Cascade Manor

Based on interview and record review it was determined the facility failed to care plan for hospice care for 1 of 1 sampled resident (#3) reviewed for hospice care. This placed residents at risk for unmet end of life needs. Findings include:

Resident 3 was admitted to the facility in 1/2023 with diagnoses including cardiac heart failure.

A review of the medical record revealed Resident 3 was admitted to hospice on 1/24/23.

A review of the care plan revealed no evidence Resident 3 was care planned for hospice care.

On 3/25/25 at 3:17 PM Staff RCM (RNCM) stated Resident 3 was admitted to hospice on 1/24/25. Staff RCM stated when a resident was placed on hospice the resident should be care planned for hospice care. Staff RCM acknowledged Resident 3 had no care plan for hospice care.

Based on interview and record review it was determined the facility failed to ensure care planned interventions to reduce the risk of injury from falls were in place for 1 of 1 sampled resident (#2) reviewed for accidents. This placed residents at risk for injury. Findings include:

Resident 2 admitted to the facility in 2021 with diagnoses including Cauda Equina Syndrome (neurological condition).

Resident 2's 12/1/24 care plan directed staff to encourage her/him to use her/his call light for assistance, to keep the call light in reach and keep the bed in the low position.

A 12/22/24 progress note revealed Staff 4 (LPN) documented on 12/21/24 at 10:55 PM Resident 2 was heard yelling and staff found her/him on the fall mat, on the ground, next to her/his bed. Resident 2 told staff, "I was looking for my call light and fell out of bed." Staff 4 inspected Resident 2's room and the call light was connected to the wall, but was not in reach of the resident.

Resident 2's 12/30/24 fall investigation summary revealed Staff 3 (RNCM) documented it became clear during the investigation the care plan was not followed as the bed was not lowered to the ground and the call light was not in reach. The root cause of the fall was the call light not in reach of the resident.

On 3/25/25 to 3/26/25 between 8:00 AM to 4:00 PM Resident 2 was observed to lay in her/his bed in the lowest position and the call light was in reach.

On 3/26/25 at 10:17 AM Staff 3 stated Resident 2's call light was expected to always be within reach when she/he was in bed and the bed was to be in the lowest position. Staff 3 confirmed on 12/21/24 at 10:55 PM Resident 2 fell due to the call light not being within her/his reach.

On 3/26/25 at 3:05 PM Staff 2 (DNS) stated she expected Resident 2 to always have her/his call light within reach when in bed. Staff 2 confirmed it was determined Resident 2 fell on 12/21/24 due to her/his call light not in reach. Staff 2 confirmed the facility completed staff training for individual, in services for all facility staff for fall preventions and the root cause analysis for the fall was brought to the Quality Assurance team.

On 12/22/24 the deficient practice was identified by the facility and was corrected by 1/3/25 when the facility completed a root cause analysis of the incident and determined the facility failed to implement care planned intervention to prevent a fall. The Plan of Correction included:
-On 12/27/24 the employee was counseled and provided training to follow the care planned interventions and ensure the call light was in reach.
-On 12/30/24 staff were trained on fall prevention, following care planned interventions including to keep the call light in resident's reach.
-On 1/3/25 staff were provided an in service/education training which included procedures with direct care interventions.

Based on observation, interview and record review it was determined the facility failed to ensure kitchen staff wore appropriate beard restraints during meal preparation and failed to ensure food was stored appropriately and discarded in a timely manner for 1 of 1 facility kitchen reviewed for sanitation and food storage. This placed residents at risk for unsanitary foods and food-borne illness. Findings include:

1. Review of the US FDA Food Code 2022 revealed:
-Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

On 3/25/25 at 12:20 PM a concurrent interview with Staff 5 (Dietary Manager) and observation of the meal preparation occurred. Staff 7 (Cook) had facial hair and was observed preparing food without a beard restraint in place. Staff 5 stated the dietary staff only were required to wear a beard restraint if the beard was long and unkempt.

On 3/26/25 at 1:00 PM Staff 5 stated she reviewed the food code and confirmed the food code did not specify only long facial hair was to be restrained and Staff 7's facial hair was at risk of contaminating food.

2. The facility's General Food Storage Standards, revised 1/2023, revealed the following:
- All stock should be rotated to utilize the first items into stock. Dating of stock aids in adherence to this principle. Any food items that reach their expiration date will be discarded.
- Storage containers need to be appropriate for product needs, labeled and dated.

On 3/24/25 at 10:17 AM a brief kitchen tour was completed and revealed the following:
- In the dry storage, a container of pancake mix was labeled to be used by 3/6/25 and a container of breadcrumbs was labeled to be used by 1/5/25.
- In the refrigerators; two individual slices of cake were in unlabeled storage containers, a jar of soy sauce was labeled to be used by 3/6/25, a jar of lemon juice was labeled to be used by 3/22/25, a container of blackberries was labeled to be used by 3/21/25, and a container of blueberries was labeled to be used by 3/23/25.

On 3/24/25 at 10:27 AM Staff 6 (Dining Room Supervisor) reviewed the items and confirmed the slices of cake were not labeled and the other items were kept past the use by date.

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OAR 411-086-0060 Comprehensive Assessment and Care Plan

Refer to F656
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OAR 411-086-0140 Quality Care: Nursing Services: Problem Resolution and Preventive Care

Refer to F689
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OAR 411-086-0250 Food and Nutrition Services: Dietary Services

Refer to F812
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Based on interview and record review it was determined the facility failed to address advance directives for 2 of 2 sampled residents (#s 7 and 9) reviewed for advanced directives. This placed residents at risk for healthcare decisions to be in conflict with resident wishes. Findings include:

1. Resident 7 admitted to the facility in 2022 with diagnoses including stroke and chronic obstructive pulmonary disease.

A 9/20/22 Skilled Nursing Facility Admission Agreement for CCRC (Continuing Care Retirement Community) Residents indicated Resident 7 had an Advance Directive.

Resident 7's clinical record revealed no Advance Directive.

On 2/22/24 at 4:28 PM Staff 5 (Health Services Coordinator) stated because Resident 7 had a POLST (Physician Orders for Life Sustaining Treatment) in her/his file she did not notify Staff 4 (Social Services Director) to ensure follow-up communication with Resident 7 regarding her/his Advance Directive took place. Staff 5 acknowledged a follow-up conversation with Resident 7 regarding her/his Advance Directive was necessary.

2. Resident 9 readmitted to the facility in 2023 with diagnoses including chronic heart disease and depression.

A 9/6/22 Skilled Nursing Facility Admission Agreement for CCRC (Continuing Care Retirement Community) Residents indicated Resident 9 had no Advance Directive.

On 2/20/24 at 11:23 AM Witness 1 (Family) indicated Resident 9 had an Advance Directive and was not asked to provide the document.

On 2/20/24 at 2:21 PM Staff 4 (Social Services Director) stated the process was to not follow-up on Resident 9's advanced directive needs after the admission agreement was signed unless there were observed changes in a residents' condition. Staff 4 stated Resident 9 needed either a POLST (Physician Orders for Life Sustaining Treatment) or an Advance Directive on file.

On 2/21/24 at 2:57 PM Staff 5 (Health Services Coordinator) stated during her routine file audits she was recently instructed to inform Staff 4 if a resident had no Advance Directive. Staff 5 acknowledged a follow-up conversation with Resident 9 about her/his Advance Directive was necessary.

Based on interview and record review it was determined the facility failed to provide Notices of Medicare Non-Coverage (NOMNC) for 1 of 2 sampled residents (#115) reviewed for liability and appeal notices. This placed residents at risk for lack of appeal information. Findings include:

Resident 115 admitted to the facility in 2023 with diagnoses including cancer and convulsions.

a. A NOMNC form indicated the last covered day was 12/22/23. The form was signed by Resident 115 on 12/28/23.

On 2/22/24 at 10:21 AM Staff 1 (Administrator) stated she did not know why the notice was signed late.

b. A NOMNC form indicated the last covered day was 1/12/24 for Resident 115's readmission.

There was no evidence in the clinical record the NOMNC form was presented to Resident 115 prior to the end of Medicare coverage.

On 2/22/24 at 10:21 AM Staff 1 (Administrator) stated she could not locate a second NOMNC form for Resident 115.

Based on interview and record review it was determined facility staff failed to meet professional standards related to care and services for a feeding tube for 1 of 1 sampled resident (#165) reviewed for a feeding tube. Resident 165 required hospitalization and surgery for feeding tube replacement. Findings include:

Resident 165 admitted to the facility in 2023 with diagnoses including dysphagia (difficulty swallowing) and a newly acquired feeding tube placement.

On 5/8/23 a FRI was received which alleged on 5/6/23 Staff 12 (Former RNCM) provided enteral feeding through Resident 165's feeding tube, had difficulty with the feeding tube and cut off the port (opening to access the feeding tube) for easier administration of the feeding. Staff 12 indicated there was no equipment to care for the tube feeding and the present equipment was dirty. A purchase order indicated supplies for the feeding tube were delivered to the facility on 5/3/23.

The FRI included the following:

- On 5/7/23 Staff 6 (RNCM) indicated she received report on the morning shift of 5/7/23 which indicated Resident 165's feeding tube was cut due to the syringes not fitting correctly. Staff 6 indicated there were supplies in the resident's room which could have been applied to the tubing for a syringe to fit for feeding. Staff 6 indicated she called Staff 2 (DNS) and reported the incident. Staff 6 indicated she did not document the incident in the progress notes.
-On 5/8/23 Staff 16 (Former RN) indicated in report she was told Resident 165's feeding tube port was cut due to the syringes not fitting well. Staff 16 indicated she had a difficult time administering the resident's feedings and medications.
-On 5/8/23 at 9:20 AM a call was placed to the Gastroenterologist two days after Staff 12 cut the feeding tube. The situation was explained regarding the cutting of the feeding tube. The physician's office indicated to send Resident 165 to the ER (Emergency Room).
-On 5/8/23 at 11:30 AM Resident 165 was sent to the ER. Physician notes indicated Resident 165 required surgical intervention including being intubated (tube placed into the throat to maintain an airway) for the replacement of the feeding tube. Resident 165 was admitted to the hospital on 5/8/23, had surgery on 5/9/23 and returned to the facility thereafter.

On 2/22/24 at 12:13 PM Staff 6 (RNCM) stated when she arrived for work on 5/7/23 she was told in report the port of the resident's feeding tube was cut on 5/6/23. Staff 6 stated Staff 12 indicated she cut the tubing due to the tubing being dirty and there were no clean supplies available for the tubing. Staff 6 stated there were supplies in the resident's room which were sent from the hospital upon admission and more supplies in the supply closet. Staff 6 stated she called Staff 2 (DNS) but did not call the doctor or write a progress note regarding the incident.

On 2/23/24 at 12:38 PM Staff 12 stated she took Resident 165 to her/his room to complete the tube feeding. Staff 12 stated there were dirty syringes with no dates and no correct equipment to administer the tube feeding so she cut the tubing so a syringe would fit on the tubing for the feeding. Staff 12 stated she told the oncoming nurse what she did and there were no supplies. Staff 12 stated another nurse showed her where the supplies were kept. Staff 12 stated she did not notify the physician, management or write a progress note. Staff 12 acknowledged she should not have cut the feeding tube due to the risk of the feeding tube leaking from not being closed tightly or possible infection.

Refer to F693

Based on observation, interview, and record review it was determined the facility failed to maintain water temperatures for 3 of 3 resident rooms (#s 20, 21, and 31) reviewed for accident hazards. This placed residents at risk for injury. Findings include:

Industry standards and best practices endorse water temperatures not to exceed 120 degrees F.

On 2/19/24 at 3:40 PM, 2/19/24 at 3:50 PM and 2/20/24 at 8:30 AM the hot water was assessed in resident Rooms 20, 21, and 31.

On 2/20/24 at 8:31 AM the surveyor checked the temperature of the water in the visitation room and the thermometer indicated the water was 122 degrees F.

On 2/21/24 at 8:11 AM Staff 13 (Maintenance Supervisor) used a thermometer to measure the water temperature in resident Room 20. The thermometer indicated the water was 135 degrees F.

On 2/21/24 at 8:12 AM Staff 13 used a thermometer to measure the water temperature in resident Room 31. The thermometer indicated the water was 135 degrees F.

Both residents in resident Room 20 were totally dependent on staff and were not able to access the water on their own.

Resident 2 in resident Room 31 required staff assistance to access the water in the sink.

On 2/21/24 at 8:27 AM Staff 13 provided temperature logs for the facility hot water system.

The temperature logs dated 1/28/24 through 2/20/24 revealed water temperatures above 120 degrees F with the majority at 123 degrees F.

On 2/21/24 Staff 13 was asked about monitoring of the temperature logs and stated the facility adjusted the water mixing valve and he would re-check the temperatures. Staff 13 stated he did not know who was reviewing the temperature logs.

On 2/21/24 at 9:14 AM Staff 14 (Director of Facility Services) stated she did not review the temperature logs and she did not know who was monitoring the temperature logs.

On 2/21/24 at 10:14 AM Staff 1 (Administrator) stated she was made aware of the hot water concerns the temperatures were being adjusted, and a new procedure for monitoring of water temperatures needed implementation.

Based on interview and record review it was determined the facility failed to ensure a resident received appropriate care and services related to a feeding tube for 1 of 1 unsampled resident (#165) reviewed for a feeding tube. Resident 165 required surgery for feeding tube replacement. Findings include:

Resident 165 admitted to the facility in 2023 with diagnoses including dysphagia (difficulty swallowing) and a feeding tube.

On 5/8/23 a FRI was received which alleged on 5/6/23 Staff 12 (Former RNCM) had difficulty with Resident 165's feeding tube while providing enteral feeding, and cut off the port (opening to access the feeding tube) for improved administration of the feeding. Staff 12 indicated there was no equipment to care for the tube feeding and the present equipment was dirty. A purchase order indicated supplies for the feeding tube were delivered to the facility on 5/3/23.

On 5/8/23 Staff 16 (Former RN) indicated in report she was told Resident 165's feeding tube port was cut due to the syringes not fitting well. Staff 16 indicated she had a difficult time administering the resident's feedings and medications.

On 5/8/23 at 9:20 AM a call was placed to the Gastroenterologist two days after Staff 12 cut the feeding tube. The situation was explained regarding the cutting of the feeding tube. The physician's office indicated to send Resident 165 to the ER (Emergency Room).

On 5/8/23 at 11:30 AM Resident 165 was sent to the ER (Emergency Room). Physician notes indicated Resident 165 required surgical intervention including being intubated (tube placed into the throat to maintain an airway) for the replacement of the feeding tube. Resident 165 was admitted to the hospital on 5/8/23 and had surgery on 5/9/23 and returned to the facility thereafter.

On 2/22/24 at 1:13 PM Staff 6 (RNCM) indicated Staff 12 stated she cut Resident 165's feeding tube due to the tube being dirty and not able to find clean supplies. Staff 6 stated she checked the resident's room and found a container on the resident's table which included clean supplies for the feeding tube. Staff 6 stated there were also feeding tube supplies in the supply closet.

On 2/23/24 at 12:38 PM Staff 12 acknowledged she cut the feeding tube port because she did not have clean equipment for the administration of the enteral feeding and did not believe the cut would cause any problems. Staff 12 acknowledged she should not have cut the feeding tube due to the risk of the feeding tube leaking from not being closed tightly or possible infection.

Based on interview and record review it was determined the facility failed to ensure the facility was staffed to include the services of a RN at least eight consecutive hours per day seven days per week for 13 of 36 days reviewed. This placed residents at risk for lack of comprehensive assessments. Findings include:

Review of the Direct Care Staff Daily Reports identified on the payroll based journal report, first quarter 2023, for no RN and from 1/19/24 through 2/18/24 revealed there were no RNs scheduled during a 24 hour period on 2/4/23 (Saturday), 2/5/23 (Sunday), 2/18/23 (Saturday), 2/19/23 (Sunday), 3/4/23 (Saturday), 3/5/23 (Sunday), 1/21/24 (Sunday), 1/26/24 (Friday), 2/3/24 (Saturday), 2/9/24 (Friday), 2/13/24 (Tuesday), 2/17/24 (Saturday), and 2/18/24 (Sunday).

On 2/20/24 at 1:57 PM Staff 1 (Administrator) acknowledged there were multiple days the facility did not have a RN scheduled to provide direct care and the facility did not have a waiver. Staff 1 stated the DNS or the RNCM was usually available during the week and available by phone if needed on the weekend. A request was made to Staff 1 to provide documentation to verify a RN was onsite on the identified dates. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure proper handwashing practices were in place and food was prepared and stored to meet food safety standards for 1 of 1 kitchen. This placed residents at risk for foodborne illness. Findings include:

An undated Anytime Menu for breakfast indicated eggs were available poached, soft boiled, fried or scrambled for residents.

An undated handwritten meal service count provided on 2/22/24 at 6:00 PM by Staff 7 (Certified Dietary Manager) indicated undercooked eggs were served 49 times to residents during the last 35 days.

On 2/19/24 at 12:25 PM no pasteurized (partial sterilization involving heat) eggs were observed in the kitchen.

On 2/19/24 at 12:38 PM two 20-quart containers that were approximately 18 inches deep of warm soup were observed on the counter in the kitchen. The soup containers were uncovered with a plastic container of ice partially immersed into the contents to promote cooling. Staff 10 (Cook) stated the facility had no practice to verify the temperatures of foods that cooled to ensure foods did not remain in the danger zone (food temperature range where bacteria grows rapidly) for an extended period of time. Staff 10 indicated he was not able to verify how long the soups remained on the counter but understood foods in the danger zone longer than four hours should be thrown out.

On 2/19/24 at 12:51 PM Staff 9 (Executive Chef) confirmed there was no clear expectation for staff on how cooked foods were to be cooled and he transferred soups into shallow pans to promote quicker cooling.

On 2/22/24 at 11:57 AM two 20-quart containers that were approximately 18 inches deep of soup were observed uncovered with a plastic container of ice partially immersed into the contents. The uncovered containers of soup were placed on a cart inside the door of the delivery dock with multiple staff observed in and out of the unsecured delivery area.

On 2/22/24 at 12:01 PM Staff 7 was shown the cart with the uncovered soup and stated on 2/21/24 she provided food safety guidelines to Staff 9 in order for staff to be educated. Staff 7 acknowledged the current setup for the cooling of the soup did not meet food safety guidelines.

On 2/22/24 at 1:22 PM Staff 8 (Dishwasher) was observed to rinse dirty dishes and pots before the items were placed in the dish washer. No hand washing was observed by Staff 8 prior to the removal of clean dishes from the dish machine. Staff 8 stated he was not aware hand washing was required during the dish washing and clean dish removal process.

On 2/22/24 at 1:45 PM Staff 7 acknowledged there were no pasteurized eggs ordered by Staff 9 because she believed pasteurized eggs was only a recommendation. Staff 7 also acknowledged a process to ensure hand washing routinely occurred in the dish room area was needed.

Based on interview and record review it was determined the facility failed to implement a physician's plan for therapy for 1 of 1 sampled resident (#9) reviewed for rehabilitation and therapy. This placed residents at risk for lack of therapy interventions. Findings include:

Resident 9 admitted to the facility in 2023 with diagnoses including chronic heart disease and depression.

A 12/22/23 revised care plan indicated Resident 9 had a problem with shortness of breath and coughing due to suspected aspiration (food or liquid in a person's airway) pneumonia.

A 12/22/23 physician progress note indicated during rounds on 12/6/23 Resident 9 was observed to cough after eating and now required antibiotics for pneumonia.

A 1/3/24 Encounter Nursing Home Visit revealed a previous speech consult was not completed as anticipated, Staff 15 (Nurse Practioner) spoke to a nurse and Resident 9 was to receive a bedside swallow evaluation. On 1/4/24 the plan was signed and acknowledged by three staff including Staff 3 (LPN).

A 1/17/24 Encounter Nursing Home Visit revealed a swallow evaluation was ordered but not conducted.

On 2/19/24 at 8:36 AM Resident 9 stated she/he had no issues with swallowing food but did have issues finding her/his voice.

On 2/20/24 at 2:06 PM Staff 3 stated after the recommendation for Resident 9's speech evaluation an order should have been sent to the physician for a signature. Staff 3 confirmed she did not see any order for Resident 9's speech evaluation.

On 2/20/24 at 2:46 PM Staff 6 (RNCM) stated the first nurse to sign and acknowledge Staff 15's plan for Resident 9's speech evaluation should have entered it into the system to generate an order. Staff 6 further stated one of the three staff who signed and acknowledged the recommendation was to ensure the order was entered. Staff 6 acknowledged there was no order generated for Resident 9's speech therapy services as expected.






Based on interview and record review it was determined the facility failed to ensure physician orders for therapy were implemented for 3 of 4 sampled residents (#s 300, 301, and 302) reviewed for rehabilitation and therapy. This placed residents at risk for lack of therapy interventions. Findings include:

1. Resident 300 admitted to the facility in 2024 with diagnoses including fracture of the spine and repeat falls.

An 4/26/24 physician order indicated OT was to evaluate and treat Resident 300.

A 5/2/24 OT Evaluation and Plan of Treatment indicated Resident 300 was to perform lower body dressing and toilet transfers with supervision with a target date of 5/15/24. Resident 300 was to be independent with the tasks by 8/8/24. The expected frequency for therapy was 12 times from 5/2/24 through 8/8/24.

A 5/9/24 Service Log Matrix for OT indicated no service hours for OT occurred after the 5/2/24 OT Evaluation.

On 5/9/24 at 11:22 AM Staff 5 (Therapy Director) stated the OT for the therapy department worked only on-call, and fulfillment for Resident 300's OT service orders was in process.

On 5/9/24 at 12:58 PM Staff 1 (DNS) stated daily meetings occurred with therapy and she was not aware OT services for Resident 300 were not provided. Staff 1 stated her expectation was Resident 300 received OT therapy at least two times a week in order to meet her/his therapy goals.

2. Resident 301 admitted to the facility in 2024 with diagnoses including a fractured left thigh bone and a history of falling.

An 4/10/24 physician order indicated OT was to evaluate and treat Resident 301.

An 4/12/24 OT Evaluation and Plan of Treatment indicated Resident 301 would perform with supervision the following by 4/25/24: adjust clothing, perform hygiene and transfer with toileting, and achieve standing balance with ADLs and lower body dressing. The expected frequency for therapy was 12 times from 4/12/24 through 7/19/24. By 7/19/24 Resident 301 was to be independent with her/his goals.

A 5/9/24 Service Log Matrix for OT indicated no service hours for OT occurred after the 4/12/24 OT Evaluation (27 days with no OT services).

On 5/9/24 at 11:22 AM Staff 5 (Therapy Director) stated the OT for the therapy department worked only on-call, and fulfillment for Resident 301's OT service orders was in process.

On 5/9/24 at 1:51 PM Staff 7 (CNA) stated Resident 301 continued to struggle with her/his balance during ADL care and toileting assistance was still needed. Staff 7 stated she did not see OT assist Resident 301.

On 5/9/24 at 3:53 PM Staff 1 (DNS) stated daily meetings occurred with therapy and she was not aware OT services for Resident 301 were not in process. Staff 1 stated her expectation was Resident 301 received OT services after the initial 4/12/24 evaluation in order to meet Resident 301's therapy goals, and communication of OT services was not provided.

3. Resident 302 admitted to the facility in 2023 with diagnoses including surgery aftercare and repeat falls.

An 4/30/24 physician order indicated OT was to evaluate and treat Resident 302.

A 5/1/24 care plan indicated Resident 302 was at risk for falls and therapy recommendations were to be utilized.

The clinical record for Resident 302 revealed no completed OT evaluation.

On 5/9/24 at 11:22 AM Staff 5 (Therapy Director) stated there was no OT evaluation or services for Resident 302.

On 5/9/24 at 12:58 PM Staff 1 (DNS) stated she believed a hard-copy of the therapy orders for Resident 302 was placed in Staff 5's inter-office mailbox.

On 5/9/24 at 2:25 PM Staff 3 (Resident Care Manager) stated on 5/9/24 she was informed Resident 302's OT evaluation was not completed as expected.

Based on interview and record review it was determined the facility failed to systematically analyze data and implement plans of action to correct identified deficiencies related to water temperatures for 12 of 12 resident rooms reviewed for accident hazards. Findings include:

On 2/21/23 at 8:12 AM Staff 13 (Maintenance Supervisor) stated five rooms a day were monitored for water temperatures. Staff 13 added he believed Staff 14 (Director of Facility Services) reviewed the temperature logs.

On 2/21/24 at 9:14 AM Staff 14 stated the "custodians" performed water temperature monitoring. Staff 14 added she participated in QAPI meetings but was unsure of expectations for reporting data and the water temperatures were not discussed.

On 2/22/24 at 5:59 PM Staff 1 (Administrator) was asked about the QAPI process. Staff 1 stated during her first QAPI meeting, she identified QAPI was an area they needed to improve.

Refer to F689

Based on observation and interview it was determined the facility failed to follow infection control standards for 1 of 1 sampled resident (#3) reviewed for transmission based precautions (TBP). This placed residents at risk for exposure to infections. Findings include:

Resident 3 admitted to the facility in 2021 with diagnoses including arthritis and low back problems.

The facility indicated Resident 3 was on contact precautions (required the use of gloves and a gown) for a wound infection.

There was no signage at the Resident's room or PPE supplies which indicated contact precautions were in place for Resident 3.

On 2/19/24 at 4:19 PM Staff 11 (RN) was asked about wound care and TBP. Staff 11 stated wound care usually occurred on day shift but she occasionally had to perform a dressing change if the dressing came off. Staff 11 indicated she only wore gloves for the dressing change.

On 2/19/24 at 4:34 AM Staff 6 (RNCM) stated there was no signage posted because the nurses performed wound care and they knew Resident 3 was on contact precautions.

On 2/20/24 at 8:18 AM Staff 3 (LPN) was asked about performing wound care for Resident 11 and stated she only wore gloves.

On 2/22/24 at 4:50 PM Staff 2 (DNS/IP) stated Resident 11 was on contact precautions for a wound infection. Staff 2 added there should be a sign indicating what precautions Resident 11 was on and PPE should be available at the resident's door for staff to use. Staff 2 indicated she would need to follow up with staff regarding TBP protocols.

OAR 411-086-0040: Admission of Residents

Refer to F578

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OAR 411-085-0320: Residents' Rights: Charges and Rates

Refer to F582

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

Refer to F658 and F693

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

Refer to F689

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OAR 411-086-0100: Nursing Services: Staffing

Refer to F727

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OAR 411-086-0250: Dietary Service

Refer to F812

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OAR 411-086-0220: Rehabilitative Services

Refer to F825

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OAR 411-086-0330: Infection Control and Universal Precautions

Refer to F880

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OAR 411-085-0220: Quality Assurance

Refer to 867
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OAR 411-086-0220: Rehabilitative Services

Refer to F825

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Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/01/2023 and 05/07/2023, 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 residents were informed of or had the opportunity to make treatment decisions related to medications for 2 of 5 sampled residents (#s 12 and 14) reviewed for medications. This placed residents at risk for being uninformed. Findings include:

1. Resident 14 was admitted to the facility in 2022 with diagnoses including liver cancer.

Hospital transfer orders dated 11/17/22 included orders for Lexapro and Cymbalta (antidepressants).

The 11/2022 MAR indicated Resident 14 received both Lexapro and Cymbalta.

On 12/16/22 at 1:33 PM Resident 14 was asked if she/he received any medications for her/his mood. Resident 14 denied taking medications for mood. Resident 14 was asked about Lexapro and Cymbalta. Resident 14 stated Cymbalta was familiar.

A Consent for Treatment with Antidepressant Medications related to Lexapro dated 11/18/22 was signed by Resident 14 on 12/16/22.

There was no evidence in the medical record to indicate Resident 14 was informed of the use of Cymbalta.

On 12/19/22 at 2:23 PM Staff 3 (RNCM) stated she did not know why the Cymbalta was discontinued and agreed there were no consent for Cymbalta and the consent for Lexapro was completed 12/16/22.
,
2. Resident 12 was admitted to the facility in 2021 with diagnoses including depression.

Resident 12's physician's orders revealed an 4/13/22 order for citalopram (an antidepressant) for depression.

A review of Resident 12's 4/2022 through 12/2022 MARs revealed she/he received citalopram daily after 4/13/22.

A review of the medical record revealed no documentation Resident 12 was informed of the use of citalopram.

On 12/16/22 at 2:23 PM Staff 3 (RNCM) provided a consent for citalopram dated 12/16/22 and confirmed there was no consent in the medical record prior to that date.

Based on interview and record review it was determined the facility failed to develop comprehensive person centered care plans for 2 of 5 sampled (#s 8 and 14) reviewed for medications. This placed residents at risk for unmet needs. Findings include:

1. Resident 8 was admitted to the facility in 2022 with diagnoses including a neuromuscular disease and bipolar disorder.

The 12/2022 MAR indicated Resident 8 was being treated for bipolar disorder, seizures and chronic obstructive pulmonary disease (COPD).

A comprehensive care plan last revised 12/15/22 did not contain information or interventions related to Resident 8's seizure disorder, bipolar disorder or COPD. Additionally, the resident was care planned to use one side rail to assist with bed mobility and to check to ensure it was in a secure position, but did not provide instructions for when the rail should be used.

On 12/19/22 at 2:03 PM The resident's care plan was discussed with Staff 3 (RNCM). Staff 3 stated Resident 8 had bipolar disorder and received antipsychotic and antidepressant medications. Staff 3 reviewed Resident's 8 care plan and agreed it was relatively basic, needed updating and was not resident specific.

2. Resident 14 was admitted to the facility in 2022 with diagnoses including falls and liver cancer.

A comprehensive care plan last revised 12/2/22 contained baseline care interventions and did not contain resident specific information and/or interventions related to Resident 14's falls history, cancer, wound, pain, diabetes and mood related to diagnosis, declining medical condition and changes in living situation.

On 12/20/22 at 12:20 PM Staff 3 (RNCM) agreed Resident 14's care plan was not comprehensive and specific to Resident 14's conditions and care needs.

Based on observation, interview and record review it was determined the facility failed to accurately assess and monitor a pressure ulcer for 1 of 1 sampled resident (#14) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers. Findings include:

Resident 14 was admitted to the facility in 2022 with diagnoses including pressure ulcer and cancer.

On 12/16/22 at 1:33 PM Resident 14 was observed in bed, laying slightly toward her/his right side.
Resident 14 was asked about her/his wound and she/he stated it was getting better but was not painful.

No wound observation was made due to the resident's transfer to the hospital and a decline in medical condition.

An Admission MDS dated 11/23/22 indicated Resident 14 had a Stage 2 (shiny or dry shallow ulcer without slough [thin, stringy light colored dead tissue]) pressure ulcer on her/his sacrum (flat bone just above the tailbone) present on admission to the facility. Resident risks were identified such as decreased mobility and loose stools.

A Skin and Wound Evaluation dated 11/18/22 identified the size of the wound and the wound bed contained 70% slough.

A Skin and Wound Evaluation dated 11/30/22 identified the size of the wound and the wound bed contained 80% slough.

A Skin and Wound Evaluation dated 12/6/22 identified the size of the wound. The evaluation did not contain information about the wound bed or progress of the wound.

On 12/20/22 at 12:20 PM Staff 3 (RNCM) stated the resident admitted with the pressure ulcer and the facility assessed the wound to be a Stage 2. Staff 3 was asked about the presence of slough in the wound and stated the hospital identified the wound as a Stage 2. Staff 3 acknowledged the 12/6/22 evaluation was not completed and the wound was not assessed weekly as was the standard of practice.

Based on interview and record review it was determined the facility failed to timely or thoroughly assess falls for 2 of 3 sampled residents (#s 6 and 8) reviewed for accidents. This placed residents at risk for falls. Findings include:

1. Resident 8 was admitted to the facility in 2022 with diagnoses including a neuromuscular disease and bipolar disorder.

On 12/1/22 at 2:20 AM Resident 8 had an unwitnessed fall and sustained some ankle swelling.

An accident investigation dated 12/1/22 was not completed until 12/15/22.

On 12/20/22 at 11:54 AM Staff 3 (RNCM) was asked about Resident 8's fall. Staff 3 agreed the investigation conclusion was not timely.
,
2. Resident 6 was admitted to the facility in 2020 with diagnoses including Alzheimer's disease.

An Un-Witnessed Fall Investigation dated 9/27/22 revealed Resident 6 had a fall in her/his room. The investigation identified the time Resident 6 was found on the floor as 7:40 PM, 8:25 PM and 8:40 PM. The investigation was completed on 12/15/22.

On 12/20/22 at 10:23 AM Staff 3 (RNCM) reviewed Resident 6's fall and the fall investigation. Staff 3 was unable to clarify the time of the fall and stated the incident did not appear to have been fully investigated. Staff 3 also acknowledged the 9/27/22 fall investigation was not completed timely.

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours in a 24-hour period for 18 of 30 days reviewed for staffing. This placed residents at risk for unassessed needs and lack of care. Findings include:

A Review of the Direct Care Staff Daily Reports from 11/15/22 through 12/14/22 revealed no RN coverage on the following dates:
- 11/17/22
- 11/18/22
- 11/20/22
- 11/21/22
- 11/22/22
- 11/26/22
- 11/27/22
- 12/1/22
- 12/3/22
- 12/4/22
- 12/5/22
- 12/6/22
- 12/7/22
- 12/10/22
- 12/11/22
- 12/12/22
- 12/13/22
- 12/14/22

On 12/16/22 at 11:44 AM Staff 2 (Director of Nursing) confirmed the identified dates with no RN coverage.

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 potentially hazardous microorganisms for 1 of 1 facility reviewed for infection control. This placed residents at risk for water borne infections. Findings include:

On 12/16/22 at 12:24 PM Staff 5 (Director of Facility Services) was asked about the facility's water management program including a risk assessment related to potential areas of Legionella growth. Staff 5 confirmed the facility did not develop or implement a water management program and did not have a water flow schematic or flow diagram.

On 12/16/22 at 1:45 PM Staff 5 stated she would continue to look for water management documentation. No further information was provided.

Based on interview and record review it was determined the facility failed to ensure eight contiguous hours of RN coverage during day and/or evening shift for 18 of 30 days reviewed for staffing. This placed residents at risk for unassessed needs and lack of care. Findings include:

A review of the Direct Care Staff Daily Reports from 11/15/22-12/14/22 revealed no RN coverage for the following dates:
- 11/17/22
- 11/18/22
- 11/20/22
- 11/21/22
- 11/22/22
- 11/26/22
- 11/27/22
- 12/1/22
- 12/3/22
- 12/4/22
- 12/5/22
- 12/6/22
- 12/7/22
- 12/10/22
- 12/11/22
- 12/12/22
- 12/13/22
- 12/14/22

On 12/16/22 at 11:44 AM Staff 2 (Director of Nursing) confirmed the identified dates with no RN coverage.

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

Refer to F552

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OAR-411-086-0060: Comprehensive Assessment and Care Plan

Refer to F656

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

Refer to F686 and F689

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OAR-411-086-0100: Nursing Services: Staffing

Refer to F727

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OAR-411-086-0330: Infection Control and Universal Precautions

Refer to F880

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Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/05/2022 and 09/11/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on 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 12/13/2021 and 12/19/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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 11/29/2021 and 12/05/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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 06/21/2021 and 06/27/2021, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to report an allegation of abuse to the administrator and other officials including the State Survey Agency. This placed residents at risk for potential abuse. Findings include:

Resident 1 was admitted to the facility in 2020 with diagnoses including dementia.

On 2/22/21 an allegation of abuse was reported by the Oregon State Board of Nursing (OSBN) to the State Survey Agency. The referral indicated the OSBN received a complaint of verbal abuse of Resident 1 on 2/11/21 by Witness 1 (Complainant).

Review of the facility records revealed no documentation the facility reported an allegation of verbal abuse of Resident 1 on 2/11/21 within 2 hours to the facility's administrator or other officials including the State Survey Agency.

In an interview on 3/1/21 at 2:15 PM Witness 1 said on 2/11/21 Resident 1 was incontinent of bowel and needed incontinence care. Witness 1 said the resident was resistant to care and requested assistance from Staff 6 (RN). Witness 1 said Staff 6 yelled at the resident and called the resident a terrible person. Witness 1 said she reported the incident to Staff 5 (DNS) on 2/12/21 and also reported the incident to the OSBN.

In an interview on 3/3/21 at 9:40 AM Staff 5 said she received a report of alleged verbal abuse of Resident 1 from Witness 1 on 2/12/21. Staff 5 said she did not report the incident to the facility administrator or the State Survey Agency within 2 hours because she conducted an investigation and did not feel Witness 1 was credible.

Based on interview and record review it was determined the facility failed to investigate an allegation of abuse for 1 of 3 sampled residents (#1) reviewed for abuse. This placed residents at risk for potential abuse. Findings include:

Resident 1 was admitted to the facility in 2020 with diagnoses including dementia.

On 2/22/21 an allegation of abuse was reported by the Oregon State Board of Nursing (OSBN) to the State Survey Agency. The referral indicated the OSBN received a complaint of verbal abuse of Resident 1 on 2/11/21 by Witness 1 (Complainant).

Review of the facility records revealed no documentation the facility conducted an investigation of the alleged verbal abuse of Resident 1 within five working days of the incident.

In an interview on 3/1/21 at 2:15 PM Witness 1 said on 2/11/21 Resident 1 was incontinent of bowel and needed incontinence care. Witness 1 said the resident was resistant to care and requested assistance from Staff 6 (RN). Witness 1 said Staff 6 yelled at the resident and called the resident a terrible person. Witness 1 said she reported the incident to Staff 5 (DNS) on 2/12/21 and also reported the incident to the OSBN.

In an interview on 3/3/21 at 9:40 PM Staff 5 said she received a report of alleged verbal abuse of Resident 1 from Witness 1 on 2/12/21. Staff 5 said she conducted an investigation of the incident and ruled out the verbal abuse because she did not think Witness 1's allegations were credible. Staff 5 said there was no documentation the investigation was conducted or completed.

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OAR 411-085-0360 Abuse

Refer to F609 and F610
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