. , 3. Resident 1 was admitted to the facility in 11/2021 with diagnoses including COVID-19 and nutritional deficiency. A review of Resident 1's weight record revealed on 11/10/21 the resident's weight was 139.2 pounds. On 11/17/21 the resident's weight was 128.6. The facility's electronic medical record flagged the 11/17/21 weight as outside the acceptable range for weight change. No re-weigh to verify the resident's weight was found. This was a 7.6% body weight loss over seven days. A review of Resident 1's clinical record revealed no indication Staff 20 (RD), the resident's family or the resident's physician were notified of the weight loss identified on 11/17/21. Resident 1's Nutritional Status care plan created on 11/11/21 indicated the resident was at risk for nutritional impairment related to COVID-19 illness. The goal was for the resident to maintain her/his admission weight within five pounds. The only intervention was to monitor the resident's meal intake. A review of Resident 1's food intake record from 11/10/21 through 11/20/21 revealed overall poor food intake including: - Seven out of ten breakfast intakes of 0-25% consumed. - Seven out of ten lunch intakes of 0-25% consumed. - Seven out of ten dinner intakes of 0-50% consumed. An RD assessment dated 11/19/21 indicated the resident had a severe weight loss and the resident was at increased nutritional risk due to poor intake and weight loss. The assessment indicated "Interventions are in place to increase calories and protein provided and remain appropriate.", however no interventions, other than meal monitoring, prior to 11/19/21 were found. On 2/25/22 at 12:00 PM Staff 20 confirmed Resident 1's weights, weight loss and poor intake. Staff 20 stated her assessment on 11/19/21 was a normal new admission assessment and was not specifically requested by the facility related to the resident's poor intake or weight loss. Staff 20 stated she would expect the facility to assess the resident and implement appropriate interventions based on the resident's documented poor intake, as well as notify her and the resident's physician. , 4. Resident 35 was admitted to the facility in 1/2022 with diagnoses including heart failure. A 1/31/22 BIMS indicated Resident 35 was cognitively intact. A 2/2/22 RD Nutritional Assessment revealed Resident 35 had a variable acceptance of meals. Resident 35's weights revealed a 13.7% severe weight loss. The RD recommendations included to provide a house diabetic nutritional shake if less than 50% of the meal was eaten and to notify the RD as needed. A 2/11/22 Progress Note revealed Resident 35's admission weight on 1/21/22 was 197.4 pounds and Resident 35's 2/11/22 weight was 158 pounds which was a 39.4 pound loss. (This was a 19.96% severe weight loss.) Resident 35's Weight Report revealed the following weights: -1/21/22: 197.4 -1/22/22: 192 -1/28/22: 170 -2/4/22: 167 -2/11/22 158 A review of the medical record revealed no documentation the RD recommended diabetic health shakes were offered or given to Resident 35 or the RD was contacted about the ongoing weight loss. On 2/14/22 at 8:25 AM Resident 35 acknowledged she had an almost 40 pound weight loss in the past three weeks and stated the facility staff did nothing to prevent or stop the weight loss. Resident 35 stated she/he was not asked about her/his dietary preferences and was not offered nutritional shakes. Resident 35 further stated she/he sometimes needed assistance with meals due to problems in both hands but staff rarely offered assistance. Resident 35 stated when she/he needed assistance and assistance was not offered she/he just would not eat. On 2/14/22 at 8:56 AM Staff 19 (Dietary Manager) stated he did not interview residents to obtain their food preferences or specific dietary needs. On 2/23/21 at 9:12 AM Staff 20 (RD) stated before she completed a nutritional assessment resident specific information such as food preferences or special dietary needs should be brought to her by the dietary manager. Staff 20 stated she relied highly on staff to communicate with her but the facility did not contact her about Resident 35's ongoing weight loss. On 2/23/22 at 3:26 PM Staff 7 (DNS) and Staff 3 (RNCM) acknowledged Resident 35's 39.4 pound weight loss and verified Resident 35's medical record had no documentation the nutritional shakes were offered. 5. Resident 22 was admitted to the facility in 1/2022 with diagnoses including muscle wasting, heart failure, dementia and a Stage 4 pressure ulcer (full thickness skin and tissue loss including tendons, ligaments and bone). On 2/22/22 at 10:24 AM Witness 10 (Complainant) stated upon admission to the facility the facility staff were aware Resident 22 only ate mandarin oranges, bananas and drank milk for lunch and dinner. Resident 22 did not eat or drink anything else. Witness 10 stated the facility did not provide the mandarin oranges, as requested prior to Resident 22's admission, and did not notify the family Resident 22 did not get them. Witness 10 further stated Resident 22 went without the mandarin oranges for three to four days until she discovered this so she brought them in for the resident. A review of Resident 22's 1/2022 admission paperwork revealed "mandarin oranges" handwritten in the top right corner of the admission paperwork. A 1/7/22 Nutrition Care Plan revealed Resident 22 was at risk for nutritional impairment related to diminished appetite and poor meal acceptance related to COVID-19. The goal was to maintain weight within five pounds of her/his admission weight. The interventions included to assess and evaluate dietary likes and dislikes and weekly weights. A 1/18/22 Nutritional Assessment indicated to continue the prescribed diet, add NEM (nutritional enhanced meals), add 120 ml of "2 cal" (nutritional supplement), provide a multivitamin with minerals to the evening medication pass and to notify the RD PRN. The specific diet of mandarin oranges, bananas and milk was not assessed. The Weight Record revealed on 1/7/22 Resident 22 weighed 113.2 pounds. No other weights were obtained during Resident 22's stay at the facility. Review of the medical record revealed no documentation the RD recommendations were initiated. On 2/14/22 at 8:56 AM Staff 19 (Dietary Manager) stated he did not interview residents for their food preferences or specific dietary needs. Staff 19 further stated he was not aware Resident 22 only ate mandarin oranges, bananas and drank milk for lunch and dinner. Staff 19 could not recall if the facility provided the mandarin oranges to Resident 22. On 2/14/22 at 9:04 AM Staff 16 (CNA) stated Resident 22 refused multiple meals and loved the bananas and milk. Staff 16 further stated the facility did not provide Resident 22 with mandarin oranges so the family brought in cans of them later on. On 2/14/22 at 9:09 AM Staff 7 (DNS) acknowledged the facility did not honor Resident 22's food preference for mandarin oranges. Staff 7 further stated there was no documentation the RD recommendations were followed. On 2/23/22 at 9:27 AM Staff 20 (RD) stated she was not aware of Resident 22's specific dietary preferences and was unaware Resident 22 only consumed mandarin oranges, bananas and milk. Staff 20 stated she would have recommended other dietary interventions had she known of Resident 22's food preferences. Staff 20 acknowledged the 1/18/22 Nutritional Assessment was not a comprehensive assessment. 6. Resident 2 was admitted to the facility in 10/2021 with diagnoses including diabetes, stroke and GERD (gastroesophageal reflux disease). A 10/15/21 RD Nutritional Assessment revealed Resident 2 had a variable acceptance of meals and "current weight is less than weight at admit to facility and indicates a 7.7% (weight loss) considered severe, recommend verify weight." The assessment further indicated Resident 2 was at an increased nutritional risk due to mechanically altered texture diet, decrease acceptance of meals and weight loss. The RD recommendations included to add NEM (nutritionally enhanced meals), provide a house supplement (nutritional shake) twice a day between meals and to document the ml's consumed on the MAR and to verify Resident 2's weight due to a 14 pound weight loss in one week. A CBG record revealed between 10/4/21 through 10/14/21 Resident 2's CBGs ranged from 76 to 503 (normal CBG range is 70 to 99). The resident's medical record revealed no documentation the NEM was initiated, the MARs did not document the twice daily house supplements and Resident 2's weight was not verified for accuracy. On 2/15/21 at 1:48 PM Staff 7 (DNS) acknowledged the RD recommendations were not followed. On 2/24/22 at 8:33 AM Staff 20 (RD) acknowledged the RD assessment did not include Resident 2's diabetes and varied CBG levels.

Immediate: Residents (1,2,9,10,22) no longer in facility. Resident 35 rereferred to RDN to ensure current recommendations are appropriate. Interview resident is regards to her desired weight, acceptance of supplements, and snack preferences. Others: Review weight report of current residents for last 7 days. Review wound report for current residents for last 7 days. Review intakes of current residents for last 7 days. Review last RDN recommendations for current residents to ensure implementation. Systematic: LNs and CNAs to be educated on importance of correct intake and weight documentation, as well as reporting of low intakes or weight variance to responsible party/MD. LNs and CNAs to be educated on importance of following and encourage compliance with RDN recommendations and proper documentation. IDT team to review weights, wounds, and intakes at weekly NAR meeting. RCM/Designee to implement RDN recommendations next working day. RCM/designee to audit refusals of hydration/nutrition next working day for acceptance of recommended hydration/nutrition, or notification/education of refused hydration/nutrition. Monitoring: DNS/designee to review 10% of residents weekly for weights, wounds, intakes, and RDN recommendation implementation and report findings at monthly QAPI.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#1) reviewed for change in condition. This placed residents at risk for adverse medication consequences. Findings include: Resident 1 was admitted to the facility in 11/2021 with diagnoses including COVID-19 and high blood pressure. A review of Resident 1's 11/2021 MAR revealed the resident was ordered carvedilol (treats high blood pressure and heart failure) 3.125 mg at bedtime with parameters to not administer the medication if the resident's systolic blood pressure (upper number in a blood pressure reading) was less than 100. On 11/11/21 Resident 1's blood pressure was documented on the MAR as 74/40 and Staff 21 (LPN) administered the carvedilol. No comments on the MAR were found to indicate the rationale for administration of the carvedilol outside the ordered parameters. On 2/23/22 at 4:41 PM and 5:19 PM Staff 21 did not recall administering carvedilol to Resident 1 on 11/11/21. Staff 21 stated in a case like this she would not administer the medication, assess the resident and notify the physician. Staff 21 was asked to review the resident's record for any additional information. After Staff 21 reviewed the resident's record she stated she must have misread the blood pressure reading. On 2/16/22 at 10:07 AM Staff 7 (DNS) stated the carvedilol should not have been administered to Resident 1.

Immediate: Resident (1) is no longer in facility. Others: Review current residents BP measure parameters to ensure medications given within parameters. Systematic: LNs educated on importance of following BP parameters. RCM/designee to review MAR of current residents with BP measure parameters to ensure medications given within parameters. Monitoring: DNS and or Designee to review 10 % of MARs of current residents with BP measure parameters weekly to ensure medications given within parameters and reporting findings at monthly QAPI.

Based on interview and record review it was determined the facility failed to ensure dietary preferences were accommodated for 1 of 3 sampled residents (#22) reviewed for food preferences. This placed residents at risk for unmet food preferences and increased nutritional risk. Findings include: Resident 22 was admitted to the facility on 1/6/22 with diagnoses including muscle wasting, heart failure and dementia. On 2/22/22 at 10:24 AM Witness 10 (Complainant) stated upon admission to the facility the facility staff were aware Resident 22 only ate mandarin oranges, bananas and drank milk for lunch and dinner. Resident 22 did not eat or drink anything else. Witness 10 stated the facility did not provide the mandarin oranges as requested prior to Resident 22's admission and did not notify the family Resident 22 did not get them. Witness 10 further stated Resident 22 went without the mandarin oranges for three to four days until she discovered this so she brought them in for the resident. A review of Resident 22's 1/2022 admission paperwork revealed "mandarin oranges" handwritten in the top right corner of the admission paperwork. A 1/7/22 Nutrition Care Plan revealed Resident 22 was at risk for nutritional impairment related to diminished appetite and poor meal acceptance related to COVID-19. The interventions included to assess and evaluate dietary likes and dislikes. The resident's medical record revealed no assessment of Resident 22's dietary likes and dislikes. On 2/14/22 at 8:56 AM Staff 19 (Dietary Manager) stated he did not interview residents for their food preferences or specific dietary needs. Staff 19 further stated he was not aware Resident 22 only ate mandarin oranges, bananas and drank milk for lunch and dinner. Staff 19 could not recall if the facility provided the mandarin oranges to Resident 22. On 2/14/22 at 9:04 AM Staff 16 (CNA) stated Resident 22 refused multiple meals and loved the bananas and milk. Staff 16 further stated the facility did not provide Resident 22 with mandarin oranges so the family brought in cans of them later on. On 2/14/22 at 9:09 AM Staff 7 (DNS) acknowledged the facility did not honor Resident 22's food preference for mandarin oranges.

Immediate: Resident (22) is no longer in the facility Others: Current residents interviewed for food preferences by Dietary Manager/designee, kitchen staff made aware of preference. Systematic: Dietary manager educated on requirement to honor/accommodate resident preferences. Dietary manager/designee to interview new residents for food preferences and ensure kitchen staff are aware of preferences. Monitoring: NHA/designee to review 10% of current residents monthly for documented preferences and kitchen awareness of those preferences, report findings at monthly QAPI.

Based on interview and record review it was determined the facility failed to update their Facility Assessment for 1 of 1 assessments reviewed. The failure to update resulted in an assessment that did not accurately reflect the acuity level needed or the training required to provide care and services to the residents and placed residents at risk for unassessed needs. Findings include: A Facility Assessment last reviewed on 3/3/22 revealed the resident acuity level indicated the facility had a "high long-term care population". The Facility Assessment further revealed the facility would provide monthly trainings, core courses taught, and re-education done as needed and that specific Licensed Nurse and CNA meetings would be coordinated for more specific training and education. On 4/2020 the facility was converted from a long term care facility into a COVID-19 recovery facility. On 3/4/22 at 9:52 AM Staff 2 (Administrator) confirmed that the acuity of the facility as well as the training regimen documented was not accurate to reflect the current acuity and training needs of the facility.

Immediate: Facility assessment updated to assess facility acuity and staff education needs. Others: Current residents have the potential to be affected by the alleged deficient practice. Systematic: Facility assessment to be update at least annually and with any changes in the resident population. Monitoring: NHA to present facility assessment at least annually at QAPI for IDT team review.

Based on interview and record review it was determined the facility failed to ensure breakfast was documented for 1 of 3 sampled residents (#9) reviewed for weight loss. This placed residents at risk for incomplete records. Findings include: Resident 9 was admitted to the facility 7/2021 with diagnoses including dementia. An Active Order list indicated staff were to document the resident's breakfast intake. Resident 9's Meal intake for 7/20/21 through 8/2021 revealed 3 out of 13 breakfasts were documented. On 2/24/22 at 10:00 AM Staff 7 (DNS) acknowledged only three breakfasts were documented for Resident 9 and staff would not be able to track meal intake and possible concerns if there was no documentation.

Immediate: Resident (9) is no longer in the facility Others: Review meal intakes of current residents for last 7 days for any missed documentation. Systematic: CNAs educated on importance of documenting meal intakes as well as reporting low intakes to nursing staff for further follow-up, and notifications to responsible party/MD. RCM/designee to review meal intakes next working day to ensure complete documentation. Monitoring: DNS and or designee to review 10% of current residents meal intakes weekly and report findings at monthly QAPI.

OAR 411-085-0310 Residents' Rights: Generally

Refer to F561 *************** OAR 411-086-0130 Nursing Services: Notification Refer to F580 *************** OAR 411-085-0360 Abuse Refer to F600, F609 and F610 *************** 411-086-0060 Comprehensive Assessment and Care Plan Refer to F636 *************** OAR 411-086-0160 Nursing Services: Discharge Summary Refer to F661 *************** OAR 411-086-0110 Nursing Services: Resident Care Refer to F677, F684 and F760 *************** OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care Refer to F686, F689, F690 and F692 *************** OAR 411-086-0250 Dietary Services Refer to F806 *************** OAR 411-086-0110 Administrator Refer to F838 *************** OAR 411-086-0300 Clinical Records Refer to F842 ***************