Every finding on record at Avamere Rehabilitation Of Lebanon

Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet resident needs in a timely manner for 3 of 4 sampled residents (#s 1, 2 and 5) reviewed for call light times. This placed residents at risk for unmet needs. Findings include:The facility's 4/29/26 Quality Assurance Resident Council meeting minutes indicated resident's call lights were not answered timely. Attached to the report were the Bi-Monthly Resident Counsel Questions. One question asked whether staff respond to call lights within a 10-minute time frame; the documented response was no. Another question asked whether there were enough staff to meet residents' needs, and the documented response was no. 1. Resident 1 was admitted to the facility in 3/2026 with diagnoses including diabetes and chronic pain. A 3/30/26 care plan indicated Resident 1 was at high risk for falls. The Call Data Report for call light wait times from 4/1/26 through 4/7/26 indicated the following:-On 4/4/26 at 4:16 PM, Resident 1's call light wait time was 20 minutes and at 6:52 PM the call light wait time was 25 minutes.-On 4/5/26 at 10:35 AM, Resident 1's call light wait time was 23 minutes. A 4/4/26 admission MDS indicated Resident 1 was cognitively intact. On 5/1/26 the State Survey agency received a public complaint alleging Resident 1's call light was not answered timely and on one occasion it took staff over 30 minutes to respond. On 5/8/26 at 8:29 AM, Resident 1 stated around the first part of 4/2026 call light wait times were long and there were not enough staff to assist the residents timely. On 5/12/26at 11:18 AM, Staff 18 (CNA) stated residents complained of long call light wait times. Staff 18 stated she did not feel the facility staffed enough CNAs for the acuity of the residents. Staff 18 stated on 4/5/26 at 10:35 AM, she could have been providing another resident with a shower and that was why Resident 1's call light time was 23 minutes long. On 5/12/26 at 11:41 AM, Staff 17 (CNA) stated the facility was most likely short-staffed on 4/4/26. Staff stated that around 4:00 PM CNAs assisted residents up for dinner, and around 7:00 PM CNAs assisted residents for bed. Staff were busy during these times and call light wait times could have been longer. On 5/12/26 at 12:51 PM, Staff 1 (Administrator) stated the expectations for staff for call light wait times was 10 minutes or less. 2. Resident 2 was admitted to the facility in 9/2019 with diagnoses including diabetes, anxiety and chronic pain. A revised Care Plan dated 6/13/24 indicated Resident 2 had alteration to musculoskeletal status due to contractures to both legs. Staff were to anticipate and meet needs; call light was to be in reach while in bed; and staff were to respond promptly to all requests for assistance. A 2/5/26 Quarterly MDS indicated Resident 2 was cognitively intact. The Call Data Report for call light wait times from 4/8/26 through 4/12/26 indicated the following:-On 4/8/26 at 11:03 AM, Resident 2's call light wait time was 25 minutes.-On 4/9/26 at 8:18 AM, Resident 2's call light wat time was 35 minutes; at 12:56 PM 34 minutes; at 3:17 PM 23 minutes; at 5:41 PM 29 minutes; at 7:13 PM: 64 minutes; and at 9:54 PM 38 minutes.-On 4/11/26 at 3:34 PM, Resident 2's call light wait time was 26 minutes; at 4:49 PM 41 minutes; at 7:04 PM 49 minutes; and at 8:59 PM 48 minutes.-On 4/12/26 at 7:07 AM, Resident 2's call light wait time was 26 minutes. A 4/9/26 Verbal Aggression Received Investigation indicated Resident 2 exited her/his room, went to the medication cart, and was yelling potty, potty time and she/he wanted to use the restroom. On 5/11/26 at 8:51 AM, Resident 2 stated when staff did not come and answer her/his call light timely, she/he would go out to get them. On 5/12/26 at 8:44 AM, Staff 19 (CNA) stated residents complained of long call light wait times all the time. Staff 19 stated she saw residents who are continent have an incontinent episode because they could not hold it long enough. Staff 19 stated Resident 2 became verbally abusive to staff when she/he waited. Resident 2 yelled she/he wet her/his brief while waiting for staff to come and assist. On 5/12/26 at 8:59 AM, Staff 20 (CNA) stated she did not feel the facility had enough staff to meet the needs of the residents. Staff 20 stated Resident 2 required two staff to assist, and sometimes it was difficult to find another staff member to assist. On 5/12/26 at 12:51 PM, Staff 1 (Administrator) stated the expectations for staff for call light wait times were 10 minutes or less. 3. Resident 5 was admitted to the facility in 4/2021 with diagnoses including diabetes and anxiety. A 2/11/26 Quarterly MDS indicated Resident 5 was moderately cognitively impaired. Resident 5 was dependent on staff for transfers. A 4/9/26 Grievance Communication Form indicated Resident 5 pushed her/his call light for two hours and no one came to assist. Resident 5 documented that she/he was supposed to be a resident and not a prisoner. The Call Data Report for call light wait times from 4/10/26 through 4/17/26 indicated the following:-On 4/10/26 at 6:13 PM, Resident 5's call light wait time was 37 minutes.-On 4/11/26 at 5:15 PM, Resident 5's call light wait time was 34 minutes; at 7:06 PM 34 minutes; and at 7:41 PM 40 minutes.-On 4/16/26 at 4:45 PM, Resident 5's call light wait time was 27 minutes. On 5/8/26 at 11:37 AM, Resident 5 stated call light wait times continued to be a problem. Resident 5 stated when there was long call light wait times, staff told her/him they were busy. Resident 5 stated she/he worried about what would happen if she/he had an emergency. On 5/12/26 at 9:51 AM, Staff 22 (CNA) stated she was concerned about evening shift staffing as there was not enough staff for the needs of the residents. Staff 22 stated mealtimes were busy, and she had observed negative resident outcomes due to waiting, such as having incontinent episodes when a resident was continent. Staff 22 stated Resident 5 was a two-person assist and at times it was difficult to find another staff member to assist, so Resident 5's call light wait times could be long. On 5/12/26 at 9:58 AM, Staff 23 (CNA) stated approximately 40 percent of the time the facility was not staffed to meet the needs of the residents for the last couple of years. Staff 23 stated at times she will be on her lunch and the other CNAs do not answer her assigned resident's call light. Another reason resident call light wait times are long was that she was providing a resident with a shower. On 5/12/26 at 12:51 PM, Staff 1 (Administrator) stated the expectations for staff for call light wait times were 10 minutes or less.

Based on interview and record review, it was determined the facility failed to reduce the risk of a potential accident hazard for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for accidents. Findings include:Resident 1 was admitted to the facility in 3/2026 with diagnoses including diabetes, foot ulcer and chronic pain. A 4/4/26 admission MDS indicated Resident 1 was cognitively intact. A 4/23/26 After Visit Summary indicated post-anesthesia/sedation instructions to not stay alone, a responsible person should be with you as you may be lightheaded, experience dizziness, and sleepiness. On 5/1/26 the State Survey agency received a public complaint alleging Resident 1 did not have a staff member accompany the resident to the medical appointment. The resident needed assistance with her/his wheelchair going long distances, up inclines and over bumps. On 5/8/26 at 8:29 AM, Resident 1 stated she/he had day surgery for her/his foot on 4/23/26. Staff 16 (CNA) accompanied her/him to the surgery, but the facility later picked up Staff 16. Resident 1 stated no one waited for her/him to assist her/him back to the facility after surgery. Resident 1 stated she/he had to return to the facility by herself/himself after being under anesthesia. On 5/12/26 at 9:23 AM, Staff 16 stated on 4/23/26 she accompanied Resident 1 to her/his surgery appointment, but she was not with Resident 1 to assist her/him with transport back to the facility. On 5/12/26 at 11:55 AM, Staff 8 (Social Services Coordinator) stated at some point Staff 16 was picked up from Resident 1's surgery appointment and Resident 1 did not have a staff member to accompany her/him back to the facility after she/he had surgery. On 5/12/26 at 12:51 PM, Staff 1 (Administrator) stated she expected staff to escort Resident 1 while transporting back from surgery to the facility.

Based on interview and record review it was determined the facility failed to obtain lab samples for 1 of 3 sampled residents (#10) reviewed for change of condition. This placed residents at risk for a delay in treatment. Findings include:Resident 10 was admitted to the facility in 3/2026 with diagnoses including kidney disease. A 4/2/26 Nursing Note indicated the physician called to inform Staff 26 (RN) there were STAT (immediately) laboratory orders for complete blood count and leukocytosis (elevated white blood cell count). A 4/3/26 Order Note indicated Staff 24 (RN) had attempted two times to obtain the STAT CBC sample but was unable to do so. On 5/12/26 at 10:28 AM, Staff 24 stated she normally wrote a note if she could not obtain a lab sample and pass it on to the next shift. Staff 24 stated a physician-ordered lab test should have been completed on the same day as the order. On 5/12/26 at 12:14 PM, Staff 26 stated the facility received numerous STAT laboratory orders. Staff 26 stated she was often switched from one side of the facility to another, and she may not have completed the order. There was no documented evidence in Resident 10's clinical record the 4/2/26 STAT laboratory order was completed. On 5/12/26 at 12:59 PM, Staff 2 (DNS) stated she expected physician orders to be followed in a timely manner. STAT laboratory orders were expected to be completed within two to four hours.

Based on interview and record review, it was determined the facility failed to ensure dependent residents received ADL assistance for bathing for 1 of 3 sampled residents (#7) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include:Resident 7 was admitted to the facility in 10/2025 with diagnoses including dementia and stroke. A 10/21/25 admission MDS indicated Resident 7 had severe cognitive impairment and was dependent on staff for showers. Resident 7's 12/2025 Documentation Survey Report (CNA task report) indicated the resident received bathing on day shift on Wednesdays and Sundays. On 12/24/25 the report was blank for bathing and on 12/28/25 the report documented Resident 7 received bathing and was dependent on staff for assistance. The facility's 12/29/25 investigation documented that Resident 7 did not receive a bath on 12/28/25, and it had been falsely documented the resident received bathing on that day. A Facility Reported Incident form dated 12/31/25, documented on 12/28/25, indicated Staff 5 (CNA) noted providing bathing to Resident 7, however, Staff 5 did not provide any type of bathing to the resident. Resident 7's 3/2026 Documentation Survey Report showed no documentation the resident received any type of bathing on 3/11/26. On 3/16/26 at 12:14 PM and 3/17/25 at 9:01 AM, attempts to contact Staff 5 were unsuccessful. On 3/17/26 at 9:55 AM, Staff 7 (CNA) stated on 12/28/25 she watched Staff 5 lay Resident 7 down. Staff 7 asked Staff 5 about her/his bathing and Staff 5 told Staff 7 she would complete Resident 7's bathing in the evening. Staff 7 stated she could not do Resident 7's bathing in the evening as she moved to a different hall on evening shift. On 3/16/26 at 12:27 PM, Staff 21 (CNA) stated usually if bathing was not documented in the resident's record, bathing did not occur. On 3/17/26 at 12:17 PM, Staff 31 (Regional Nurse) stated staff should provide scheduled bathing to residents.

Based on interview, and record review, it was determined the facility failed to obtain orders and provide treatment for non-pressure skin wounds for 1 of 3 sampled residents (#2) reviewed for change of condition. This placed residents at risk for worsening wounds. Findings include:Resident 2 was admitted to the facility in 10/2025 with diagnoses including diabetes and non-pressure chronic ulcer on the left foot. The hospital Physician Admissions Orders dated 10/29/25 documented an ulcer of the left second toe, limited to breakdown of skin and pain of the toe. A 10/30/25 admission Nursing Database assessment recorded scabs on Resident 2's 2nd and 4th toes and the top of her/his left foot. A 11/6/25 admission MDS indicated Resident 2 had a non-pressure chronic ulcer on the left foot. No physician orders or treatment were found in Resident 2's clinical records for her/his left foot ulcer from 10/30/25 through 11/15/25. A Nursing Care Note dated 11/16/25 documented staff sent a message to the physician which indicated Resident 2's left second toe had a scab and treatment was initiated. On 3/17/26 at 11:32 AM, Staff 28 (Agency LPN) stated she could not remember whether she had confirmed physician orders for treatment when she completed the 10/30/25 admission Nursing Database assessment. Staff 28 stated the normal practice would be if there were no orders on admission, the physician would need to be contacted for clarification. On 3/17/26 at 12:11 PM, Staff 31 (Regional Nurse) stated staff should ensure physician orders existed for a resident with skin wounds.

Based on interview and record review it was determined that facility failed to demonstrate active involvement of staff and residents to determine staffing needs for 1 of 1 facility assessment. This placed residents at risk for inadequate staffing to meet resident needs. Findings include:The 2025 Facility Assessment indicated the facility had areas of insufficiencies in staffing, training, services and personnel.On 9/4/25 at 4:59 PM, Staff 23 (CNA) stated staff were not asked to provide input regarding staffing needs based on the acuity (severity of condition) of residents. On 9/5/25 at 11:07 AM, members of the Resident Council stated concerns about staffing had been discussed during previous meetings, but no resolution had been reached. The Resident Council reported the facility utilized agency staff and felt the staff members required additional training. On 9/7/25 at 2:42 PM, Staff 7 (Resident Care Manager-LPN) stated staff were not fully trained which resulted in some staff resignations. Staff 7 stated there was no formal process to provide feedback to management related to staffing needs. On 9/8/25 at 1:08 PM, documentation was requested to demonstrate how staffing hours, as well as resident and staff feedback, were incorporated into the facility assessment. Staff 1 (Administrator) stated no such documentation was available

Based on observation, interview and record review it was determined the facility failed to follow appropriate infection control practices during a COVID-19 outbreak for 2 of 2 halls reviewed for infection control. This placed residents at risk for exposure to the COVID-19 virus and other infectious disease. Findings include: The facility's COVID-19 Testing Program Guidelines dated 6/7/24 included the following: Facility testing programs for both the residents as well as the facility staff are implemented at the facility in addition to other infection prevention and control activities and interventions aimed at preventing the spread, detecting cases quickly and stopping transmission. These infection control activities including the testing programs are coordinated and overseen by the facility Infection Preventionist who is in contact with the local health department as needed. The facility's COVID-19 Identification and Management of Ill Residents policy dated 7/2020 included the following: Staff caring for residents with suspected or confirmed COVID-19 must strictly adhere to infection prevention and control practices. Residents with known or suspected COVID-19 are cared for using all recommended PPE, including an N95 or higher-level respirator (or facemask if respirators are not available), eye protection, gloves and gown. 1. The following observations were made while in the facility: On 9/3/25 at 7:06 AM, a bedside table was stationed inside of the facility next to the North exit door. There were used COVID rapid tests lined up on the bedside table. Staff 21 (Housekeeping Manager) stated all staff were required to take a COVID rapid test prior to the start of their shift. Staff and residents were observed going in and out of the North door where the bedside table was located. On 9/3/25 at 3:01 PM, Staff 31 (CNA) was observed entering room [ROOM NUMBER], which was identified to be on Droplet Precautions wearing an N95, gloves, and a gown. When she exited the room, she acknowledged forgetting to don a face shield. She stated she also forgot to doff the N95 respirator on her face before leaving the room. On 9/4/25 at 12:18 PM, Staff 11 (LPN – Infection Preventionist) acknowledged staff were testing at the North and South exit doors for COVID-19. Staff 11 stated staff were expected to take COVID tests inside of the medication rooms and a nurse was to administer the COVID-19 test. The used COVID-19 tests were to remain in the medication room. The nurse was to check the test after 15 minutes and throw it away. Staff 11 also stated she expected all staff to follow PPE guidelines provided on the signs posted by resident doors, which included doffing PPE before leaving the room. She acknowledged the Droplet Precautions were incorrect, as they had additional instructions posted on the back of the sign, which staff could not see. She stated the appropriate sign read, Special Droplet/Contact Precautions, as it did not have additional instructions on the back. On 9/8/25 at 12:40 PM, Staff 1 (Administrator) and Staff 3 (Regional Director of QA) stated they expected staff to follow appropriate PPE guidelines posted outside of resident doors. 2.An observation on 9/4/25 at 9:08 AM revealed used COVID-19 tests on top of the North Nurses Station. Staff 11 (LPN-Infection Preventionist) retrieved a paper towel, picked up the used tests, discarded them in the trash, then donned a glove to pick up the paperwork the tests had been placed on. Staff 11 stated the COVID-19 tests should not have been left in the open. Staff 11 stated testing was to be completed in the locked medication storage room to prevent the spread of COVID-19. The nurse was to read the test results within 15 minutes and discard the used tests. Staff 11 stated the night nurse had performed the COVID-19 tests and acknowledged the tests had remained on the North Nurses Station for an extended period and stated the tests should have been secured in the locked medication storage room. Staff 11 stated her expectation was for staff to place used Covid-19 tests in a closed locked room, not on top of the nurse's station counter to avoid the spreading of Covid-19. 3. Resident 26 was admitted to the facility in 6/2025 with a diagnosis of chronic obstructive pulmonary disease (chronic respiratory illness). Resident 26 resided in room [ROOM NUMBER]. A 9/2/25 revised care plan revealed Resident 26 had COVID-19 (respiratory illness) and was on Special Droplet Precautions. On 9/2/25 at 12:10 PM, a sign was observed outside the door of room [ROOM NUMBER] which indicated Resident 26 was on Special Droplet Precautions. Staff 26 (CNA) was observed to exit the room, disposed of her respirator facemask, and placed a new respirator facemask on as she exited the room. Staff 26 did not perform hand hygiene before donning her clean mask and acknowledged she neglected to perform hand hygiene as needed. On 9/4/25 at 12:20 PM, Staff 11 (IP) stated she expected staff to perform hand hygiene before donning a clean facemask.

Based on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital and notify the Ombudsman for 4 of 4 sampled residents (#s 10, 11, 67, and 69) reviewed for hospitalization and discharge. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities. Findings include:A review of the facility's Transfer or Discharge, Emergency Acute Care and Bed-Holds and Return policy dated 10/2022 revealed the following: -When a resident is transferred to an acute care facility a notice of transfer is provided to the resident and resident representative. -A Copy of the transfer was also sent to the LTC Ombudsman. -All resident/representatives were provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence. 1.Resident 10 was admitted to the facility in 6/2025 with diagnoses including heart failure and kidney disease. A review of Resident 10's clinical record revealed she/he was transferred to the hospital on 8/16/25. No evidence was found in the clinical record to indicate written notice of the facility's bed-hold policy was provided to the resident or her/his representative. No documentation was found indicating the LTC Ombudsman was notified of the transfer. On 9/8/25 at 12:01 PM, Staff 1 (Administrator) stated a written bed-hold notification was not provided to Resident 10 or her/his representative at the time of transfer to the hospital. Staff 1 stated the LTC Ombudsman was not notified of the transfer. 2.Resident 67 was admitted to the facility in 7/2025 with diagnoses including weakness and stroke. A review of Resident 67's clinical record revealed she/he was discharged home on 8/1/25. No documentation was found in the clinical record indicating the LTC Ombudsman was notified of the discharge. On 9/8/25 at 12:01 PM, Staff 1 (Administrator) stated his expectation was the LTC Ombudsman should have been notified of Resident 67's discharge home. 3.Resident 69 was admitted to the facility in 7/2025 with diagnoses including alcohol abuse. A review of Resident 69's clinical record revealed she/he was discharged home on 8/14/25. No documentation was found in the clinical record indicating the LTC Ombudsman was notified of the discharge. On 9/8/25 at 12:01 PM, Staff 1 (Administrator) stated his expectation was the LTC Ombudsman should have been notified of Resident 69's discharge home. 4. Resident 11 was admitted to facility in 8/2023 with diagnoses including chronic kidney disease. A review of Resident's clinical record revealed she/he was hospitalized on [DATE], 7/29/25, 8/13/25 and 8/18/25. No evidence was found in the clinical record to indicate written notice of transfer or the facility's bed-hold policy was provided to the resident or her/his representative. On 9/5/25 at 2:50 PM, Staff 14 (Social Services Director) stated she did not have or send copies of notice of transfers to the Ombudsman. On 9/8/25 at 12:40 PM, Staff 1 (Administrator) stated Resident 11 did not receive a notice of transfer or have a signed acknowledgement of the bed-hold policy for her/his hospitalizations.

Based on observation and interview the facility failed to provide covered refuse containers for 3 of 4 exterior refuse containers observed. This placed residents at risk for pest infestations. Findings include: On 9/2/25 at 10:04 AM, an uncovered exterior refuse container was observed outside a North Hall exit. The container held food containers and other trash. On 9/4/25 at 10:03 AM, uncovered exterior refuse containers were observed outside a second North Hall exit and a rear exit. The containers held food debris and other trash. On 9/5/25 at 10:00 AM, Staff 4 (Maintenance Lead) observed the uncovered refuse containers and stated there were no lids available for the containers. On 9/8/25 at 12:38 PM, Staff 1 (Administrator) and Staff 3 (Regional Director of Quality Assurance) acknowledged exterior refuse containers needed to be covered and there were refuse containers without covers at 3 exterior doors.

Based on interview and record review it was determined the facility failed to ensure residents were informed of their rights both orally and in writing on an ongoing basis for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for not being informed of their rights. Findings include:A review of the Resident Council Meeting Minutes from 6/28/25, 7/25/25, and 8/27/25 revealed resident rights were not reviewed during any of the meetings.On 9/4/25 at 2:08 PM, Staff 27 (Activity Director) stated he did not review resident rights during Resident Council meetings.On 9/5/25 at 10:51 AM, members of the Resident Council confirmed resident rights were not reviewed during the meetings.On 9/8/25 at 11:38 AM, Staff 1 (Administrator) stated the expected resident rights to be reviewed with residents during Resident Council meetings.

Based on observation, interview, and record review it was determined the facility failed to timely address a new identified behavior for 1 of 2 sampled residents (#2) reviewed for mood and behavior. This placed residents at risk for lack of emotional and behavioral health needs. Findings include:Resident 2 was admitted to the facility in 7/2025 with diagnoses including anxiety and heart failure. The 2/2025 Facility Assessment revealed behavior health staffing was insufficient. The 7/23/25 admission MDS revealed Resident 2 had a BIMS score of 15 which revealed she/he was cognitively intact, was depressed two to six days during the previous two weeks and received no antidepressant medications. The 8/2025 Behavior Monitoring Record revealed Resident 2 exhibited inappropriate behaviors on nine of 31 days which included refusal of care, confabulation (fabrication of false memories), and verbal aggression. On eight out of nine days, behavior interventions did not alter the outcome. The 8/1/25 through 9/5/25 Progress Notes revealed Resident 2 exhibited no additional behaviors. An 8/12/25 physician order revealed Resident 2 started melatonin (a supplement used to regulate sleep) for insomnia and anxiety. The 8/24/25 revised care plan indicated staff were to addressed Resident 2's behaviors through interventions which included: redirection, assessment of her/his pain, one on one interactions, toileting, snacks, to leave the room and then return, and repositioning. Resident 2's triggers included pain, feeling the loss of independence, and being upset. On 9/3/25 at 9:26 AM, Resident 2 stated she/he banged her/his walker against the wall a few days earlier because staff did not respond to her/his needs. Resident 2 was observed wringing her/his hands while speaking and stated she/he wanted to ensure the correct person was blamed for her lack of care. On 9/4/25 at 1:18 PM, Staff 17 (CMA) stated Resident 2's behaviors were challenging to address. Staff 17 stated she witnessed Resident 2 bang her/his walker against the wall in her/his room over ten days ago. Staff 17 stated she said did not report the incident because she believed other staff were aware. On 9/4/25 at 7:10 PM, Staff 28 (LPN) stated Resident 2 accused Staff 28 of providing inadequate care, which was dismissed following an investigation. Staff 28 acknowledged Resident 2's mood and behaviors impacted her/his care. On 9/5/25 at 12:38 PM, Staff 14 (Social Services Director) stated she was aware of Resident 2's verbal aggression towards staff, refusal of care, and confabulation related to staff. Staff 14 stated she witnessed Resident 2 bang her/his walker against the wall a few days earlier, which Staff 14 identified as a change in behavior. Staff 14 was unaware of Resident 2's prior physically aggressive behavior and expected documentation of behavioral changes to ensure timely interventions. Staff 14 stated behavioral services should be considered due to change in Resident 2's behaviors. Staff 14 stated she needed to complete a new behavioral assessment for Resident 2 to obtain additional behavioral services. On 9/5/25 at 1:03 PM, Staff 2 (DNS) stated she was unaware of Resident 2's physical aggressive behavior and expected documentation of the incident to support the management team in addressing the behavioral change.

Based on observation, interview, and record review, it was determined the facility failed to coordinate the appropriate services to address communication needs for 1 of 1 sampled resident (#6) reviewed for communication. This placed residents at risk for ineffective communication and unmet needs. Findings include: Resident 6 was admitted to the facility in 4/2025 with diagnoses including persistent vegetative state (awake with no environmental awareness) and traumatic brain injury.The 4/24/25 admission MDS indicated Resident 6's ability to understand others was not assessed.A 5/26/25 physician order indicated PT, OT, SLP per family request. A 7/21/25 facility Care Conference Information form indicated Witness 2 (Family Member) requested Staff 6 (Resident Care Manager-LPN) coordinate referrals for OT. PT, SLP and a neurologist (brain disorder specialist).A 7/23/25 revised care plan indicated Resident 6 was not able to make her/his needs known and used non-verbal techniques to supplement her/his communication.On 9/2/25 at 12:59 PM, Witness 2 stated Resident 6 previously communicated using flash cards and wanted her/him assessed for improved communication technology.On 9/4/25 at 9:08 AM, Resident 6 was observed lying in bed and grunting while the television was on.On 9/4/25 at 2:08 PM, Staff 27 (Activities Director) stated he observed Resident 6's eyes respond and noted increased grunting when she/he was engaged in an activity of interest.On 9/5/25 at 4:00 PM, Staff 23 (CNA) stated Resident 6 made her/his needs known by swatting Staff 23's hand when undesired care was attempted.On 9/8/25 at 9:44 AM, Staff 6 acknowledged Resident 6 communicated using her/his eyes, but Staff 6 was unsure how an SLP could assist. Staff 6 stated a referral to a neurologist was ordered within the last few days and did not know if SLP had been contacted following the care conference.On 9/8/25 at 11:20 AM, Staff 3 (Regional Director of Quality Assurance) stated staff were expected to initiate referrals for communication services and specialists as soon as the request was made. Staff 3 acknowledged communication services for Resident 6 were delayed.

Based on interview and record review it was determined the facility failed to provide bathing and shower care for 1 of 3 sampled residents (#16) reviewed for ADLs. This placed residents at risk for poor hygiene. Findings include: Resident 16 was admitted to facility on 7/5/25 with diagnoses including chronic obstructive pulmonary disease and metabolic encephalopathy (temporary or permanent brain dysfunction caused by a problem with the body's metabolism).Resident 16's 7/5/25 Care Plan indicated she/he required two staff to assist with bathing.Resident 7/13/25 admission MDS indicated the resident was dependent on assistance with bathing/showering.Resident 16's 7/2025 Bath/Shower task logs indicated the resident received showers on 7/8/25, 7/15/25 and 7/22/25. There was no documentation for 7/11/25, 7/18/25, and 7/29/25, which were Resident 16's scheduled shower days, as those entries were left blank.A review of Resident 16's Progress Notes from 7/5/25 through 7/30/25 revealed no evidence the resident was offered additional a showering opportunity when a shower was refused or not provided. On 09/04/2025 7:35 AM Staff 8 (CNA) stated there were times when staff would get too busy to chart tasks performed on residents. She stated after performing a shower task on residents, she would chart the shower task as completed.On 9/8/25 at 10:14 AM, Staff 6 (Resident Care Manager - LPN) stated if the Bath/Shower task logs were blank, it would indicate the task was not given. She stated residents were typically given baths/showers two times per week, and the expectation was for staff to complete resident showers and documenting they were done. At 11:53 AM, Staff 6 provided documentation stating on 7/11/25, Resident 16's bath/shower was not completed due to being short-staffed.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 1 of 4 sampled residents (# 49) reviewed for infection control. This placed residents at risk for wound infections. Findings include:Resident 49 was admitted to the facility in 8/2025 with diagnoses including a leg fracture.An 8/8/25 Orthopedic Physician Order directed staff to remove Resident 49's dressing one week after 8/8/25. Staff were instructed to gently cleanse the incision using warm water and soap, pat dry, apply a nonadhesive pad or gauze dressing secured with tape, and change the dressing every one to two days until the follow-up appointment. Staff were to contact Trauma/Orthopedics if signs or symptoms of redness, drainage, onset of pain, chills, fever, sweats, or infection were observed.The 8/25 TAR did not contain the Orthopedic Physician's order for wound care. There was no evidence the wound care was completed.On 8/25/25, a Progress Note indicated Resident 49's middle incision on her/his left thigh was red, swollen, and warm to the touch. Resident 49 reported a burning sensation and tenderness.On 9/2/25 at 10:01 AM, Resident 49 stated staff did not remove her/his wound dressing for nearly two weeks after she/he was admitted to the facility, and her/his incision became infected and painful. Resident 49 stated she/he reported the pain to staff multiple times but staff did not check the incision until the incision was infected.On 9/8/25 at 9:29 AM, Staff 29 (LPN) stated when residents were admitted , Staff 30 (Medical Records) placed the orders in the resident's electronic record. Staff 6 stated two nurses verified the orders were correct and placed them on the MAR and TAR. Staff 6 verified the Orthopedic Physician's order was not on the TAR, dressing changes were not initiated, and Resident 49 developed an incision infection.On 9/8/25 at 9:45 AM, Staff 30 stated upon a new admission she reviewed the orders and uploaded the orders into the electronic record. Staff 30 stated two nurses reviewed the orders, confirmed they were correct, and placed them on the MAR and TAR. Staff 30 verified the Orthopedic Physician's order was not on the TAR and acknowledged the order was missed.On 9/8/25 at 12:28 PM, Staff 6 (Resident Care Manager-LPN) stated upon admission, the resident's new orders were placed in the electronic record by Staff 30 and reviewed by two nurses to verify accuracy. Staff 6 verified the Orthopedic Physician's order was not on the 8/2025 TAR. Staff 6 acknowledged dressing changes were not initiated for Resident 49 and she/he developed an incision infection.On 9/8/25 at 12:38 PM, Staff 3 (Regional Director of Quality Assurance) stated the process for new admissions was for Staff 30 to upload the new orders into the electronic record. Staff 3 stated two nurses were to verify the orders were uploaded correctly and placed on the MAR and TAR. Staff 3 verified the Orthopedic Physician's order was not on the 8/2025 TAR and acknowledged Resident 49 developed an incision infection.

Based on observation, interview and record review the facility failed to comprehensively assess 1 of 3 resident (#11) reviewed for positioning and hospitalization. This placed resident at risk for unassessed needs. Findings include:Resident 11 was admitted to facility in 8/2023 with diagnoses including chronic kidney disease.On 9/2/25 at 2:19 PM, Resident 11 stated she/he was not certain of what her/his care needs consisted of, as she/he had recently experienced multiple hospitalizations.A review of Resident 11's clinical record revealed her/his Annual MDS completion deadline date was 8/2/25 and was incomplete as of 9/7/25. A review of Resident's clinical record revealed she/he was hospitalized on [DATE], 7/29/25, 8/13/25 and 8/18/25 and her/his most recent entry back to facility was on 8/22/25. No evidence was found in the clinical record to indicate a significant change assessment, or an admissions assessment was completed as of 9/7/25.On 9/8/25 at 8:58 AM, Staff 15 (Regional Reimbursement Analyst) acknowledged a comprehensive assessment had not been completed timely for Resident 11. He stated although Resident 11 had multiple hospitalizations, the expectation was for a comprehensive assessment to be completed timely.On 9/8/25 at 12:40 PM, Staff 1 (Administrator) acknowledged Resident 11's MDS assessment was not completed timely. He stated the expectation was for MDS Assessments to be completed timely and accurately for each resident.

Based on interview and record review, it was determined the facility failed to ensure annual performance reviews for CNA staff were completed for 2 of 5 sampled CNA staff (#s 24 and 25) reviewed for staffing. This placed residents at risk due to lack of competent staff. Findings include:A review of personnel profile records revealed the following.-Staff 24 (hired on 5/14/20): The last performance review was dated 6/12/24.-Staff 25 (hired on 8/1/18): The last performance review was dated 8/15/24.On 9/8/25 at 11:36 AM, Staff 1 (Administrator) stated he expected the timely completion of annual staff evaluations.

Based on observation, interview and record review it was determined the facility failed to implement care plan interventions related to smoking safety for 1 of 2 sampled residents (#37) reviewed for accidents. This placed residents at risk for increased smoking hazards and avoidable accidents. Findings include: The facility provided the following schedule for smoking:3:00 AM9:30 AM1:30 PM4:00 PM7:45 PM11:00 PMResident 37 was admitted to the facility in 9/2019 with diagnoses including inhalant dependence with inhalant-induced dementia (a condition where an individual has developed a physical or psychological reliance on substances which are inhaled to induce psychoactive effects).Resident 37's 8/8/25 Annual MDS assessment indicated she/he was cognitively intact.Resident 37's comprehensive Care Plan related to smoking safety last revised 8/26/25 indicated although she/he was assessed to be independent with smoking, she/he was to smoke in the smoking areas and to follow the smoking schedule. The care plan also indicated Resident 37's clothing and hands were to be checked for burns and for the facility to store her/his tobacco and fire materials in a lock box at the nurse's station.On 9/2/25 at 1:59 PM, Resident 37 stated she/he did not smoke where the others gathered in the designated courtyard of the facility. Resident 37 was observed entering a code into a keypad, exiting out the North exit door, and using a vape box.The following observations were made on 9/3/25:At 6:59 AM, Resident 37 was observed vaping/smoking outside of the North exit door.At 7:08 AM, Resident 37 was observed placing a box of cigarettes, lighter, and vape box on the counter of the nurse's station before entering her/his room. At 7:16 AM, Resident 37 came out of her/his room, picked up the box of cigarettes, lighter, and vape box off the counter of the nurse's station and exited through the North exit door.The following observations were made on 9/4/25:At 7:20 AM, Resident 37 was observed entering the facility from the North exit door, placed a box of cigarettes, lighter, and vape box on the nurse's station counter and entered her/his room.At 7:29 AM, Resident 37 was observed exiting her/his room, picked up the box of cigarettes, lighter, and vape box and exited through the North exit door.At 7:38 AM, Resident 37 was observed placing a box of cigarettes, lighter, and vape box on the nurse's station counter.At 7:47 AM, Resident 37 took a vape box and exited through the North door. The box of cigarettes and lighter were still on the counter.On 9/4/25 at 2:59 PM, Staff 9 (CNA) stated Resident 37 was able to smoke without supervision, but the smoking items were to be kept in a lock box. Staff 9 stated the items were given to Resident 37 when she/he asked. Staff 9 stated Resident 37 could smoke whenever she/he wanted to and did not need to go during designated times with the other residents who smoked in the designated courtyard. She stated Resident 37 could go through the North exit door independently.On 9/4/25 at 3:06 PM Staff 2 (DNS) stated the only designated smoking area on the premises was the courtyard, not where Resident 37 was going outside of the North exit doors. She stated Resident 37 had a lockbox kept in a cupboard for staff to keep the smoking materials. She stated her expectations were for staff to immediately take the smoking materials and lock the items in the lock box. Staff 2 stated she expected for staff to check Resident 37 for burns, but was not sure of the frequency.

Based on observation, interview and record review it was determined the facility failed to follow up on dental services for 1 of 2 sampled residents (#11) reviewed for dental care. This placed residents at risk for lack of dental services. Findings include:The facility's Dental Services policy dated 12/2016 included the following:Social services representatives will assist residents with appointments, transportation arrangements, and reimbursement of dental services. All dental services provided are recorded in the resident's medical record.The facility's Referrals to Social Service Director dated 11/2024 included the following:Any referrals for the following areas will be made to the social services department: dental.Social services is responsible for the follow up and communication with outside providers for any of the above referrals.The Social Services Director will document any referrals made to ancillary services, mental health services, or additional community services/supports and will also document the outcomes following these referrals.Resident 11 was admitted to facility in 8/2023 with diagnoses including chronic kidney disease.Resident 11's Care Plan related to dental revised on 7/11/25 revealed staff were to coordinate arrangements for dental care and transportation as needed.A review of Resident 11's clinical record revealed no evidence of dental services referred from 6/2025 through 9/2025.On 9/18/25 at 8:15 AM, Staff 14 (Social Services Director) provided documentation which showed a dental referral for Resident 11 was provided on 7/3/25, when the provider was at the facility. Staff 14 stated she was unsure of what occurred afterward and found no notes or documentation indicating a follow-up dental appointment was scheduled for Resident 11.

Based on observation and interview it was determined the facility failed to ensure treatment carts were locked and secured appropriately for 2 of 2 treatment carts observed during random observations for medication and treatment cart storage. This placed residents at risk for unsafe access to stored medications. Findings include: 1. On 9/4/25 at 7:15 AM, the North Hall treatment cart was unlocked. Staff and residents were observed to be walking by the treatment cart.On 9/4/25 at 7:17 AM, Staff 17 (CMA) walked by the cart, walked back, and locked the cart. Staff 17 stated she was not in charge of the treatment cart, but noticed it was unlocked and locked it on behalf of Staff 19. She stated Staff 19 was with a resident. On 9/4/25 at 7:19 AM, Staff 19 (RN - Charge Nurse) stated she usually locked the treatment cart before walking away, but was unsure why she did not lock the treatment cart. The treatment cart contained insulin, needles, glucometers, and IV supplies.On 9/8/25 at 12:40 AM, Staff 1 (Administrator) and Staff 3 (Regional Director of QA) stated they expected treatment carts to be locked at all times when staff walked away from the cart.2. On 9/4/25 at 8:03 AM, the South Hall treatment cart was unlocked. There were no staff members observed to be near the treatment cart.On 9/4/25 at 8:05 AM, Staff 20 (LPN - Charge Nurse) stated she was supposed to lock the treatment cart before walking away from it. Inside of the cart were insulin, syringes and prep pads. Staff 20 stated the small vials of liquid were anticoagulant and antibiotic medications.On 9/8/25 at 12:40 AM, Staff 1 (Administrator) and Staff 3 (Regional Director of QA) stated they expected treatment carts to be locked at all times when staff walked away from the cart.

Based on observation, interview, and record review it was determined the facility failed to provide adequate staffing to meet resident needs for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include:1. Resident 3 was admitted to the facility in 3/2025 with diagnoses including dementia and stroke. A 5/2025 Documentation Survey Report revealed Resident 3’s showers were typically provided during the evening shifts. The resident was scheduled to receive a shower on 5/27/25, and there was no documentation Resident 3’s shower was completed. The 5/27/25 Direct Care Staff Daily Report indicated five CNAs worked during the evening shift with a facility census of 56 residents. A 6/2/25 public complaint was received which alleged, on 5/27/25, each CNA had 12 residents during the evening shift due to call outs, and it was possible resident showers were not provided. A 6/12/25 revised care plan indicated Resident 3 required one person to assist with bathing. On 7/21/25 at 12:14 PM, Staff 13 (LPN) stated she recalled 5/27/25 as a “terrible” day. Staff 13 stated the facility was understaffed, she answered numerous call lights, and there was a lack of assistance from management to help on the floor. Staff 13 stated she often skipped breaks and stayed after hours to complete her charting when there was a lack of CNA staffing. On 7/21/25 at 2:20 PM, Staff 6 (CNA) stated on 5/27/25 the staff were unable to complete Resident 3’s shower due to insufficient staff. Staff 6 stated showers were frequently missed for residents due to unresolved facility staffing issues. On 7/21/25 at 3:54 PM, Staff 4 (Social Service Director) confirmed on 5/27/25 efforts were made to contact agency staff resources, and no staff responded to the request for assistance. Staff 4 acknowledged staff not working when scheduled remained an issue. On 7/22/25 at 2:20 PM, Staff 1 (Administrator) stated the facility’s issues related to staffing and meeting the needs of residents remained a concern and a focus since 12/2024. Staff 1 confirmed resident needs were not met on 5/27/25 since the facility was short-staffed. Staff 1 acknowledged additional staffing resources were necessary to meet resident needs. 2. A public complaint received on 2/4/25 alleged the facility did not provide adequate staffing on 2/1/25. A review of the 2/1/25 Daily Nursing Assignment revealed there were five CNAs scheduled to work from 2:00 PM to 10:00 PM, one CNA to float between 2:00 PM and 4 PM, and two CNAs scheduled to work 6:00 PM to 10:00 PM. On 7/21/25 at 11:21 AM, Resident 4 stated she/he preferred to go to bed between 7:00 PM and 8:00 PM. Resident 4 stated there were frequently not enough CNAs scheduled and management did not help the CNAs when there were not enough CNAs. Resident 4 stated the CNAs would give up their lunch and breaks to provide care to the residents when they were short staffed. On 7/21/25 at 10:09 AM Witness 7 (Complainant/Former CNA) stated on 2/1/25 there were not enough CNAs scheduled for evening shift causing residents to get to bed late, missed showers, and residents were unable to get oral care due to staffing. Witness 7 stated she was Resident 4’s CNA on 2/1/25 and she did not put Resident 4 to bed until approximately 9:30 PM on 2/1/25. On 7/21/25 at 12:03 PM Staff 16 (CNA) stated the facility was short CNAs every day in 2/2025 and when they were short CNAs, he would have to prioritize care and sometimes showers would not get completed. Staff 16 stated he was Resident 5’s CNA on 2/1/25. Staff 16 stated if he did not chart a shower was completed, the shower was not completed. A review Resident 5’s 2/2025 Documentation Survey Report revealed no documentation Resident 5 received her/his scheduled shower on 2/1/25. On 7/21/25 at 12:23 PM, Staff 12 (Former Staff Coordinator/CNA) stated she was unable to remember if the facility was short CNAs on 2/1/25 but stated the facility was short on CNAs a lot. Staff 12 stated the facility continued to admit new residents even though there were not enough CNAs. On 7/21/25 at 1:20 PM, Staff 3 (LPN Resident Care Manager) stated she was sure the facility was short CNAs in 2/2025, but she could not remember specific dates. Staff 3 acknowledged when the CNAs worked short, they were unable to complete all required tasks. On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residents’ needs on 2/1/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering. 3. A review of the 7/19/25 Direct Care Staff Daily report revealed the following: -On 7/19/25 day shift the census was 65 and there were eight CNAs scheduled. -On 7/19/25 evening shift the census was 64 and there were five and one half CNAs scheduled. A review of Oregon CNA ratios revealed the following: -Dayshift with a census of 65 required 10 CNAs. -Dayshift with a census of 63 required nine CNAs. -Evening shift with a census of 64 required seven CNAs. -Evening shift with a census of 63 required seven CNAs. On 7/21/25 at 11:21 AM, Resident 4 stated there were frequently not enough CNAs scheduled and management would not help the CNAs when there were not enough CNAs. Resident 4 stated the CNAs would give up their lunch and breaks to provide care to the residents when they were short staffed. On 7/21/25 at 12:23 PM, Staff 12 (Former Staffing Coordinator/CNA) stated the facility had a ton of CNA shortages, but the facility kept admitting new residents even though there were not enough staff. On 7/21/25 at 12:32 PM, Staff 15 (LPN) stated the staffing was getting better, but the last week was the worst. Staff 15 stated they were short CNAs a lot but especially on 7/19/25. Staff 15 stated the census was going up and the facility did not have the staff to care for the residents. On 7/21/25 at 1:20 PM Staff 3 (LPN Resident Care Manager) stated the facility was short CNAs off and on throughout the year. Staff 3 stated she was on call on 7/19/25 and there were not enough CNAs for day and evening shifts. Staff 3 stated the CNA staff informed her they needed help, and she attempted to find coverage but was unable to. On 7/21/25 at 4:35 PM, Staff 7 (CNA) stated they frequently worked without enough CNAs on day shift and evening shift. Staff 7 stated she could complete all required tasks but frequently stayed late to finish. On 7/22/25 at 11:15 AM Staff 8 (RN) stated they were short CNAs on 7/19/25. Staff 8 stated another nurse called the on-call nurse, Staff 3, and Staff 2 (DNS) to request help. Staff 8 stated, “no managers came in to help us, they just left us short staffed.” On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residents’ needs on 7/19/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering. a. Resident 9 was admitted to the facility in 1/2024 with a diagnosis of a stroke. Resident 9’s Care Plan Report revealed she/he required one person assistance for bathing. Resident 9’s 4/17/25 quarterly MDS revealed she/he was moderately cognitively impaired, was able to participate in the mood interview, and was able to express her/his needs. Resident 9’s 7/2025 ADL report revealed she/he was to be bathed on Wednesdays and Saturdays. There was no documentation for 7/19/25, Saturday, to indicate if bathing was provided. On 7/21/25 at 1:14 PM Staff 18 (CNA) stated Resident 9 did not receive a shower on 7/19/25 due to short staffing. On 7/22/25 at 1:21 PM Resident 9 indicated she/he did not receive a shower on 7/19/25, and she/he did not decline a shower. Resident 9 also indicated she/he was not happy she/he did not receive a shower. On 7/22/25 at 9:53 AM Staff 3 (LPN Resident Care Manager) stated on 7/19/25 she was aware showers were not provided due to staffing, including Resident 9’s shower, and “make-up” showers were provided on 7/21/25. On 7/22/25 at 10:09 AM Staff 2 (DNS) stated she was aware there were concerns related to short staffing, staff were not able to complete charting, but she was not aware bathing was not being completed. On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residents’ needs on 7/19/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering. b. Resident 10 was admitted to the facility in 7/2018 with a diagnosis of a stroke. Resident 10’s 5/16/25 annual MDS revealed she/he was cognitively impaired and required extensive assistance with bathing. Resident 10’s 7/2025 ADL report revealed she/he was to be bathed on Wednesdays and Saturdays. On 7/19/25, Saturday, it was documented Resident 10 refused bathing. On 7/22/25 at 9:45 AM Staff 5 (CNA) stated Resident 10 did not refuse to bathe on 7/19/25 but there were no options to document staff did not have time to provide bathing. Staff 5 stated they did not have enough staff, and she did not have time to provide Resident 10 her/his bath. Staff 5 stated Resident 5 was provided a make-up bath on 7/21/25. On 7/22/25 at 9:53 AM Staff 3 (LPN Resident Care Manager) stated on 7/19/25 she was aware showers were not provided due to staffing, including Resident 10’s shower, and “make-up” showers were provided on 7/21/25. On 7/22/25 at 10:09 AM Staff 2 (DNS) stated she was aware there were concerns related to short staffing, staff were not able to complete charting, but she was not aware bathing was not being done. On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residents’ needs on 7/19/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering. c. Resident 11 was admitted to the facility in 2/2017 with a diagnosis of cancer. Resident 11’s 11/26/24 annual MDS revealed she/he had limited mobility and required the assistance of one staff for bathing. Resident 11’s 5/24/25 quarterly MDS revealed she/he was cognitively intact. Resident 11’s ADL report revealed she/he was to be bathed on Wednesdays and Saturdays. It was documented Resident 11 refused to shower on 7/19/25. On 7/21/25 at 2:05 PM Resident 11 stated on Saturday, 7/19/25 the staff were short staffed and very busy, and she/he did not refuse to take a shower. Resident 11 stated she/he received a “make-up” shower today. On 7/21/25 at 7:40 PM Staff 19 (CNA) stated the facility worked short staffed on 7/19/25 and Resident 11 was not provided a shower. Resident 11 did not refuse to take a shower, but there were no additional code options to document indicating a shower was not provided due to low staffing. On 7/22/25 at 9:53 AM Staff 3 (LPN Resident Care Manager) stated she was aware showers were not provided due to staffing on 7/19/25 and “make-up” showers were provided on 7/21/25, including Resident 11. On 7/22/25 at 10:09 AM Staff 2 (DNS) stated she was aware there were concerns related to short staffing, staff were not able to complete charting, but she was not aware bathing was not being done. On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility had not provided adequate CNA staff to provide for residents’ needs on 7/19/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering. 4. A review of 7/20/25 Direct Care Staff Daily report revealed the following: -On 7/20/25 day shift the census was 63 and there were seven CNAs scheduled. -On 7/20/25 evening shift the census was 63 and there were five CNAs scheduled A review of Oregon CNA ratios revealed the following: -Dayshift with a census of 63 required nine CNAs. -Evening shift with a census of 63 required seven CNAs. On 7/21/25 at 11:21 AM, Resident 4 stated there were frequently not enough CNAs scheduled and management would not help the CNAs when there were not enough CNAs. Resident 4 stated the CNAs would give up their lunch and breaks to provide care to the residents when they were short staffed. On 7/21/25 at 12:23 PM, Staff 12 (Former Staffing Coordinator/CNA) stated the facility had a ton of CNA shortages, but the facility kept admitting new residents even though there were not enough staff. Staff 12 stated on 7/20/25 they had seven CNAs on day shift and five CNAs on evening shift. On 7/21/25 at 12:32 PM, Staff 15 (LPN) stated the staffing was getting better, but the last week was the worst. Staff 15 stated they were short CNAs a lot but especially on 7/20/25. Staff 15 stated the census was going up and the facility did not have the staff to care for the residents. On 7/21/25 at 1:20 PM Staff 3 (LPN Resident Care Manager) stated the facility was short CNAs off and on throughout the year. Staff 3 stated she was on call on 7/20/25 and there were not enough CNAs for day and evening shifts. Staff 3 stated the CNA staff informed her they needed help, and she attempted to find coverage but was unable to. On 7/21/25 at 2:49 PM, Staff 14 (CNA) stated they worked short a lot, especially on 7/20/25. Staff 14 stated when there was enough CNAs, she would prioritize care and was unable to complete showers, oral care, and personal hygiene. Staff 14 stated there were some days when they were short CNAs and she was only able to change residents, get them up for their meal, and lay them back down in bed after dinner. On 7/21/25 at 4:35 PM, Staff 7 (CNA) stated they frequently worked without enough CNAs on day shift and evening shift. Staff 7 stated she could complete all required tasks but frequently stayed late to finish. On 7/21/25 at 4:45, Staff 5 (CNA) stated they were short CNAs a lot, for the last week they were short one to two CNAs every day. Staff 5 stated the management knew there was not enough staff, and they kept admitting new residents. Staff 5 stated on 7/20/25 they did not have enough CNAs, and she was unable to complete one of two showers she was assigned. On 7/22/25 at 2:20 PM Staff 1 (Administrator) acknowledged the facility did not provide adequate CNA staff to provide for residents’ needs on 7/20/25. Staff 1 stated they had a census cap of 63 related to staffing and he would look at lowering.

Based on observation, interview, and record review it was determined the facility failed to ensure physician ordered diets were provided as ordered for 3 of 5 sampled residents (#s 3, 39 and 57) reviewed for nutrition. This deficient practice was determined to be an immediate jeopardy situation. Resident 57 was provided food not prepared according to their physician ordered diet texture, and this resulted in a severe coughing episode and risk of choking and/or aspiration. Staff were aware the food they were providing the resident was not appropriate. Findings include: 1. Resident 57 admitted ,d+[DATE] with a diagnosis of pneumonitis (inflamation of lung tissue) due to inhalation of food and vomit, and CVA (cerebral vascular accident) with severe expressive aphasia (non-verbal) as well as severe oropharyngeal dysphagia (difficulty swallowing). Resident 57 was physician ordered for minced and moist textured food and care planned to be supervised for all oral intake. She/he had a recent history of aspiration (food or fluid enters the lungs), and pneumonia related to aspiration. Resident 57 was non-verbal and required total assistance from staff for eating. On 7/15/24 at 1:04 PM Resident 57's midday meal was observed. The chicken on the meal tray prepared by the kitchen was white meat with no gravy. While Staff 4 (CNA) assisted Resident 57 with eating a bite of chicken, she/he had a severe coughing episode for approximately three minutes. Resident 57's eyes became large, watery and she/he appeared panicked, and her/his face became flushed. Staff intervened and altered Resident 57's posture forward to assist with coughing until the coughing episode subsided. The resident's meal was discontinued. She/he had an elevated respiratory rate and appeared fatigued. On 7/15/24 at 1:08 PM Staff 4 stated she knew Resident 57's diet texture order was minced and moist, but no gravy was on or mixed in to the minced chicken. Staff 4 stated she was aware of the diet texture error, but did not obtain the necessary gravy because the kitchen was busy and chaotic. On 7/15/24 at 5:27 PM the faciity administrative staff including Staff 1 (Administrator), Staff 2 (DNS)and Staff 3 (Regional Support Lead)were notified of the immediate jeopardy (IJ) situation related to the facility's failure to provide a physician ordered diet. On 7/15/24 at 6:44 PM an acceptable immediate risk removal plan to to address the serious risk to residents' health and welfare was received from and implemented by the facility. The plan indicated the following facility actions: -Resident 57 was assessed for s/sx of aspiration, her/his physician was notified, and the resident was placed on alert charting. -Staff 4 was suspended and slated for 1:1 inservice training prior to returning to work related to food textures, ensuring food textures served matched the meal ticket, and the process for what to do if there was a discrepency. - Kitchen staff currently working were trained regarding proper diet textures. Other kitchen staff were slated to be educated prior to the start of their next shift until 100% were inserviced. Inserving was scheduled to be provided by a Certified Dietary Manager independent of the facility. -Nursing staff were slated to be inserviced regarding appropriate food textures and ensuring residents received the correct texture. -All residents with mechanically altered diets would have their meal tickets audited for correct texture prior to leaving the kitchen by the Certified Dietary Manager or designee, and a second check would occur by IDT team members in collaboration with CNAs prior to meals being served to residents. -Audits would be conducted of each meal for two weeks, then daily for four weeks, then weekly for four weeks. All findings were to be reported to the QAPI committee. Audits were to be conducted by the Certified Dietary Manager or designee. 35855 2. Resident 3 admitted to the facility in 7/2021 with diagnoses including difficulty swallowing. A 9/5/21 physician order instructed staff to provide Resident 3 with easy-to-chew textured diet. Review of Resident 3's care plan dated 4/18/24 indicated Resident 3 had impaired swallowing and was at risk for aspiration following a choking incident. Interventions included providing meals as ordered, ensuring Resident 3 remained upright for 30 minutes after eating, and serving an easy-to-chew texture diet. It was recommended to encourage Resident 3 to eat outside of bed; if in bed, the bed should be elevated to 90 degrees with the TV off. A Nursing Care Note on 4/18/24 documented Resident 3 choked on a piece of meat during lunch, which became lodged in the throat. Resident 3 was unable to clear the obstruction and was unable to swallow anything else. The physician was notified, was onsite at the facility at the time of the incident, and recommended transfer to the emergency department for treatment. An 4/18/24 physician Progress Notes indicated Resident 3 choked on a piece of pork during lunch, aspirating for approximately 20 minutes before medical intervention. The physician adjusted the bed to 90 degrees and attempted to provide water, which was coughed back up. The decision was made to transfer Resident 3 to the emergency department. A review of an 4/18/24 Emergency Department Encounter indicated Resident 3 sought medical attention for a feeling of a foreign body in the throat after eating pork. A review of the Documentation Survey Report from 7/1/24 through 7/17/24 revealed Resident 3 was to be supervised in the dining room for all meals. For day and evening shift Resident 3 refused 16 instances on day shift and one instance had no documentation, refused 10 times on evening shift, accepted two times and for five instances there was no documentation. Documentation revealed staff were to encourage Resident 3 to be out of bed for meals to decrease risk for aspiration with 16 refusals for breakfast and one accepted, 14 refusals for lunch with three accepted, nine refusals for dinner, and five instances with no documentation and three accepted. In an interview on 7/15/24 at 12:29 PM Witness 5 (Family Member) stated Resident 3 had a choking episode while she/he was lying down and had to go to the hospital. Witness 5 stated Resident 3 was supposed to go to the dining room for meals to be supervised but she/he refused and there was not enough staff to supervise her/him in her/his room. During observation and interview on 7/18/24 at 1:20 PM an easy-to-chew test tray was provided to the survey team and found to have inadequately cooked potatoes with crunchy pieces, and tough portions in the breaded pork. At 1:27 PM Staff 5 (Certified Dietary Manager) confirmed these findings. During an interview on 7/19/24 at 7:47 AM Staff 16 (CMA) stated Staff 17 (CNA) reported Resident 3 was choking and staff rushed into her/his room. Staff could hear Resident 3 trying to expel a piece of pork out of her/his throat. When she/he tried to swallow it made a horrible sound. Staff 16 stated everyone complained that day about how dry the pork was. On 7/19/24 at 10:54 AM Staff 17 stated on 4/18/24 she delivered Resident 3's tray and cut up everything on her plate and she remembered the pork being dry. 47001 3. Resident 39 admitted to the facility in 4/2022 with diagnoses including a stroke and dysphagia (swallowing difficulties). A review of Resident 39's record revealed a 4/14/22 order for easy chew 7 diet texture (foods the require less chewing and reduce the risk of choking). A review of a 5/13/24 Physician Progress Note revealed Resident 39 had an episode of post-tussive emesis (vomiting produce by coughing) while eating her/his lunch. A review of Resident 39's record revealed a 5/22/24 care plan for dysphagia and an 4/14/22 intervention to monitor and document ability to chew and swallow, and if presenting with problems obtain an order for ST to evaluate and treat. Resident 39 was observed eating lunch on 7/15/24. At approximately 1:00 PM Resident 39 was observed coughing on a tortilla for about 20 seconds. On 7/15/24 at 2:03 PM Staff 5 (Certified Dietary Manager) confirmed Resident 39 should have received a piece of bread instead of a tortilla based on her/his diet texture of easy chew 7.

Based on observation, interview and record review it was determined the facility failed to ensure care planned interventions were implemented and to revise the care plan to be reflective of current resident behaviors related to a fall risk for 1 of 3 sampled residents (#64) reviewed for accidents. Resident 64 sustained a left arm fracture requiring acute care intervention. Findings include: Resident 64 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 64's 2/19/18 Behavior, Cognitive Loss/Dementia and Falls CAAs revealed the following: *The resident could become agitated with staff and become verbally or physically aggressive, but was easily redirected. *The resident had long and short term memory issues and was forgetful, but knew what was being said to her/him and was able to make her/his needs known. *The resident preferred to be helped immediately and became angry when she/he had to wait for staff assistance. *The resident was a fall risk related to weakness, decreased mobility and forgetfulness. Resident 64's current undated Kardex (CNA care plan) directed staff to toilet the resident upon waking, before and after meals and at bedtime. The resident was noted to use both a urinal and the bathroom. There was no indication the resident had a history of [REDACTED]. The Kardex further indicated Resident 64 was to be transferred with the assistance of one staff using a gait belt (a resident transfer belt). The Kardex did not indicate the resident had a history of [REDACTED]. The Kardex further directed staff to keep the resident's bed in the lowest position except during care. Resident 64's 3/21/16 comprehensive care plan for falls included a 6/16/16 intervention to have bilateral fall mats in place, and on 11/30/17 intervention for her/his bed to be in the lowest position except when receiving cares. The resident's comprehensive care plan further revealed a 7/9/18 focus indicating she/he was at risk for urinary tract infections [MEDICAL CONDITION]. Review of the care plan did not reveal information the resident had a history of [REDACTED]. laboratory results dated [DATE] indicated Resident 64 tested positive for a UTI. Review of Resident 64's 6/2018 MAR indicated [REDACTED]. A 6/23/18 fall investigation indicated Resident 64 had an unwitnessed fall from her/his bed. The resident stated she/he rolled out of her/his bed and onto the floor. Resident 64 further indicated she/he fell and believed she/he broke her/his left arm. The resident was noted as needing to urinate shortly after the fall, and three facility staff attempted to assist the resident to the the bathroom but the resident refused to be transferred. The resident was assisted to use a urinal. The investigation indicated the resident's bed was in the lowest position when he/she was found, but did not indicate if bilateral fall mats were in place at the time of the resident's fall. Witness interviews conducted by Staff 1 (DNS) revealed the resident refused to use her/his fall mats, and indicated the resident believed it was a fall risk. Witness interviews indicated the resident had a history of [REDACTED]. Witness interviews further indicated the resident was last seen and toileted at 3:30 AM, and the fall occurred at 5:00 AM and was transferred to the emergency department (ED) for evaluation for potential injury from the fall. Hospital records dated 6/23/18 indicated Resident 64 sustained a fractured left arm and returned to the facility on the same day. A review of progress notes dated 6/25/18 through 7/7/18 revealed the following: *6/25/18 Nursing Care Note -- Resident presents with concern of urgency with voiding. *6/30/18 Behavior Note -- Resident requiring assistance every five minutes even when staff recently completed assisting her/him with cares. *6/30/18 SBAR (Situation, Background, Assessment and Recommendation) Progress Note -- Resident was increasingly agitated and blamed the facility for breaking her/his arm. When staff told her/him it happened when she/he rolled out of bed, the resident did not believe staff. *7/1/18 SBAR Progress Note -- Resident sat on the edge of bed waiting for help to restroom, yelled out for help loudly even though he/she had just gone to the bathroom [ROOM NUMBER]-15 minutes earlier. *7/2/18 SBAR Progress Note -- CNAs reported the resident was forgetful and could not remember going to the restroom five times in a half hour period. *7/3/18 Nursing Care Note -- Laboratory results received indicated the resident had a [DIAGNOSES REDACTED]. 7/6/18 Behavior Note -- Resident refused to use call light, called out for staff assistance and complained she/he had to wait for assistance to go to the bathroom. Physician notes dated 7/6/18 indicated Resident 64 was symptomatic for a UTI with urgency, and frequent painful urination. Lab reports confirmed the presence of a UTI and the resident was ordered to have [MEDICATION NAME] 500 mg TID for seven days. On 8/28/18 at 1:25 PM Resident 64 was observed to be in bed. The resident was not currently receiving care and her/his bed was not in the lowest position. On 8/28/18 at 1:42 PM Staff 14 (LPN) confirmed she transferred the resident back into bed and did not put her/his bed in the lowest position despite the resident not currently receiving care. On 8/28/18 at 3:29 PM Witness 1 (Former CNA Staff) stated she was working with the resident on the morning of her/his 6/23/18 fall. She stated it was typical for Resident 64 to self transfer out of bed prior to her/his fall, had frequency of urination and she was unsure when the resident was last toileted before her/his fall. She further stated the fall mat was not in place at the time of the resident's fall, and she believed it was possible the resident could have attempted to transfer out of bed at the time of her/his fall. On 8/31/18 at 1:29 PM Staff 1 stated Resident 64's fall mats were up against the wall at the time of her/his fall. Staff 1 acknowledged staff were well aware the resident did not like her/his fall mats in place beside her/his bed and would kick them away. She further acknowledged the fall mat intervention was not removed from the resident's care plan until after the date and time of her/his fall on 6/23/18. Staff 1 described the resident to have a history of attempts to self transfer out of bed and into the bathroom, and confirmed the documented UTIs prior to the resident's fall, and post the resident's fall. Staff 1 stated she/he believed it was possible the resident had a UTI at the time of her/his fall. Staff 1 acknowledged the care plan was never updated to reflect the residents behavior of self transferring to the bathroom and frequency and urgency of urination. On 8/31/18 at 4:16 PM Staff 13 (CMA) stated it was common knowledge the resident did not like her/his fall mat prior to the time of the resident's 6/23/18 fall, but staff continued to try and attempt to place it by the bedside because it was a care planned intervention for falls. On 8/31/18 at 4:18 PM Staff 12 (CNA) stated the resident would attempt to self transfer out of bed and into the bathroom prior to her/his 6/23/18 fall, and further stated the resident had to urinate frequently. On 8/31/18 at 4:19 PM Staff 16 (CNA) stated the resident did not like the fall mat but staff would continue to attempt to place it at the bedside due to the resident being a fall risk. On 8/31/18 at 5:00 PM Staff 17 (CNA) stated at the time of Resident 64's 6/23/18 fall staff attempted to place fall mats by the resident's bed but she/he threw them out and became verbally offensive to staff. She stated the resident needed to urinate very frequently, and would become frustrated. Staff 17 further stated the resident would attempt to transfer out of bed, into her/his wheelchair and into the bathroom before the time of her/his fall. On 9/5/18 at 10:41 AM Staff 18 (LPN) stated she was the charge nurse on duty on the morning of Resident 64's fall. She stated she believed it was possible the resident was trying to transfer out of bed at the time of her/his fall, and that she/he frequently did so. Staff 18 also stated the resident had frequency and urgency of urination at the time of her/his fall and stated fall mats were not in place at the time of the resident's fall.

Based on observation, interview, and record review it was determined the facility failed to accurately stage pressure ulcers, initiate therapy recommendations, and evaluate pressure reducing devices for 1 of 3 residents (#20) reviewed for pressure ulcers. As a result the resident's facility acquired wound progressed from an abrasion to a Stage IV Pressure Injury. Findings include: The National Pressure Ulcer Advisory Panel defined Suspected Deep Tissue Injury, Stage IV and Unstageable Pressure Injury as follows: Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Depth varies by anatomical location. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Resident 20 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. On 10/16/15 the resident's progress notes indicated the resident had a red area on the back of her/his left heel. There were no further notes related to the resident's heel until 10/30/15 when the facility initiated weekly wound notes and classified the area as an unstageable abrasion that measured 1.5 cm x 0.7 cm and was covered with a scab. On 11/4/15 the progress notes indicated the abrasion progressed to a suspected deep tissue injury possibly caused by the resident's footwear. On 11/6/15 a Physical Therapy wheelchair assessment indicated the abrasion was likely due to the resident's positioning in bed and propensity to lay with her/his ankles crossed. Recommendations were made to add bolsters to the wheelchair arms, lower the wheelchair, and to wear boots in bed to prevent pressure. There was no documentation the recommendations were completed. Between 11/7/15 and 12/7/15 the weekly skin notes indicated the left heel wound continued to be an unstageable abrasion with minor changes in size and no indications of healing. The documentation of the type and the stage of wound was not changed to reflect a suspected deep tissue injury. There was no documentation the resident was wearing boots to prevent pressure as recommended by Physical Therapy on 11/6/15. On 12/14/15 the wound notes indicated the abrasion had opened with a pink/yellow wound bed and on 12/21/15 the wound bed was covered with thick white slough (dead tissue). On 1/12/16 the wound was described in the weekly wound note as 1.7 cm x 1.0 cm and a depth of 0.1 cm with shiny white tissue in the wound. On 1/18/16 the area was assessed as an unstageable abrasion and noted to be full thickness (tissue destruction extending through the dermis to involve subcutaneous issue) with visible tendon covering approximately 70% of the wound bed. There was no indication the facility had identified the wound was a Stage IV pressure injury instead of an abrasion. There was no documentation the resident was wearing boots to prevent pressure. On 1/20/16 the resident was seen at a surgical clinic for a consultation of the left heel open wound. The resident was wearing a boot to off load the pressure in the left heel when she/he arrived at the clinic. The wound measured 1.5 cm x 2.0 cm and the physician noted the achilles tendon at the base of the wound. On 1/28/16 the resident returned to the surgical clinic. The physician changed the dressing orders and ordered the continued use of the boot. On 3/9/16 the resident was seen at a wound ostomy clinic for follow-up of the left posterior ankle wound. The clinic identified the protective boot was rigid and rubbed directly on the area of the wound. The wound was non-healing and measured 1.2 cm x 1.9 cm x 0.2 cm depth. A different boot was provided that was softer and did not traumatize the wound. There was no evidence the facility was aware the original protective boot rubbed the wound area or had re-evaluated the appropriate use of the boot. On 3/18/16 the weekly wound note indicated the wound was a Stage IV Pressure Injury, two months after the wound progressed to full thickness with visible tendon in the wound bed. On 3/30/16 a Significant Change MDS was completed and identified the resident had a Stage IV unhealed pressure injury which measured 1.3 cm x 1.9 cm. The pressure ulcer CAA indicated the resident had a Stage IV wound to her left heel that appeared to have started as an abrasion and the resident was at risk for further breakdown. The resident's care plan was revised on 4/4/16 and indicated the resident had a Stage IV wound to her/his left heel and was at risk for skin impairment related to decreased mobility, cognitive loss, and incontinence. Interventions included air flow mattress in bed, wheelchair cushion, foot wear that did not put pressure on back of heels/ankles, offloading boots to bilateral lower extremities at all times except during transfers, treatment per physician orders, and to float heels while in bed On 5/4/16 the weekly wound assessment indicated the wound was a facility acquired unstageable pressure injury, measured 1.5 cm x 1.2 cm x 0.3 cm depth, and had white [MEDICATION NAME] slough covering 100% of the wound bed. On 5/4/16 at 12:24 pm Resident 20 was observed sitting in a wheelchair with a gel seat cushion near the nurses station. The resident was wearing nonskid socks. Her/his right lower leg/foot had a blue pillow boot with straps over the arch of the foot and around the calf. The left lower leg/foot had a light blue pillow boot with a larger 5-6 inch strap at the calf, a white strap at the heel, and a black strap around the foot. The boot had a wedge shaped cushion attached to it between the resident's leg and the wheelchair foot rest bar. On 5/5/16 at 1:09 pm Staff 2 (RCM) stated the resident's wound was first discovered as a scab in October 2015. She stated the facility thought it was from the resident's socks/slippers, at some point the scab came off, and there was slough under it so the facility started to treat the wound aggressively. On 5/5/16 at 1:25 pm Staff 2 reviewed the resident's wheelchair and was unsure if any changes were made based on the 11/6/15 Physical Therapy evaluation to the wheelchair. On 5/6/16 at 9:34 am Staff 4 (Director of Therapy) was asked about the 11/6/15 wheelchair evaluation. Staff 4 stated the wound was from the resident crossing her/his legs. Staff 4 verified there was no follow up documented regarding the recommendations for bolsters and lowering the wheelchair. Staff 4 verified therapy would be responsible to do both recommendations and he could not tell if the recommendations were done. On 5/6/16 between 10:00 am and 12:25 pm the weekly wound notes, wound clinic and surgery clinic notes were reviewed with Staff 2 and Staff 3 (Regional RN Consultant). Staff 2 demonstrated the original boot and verified the spot where it rubbed on the resident's wound had not been identified by the facility until after it was noted by the wound clinic. Staff 2 and Staff 3 also verified the delay in accurate staging of the wound until two months after the wound progressed to full thickness with visible tendon in the wound bed.

Based on interview and record review it was determined the facility failed to update, revise or initiate new interventions for complication related to foley catheter use and skin breakdown and ensure resident care plans were created in collaboration with hospice services, or review and revise care plans for 4 of 13 sampled residents (#s 5, 34, 66 and 88) who were reviewed for hospice, participation in care planning, foley catheter use, skin breakdown and restorative services. This resulted in surgical repair for Resident 66 and placed residents at risk for unmet needs. Findings include: 1. Resident 66 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. A nursing progress note dated 10/29/14 at 10:00 am indicated the resident had "tearing to meatus (tip of the penis) related to foley cath." On 11/9/14 the resident was seen by a wound care nurse for the tearing and skin breakdown on the resident's penis and no new interventions were recommended. On 11/25/14 the resident was seen by a urologist and orders were received which included to keep tension off the foley catheter. On 11/30/14 the resident was seen by the urologist again. The urologist documented the resident had erosion of the foreskin and again ordered "foley off tension." On 3/3/15 at 10:13 am a history and physical was written by the urologist in preparation for debridement of the resident's wound and surgical placement of a suprapubic catheter on 3/4/15. The physician documented the resident had a foley catheter due to issues of urinary incontinence and the physician recommended to keep the foley off of tension. The physician noted on 3/3/15 there was no catheter strap on the resident's leg and the foley remained on tension. The urologist concluded the resident had worsening of the erosion and the foley was "still not off of tension as seen today. " The resident's care plan, initiated 4/9/13 and updated 3/31/15, indicated the resident had a suprapubic catheter related to chronic use of an indwelling foley catheter with erosion of the resident's urethra. The care plan indicated the size of the catheter and directed staff to assist with incontinent care, and to have "straight drainage from supra pubic to drainage bag at all times". There was no direction to staff to keep off of tension as previously ordered by the physician. The status sheets used by staff for the resident's care, dated 4/1/15, was inaccurate and indicated the resident had a foley catheter and was to use a leg drainage bag during the day. There was no direction to staff to keep the foley off of tension with a catheter strap. Staff 7 (CNA) verified the 4/1/15 status sheet inaccurately indicated the resident had a foley catheter and was to wear a leg bag. Staff 7 verified the resident had a suprapubic catheter and did not have leg bag used due to the length of the suprapubic catheter tubing. On 4/3/15 at 7:00 am, Resident 66 was observed in bed while Staff 3 (LPN) did a dressing change to the resident's suprapubic insertion site. There was no catheter strap in place and the drainage tube was hanging off the bed placing tension on the insertion site. When the dressing was removed from the resident's lower abdomen the right side of the insertion site had a slight amount of slough and indentation from the tubing laying against it under the dressing. Staff 3 placed a clean dressing over the site and did not apply a catheter strap or other means of tension removal. On 4/3/15 at 7:22 am Staff 3 verified the indentation on the right side of the insertion site and stated the resident used a leg bag when out of bed and a catheter strap. Staff 3 was unable locate the resident's catheter strap and verified the resident used a drainage bag under her/his wheelchair frequently instead of a leg bag. On 4/6/15 at 12:55 pm Staff 7 (CNA) verified a catheter strap was frequently not used on the resident. On 4/7/15 at 10:05 am, Staff 2 (RNCM) acknowledged the plan of care was not revised, did not include directions to keep the catheter off of tension, and the resident status sheet was not revised when the resident's status changed in 3/2015. Refer to F315 2. Resident 5 was admitted to the facility in 9/2014 with [DIAGNOSES REDACTED]. The resident's 2/4/15 annual MDS indicated the resident did not walk and required extensive staff assistance for bed mobility, transfers, and locomotion. The resident's care plan dated 12/2014 indicated the resident was to receive restorative (RA) services but had not been revised to include the RA program components or frequency of treatment. On 4/3/15 at 12:53 pm, Staff 6 (LPN Resident Care Manager) verified Resident 5's care plan had not been updated to identify the resident's specific RA program components. Surveyor: Boggess, Bennett 3. Resident 88 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 88's 11/5/14 MDS indicated the resident was on hospice. Resident 88's facility care plan for end of life care dated 11/11/14 indicated the facility would collaborate with hospice services for pain and symptom management and aspects of the resident's care. Resident 88's hospice service's care plan dated 1/15/15 indicated hospice would provide chaplain visits, massage therapy, social services visits and skilled nursing visits. The facility's care plan did not specify what services hospice was to provide or what services the facility was to provide. The interventions were generic and not specific to the resident. The care plan was not revised with information from the hospice service's 1/15/15 care plan. On 4/2/15 at 2:03 pm, Staff 1 (DNS) acknowledged the care plan was generic, not resident specific, and should have reflected the care hospice and the facility provided. 4. Resident 34 was admitted to the facility in 2006 with [DIAGNOSES REDACTED]. Resident 34's 1/17/15 MDS indicated the resident was on hospice. Resident 34's hospice service's care plan dated 1/17/15 indicated hospice would provide chaplain visits, social services visits and skilled nursing visits. A review of Resident 34's facility care plan for end of life care dated 1/23/15 indicated the facility would collaborate with hospice services for pain and symptom management. The facility's care plan did not specify what services hospice was to provide or what services the facility was to provide. The interventions were generic and not specific to the resident. On 4/3/15 at 11:26 am, Staff 1 (DNS) acknowledged Resident 34's care plan was not comprehensive and did not accurately reflect the resident's status.

1. Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services for 1 of 3 residents (#66) reviewed for catheter care. As a result the resident sustained [REDACTED]. Findings include: Resident 66 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The resident's 4/2014 annual MDS indicated the resident had an indwelling urine catheter. The Incontinence and Indwelling Catheter CAA identified the resident had a foley catheter due to his history of inability to void without a catheter. A NN dated 9/24/14 at 8:48 pm indicated the resident developed swelling of his genitals. The nursing progress notes indicated if the swelling did not improve by the following day the doctor would be notified and the resident would be placed on alert charting. There was no follow up or doctor notification documented on 9/25/14 and the resident was not started on alert charting to monitor the swelling. On 9/30/14 at 1:26 pm a new physician's orders [REDACTED]. There was no assessment documented of the appearance of the swelling or the drainage. The next nursing progress note related to the resident's genital status was dated 10/28/14 at 9:50 pm and indicated the resident had a brownish discharge. On 10/29/14 at 10:00 am a nursing progress note indicated the resident had an "increased tearing to meatus" related to the foley catheter, and discharge noted from the meatus. The doctor was notified and a referral to a wound clinic was received. There was no skin/wound assessment documented. On 10/30/14 at 1:22 pm a nursing progress note indicated the area around the resident's catheter was "beefy red tissue with slight exudate." There was no measurements of the wound size or depth or additional assessment of the wound characteristics. On 11/10/14 the resident was seen by a wound care nurse who referred the resident to a urologist but made no recommendations for management of the meatus tearing. On 11/25/14 the resident was seen by a urologist and orders were received which included to keep the foley off tension. Review of the nursing progress notes revealed no further information about the resident's tearing meatus until 11/26/14 when a note indicated "opening on penis draining yellow exudate." There was no further assessment of the wound. On 11/30/14 the resident had another visit with the urologist. The urologist documented the resident had erosion of the foreskin and again ordered "foley off tension." A Bowel and Bladder evaluation on Resident 66 was completed on 12/31/14. The evaluation indicated the resident was a good candidate for bladder retraining and indicated the resident had no genital, perineal, or buttocks skin conditions. On 2/6/15 the resident had another urologist appointment to address the issue of "hole is larger on scrotum." There was no assessment of the wound size or appearance. The urologist documented continued erosion and planned to surgically debride the genital wound and place a suprapubic catheter. On 3/3/15 at 10:13 am a history and physical was written by the urologist in preparation for debridement of the resident's wound and surgical placement of a suprapubic catheter on 3/4/15. The physician documented the resident had a foley catheter due to issues of urinary incontinence and the physician recommended to keep the foley off of tension. The physician noted on 3/3/15 there was no catheter strap on the resident's leg and the foley remained on tension. The urologist concluded the resident had worsening of the erosion and the foley was "still not off of tension as seen today. " A physician's orders [REDACTED]. A nursing progress note dated 3/19/15 at 9:42 am, indicated the area around the suprapubic catheter was macerated with some yellow slough noted. On 3/31/15 at 1:55 pm Staff 2 (RNCM) stated the resident had a "permanent foley that didn't work out." Staff 2 provided the [DIAGNOSES REDACTED]. The resident's care plan was revised on 3/31/15 and identified the resident had a suprapubic catheter related to chronic indwelling foley catheter with erosion of the urethra. The interventions listed included directions to assist with incontinent care as needed, the size of the catheter tubing, and to have straight drainage from the suprapubic to drainage bag at all times. The care plan also addressed the resident's genital erosion but included no interventions to prevent further erosion. The facility's status sheet, used by staff for resident care dated 4/1/15 inaccurately indicated Resident 66 had a foley catheter and was to use a leg drainage bag during the day. There were no directions to keep the foley off of tension as per the urologist directions. The facility's Urinary Catheter Care Procedure directed staff to ensure that catheters remained secured with a leg strap to reduce traction and movement at the insertion site. The care procedure also noted catheter tubing should be strapped to the resident's inner thigh. On 4/3/15 at 7:00 am Staff 3 (LPN) was observed while performing a dressing change to Resident 66's suprapubic insertion site and surgical wound. Staff 3 removed and disposed of the used dressing. The catheter tubing protruding from the resident's mid lower abdomen was tilted and resting against the right side of the insertion site/hole. A small amount of slough, erosion, and an indentation the size of the tubing was observed on the right side of the insertion site. There was no catheter strap or tubing anchor present and a drainage bag was hanging on the right side of the resident's bed. Staff 3 completed the dressing change, covered the site with a gauze pad, repositioned the drainage bag tubing, but did not secure the catheter tubing to prevent pulling or potential erosion of the insertion site. On 4/3/15 at 7:22 am Staff 3 verified the indentation on the right side of the insertion site. Staff 3 stated the resident used both a leg bag and a straight drainage bag. Staff 3 also stated the resident wore a catheter strap but was unable to locate it in the resident's room and stated it was probably dirty and in the laundry. Staff 7 (CNA) stated on 4/5/15 at 12:55 pm catheter straps were frequently not used. On 4/7/15 at 7:45 am Staff 8 (Central Supply) stated the facility's catheter straps were not to be reused. She stated staff were to obtain new straps because the Velcro on the catheter straps did not tolerate the wash cycle. On 4/7/15 at 10:05 am Staff 2 (RNCM) stated the resident's penile erosion was first noted on 10/30/14 and was caused by chronic foley catheter use combined with pressure and tension. Staff 2 stated the facility sought a wound referral, provided treatment for [REDACTED]. Staff 2 stated the facility couldn't "glue it to his leg" and verified the lack of routine use of a catheter strap or other form of an anchor to prevent tension and further erosion. Staff 2 was unaware of the indentation of the suprapubic insertion site. The facility's clinical protocol for Pressure Ulcers/Skin Breakdown indicated a full assessment of pressure sores should include location, stage, length, width, depth, and presence of exudates or necrotic tissue. The facility's protocol for Pressure Ulcer Risk Assessment directed for nurses to conduct skin assessments at least weekly. The assessment documentation should include the wound appearance (wound bed, edges, drainage, color, size, etc.) and potential complications such as pain, redness, bleeding, swelling, and drainage. On 4/7/15 at 10:35 am Staff 2 stated the facility would normally complete an incident report for pressure ulcers but did not perform an incident report for the resident's genital erosion injury caused by pressure and tension. Staff 3 verified the facility did not follow it's own protocol of weekly wound assessments and reports. 2. Based on observation, interview and record review it was determined the facility failed to provide restorative bladder care for 1 of 3 residents (#60) reviewed for catheter care. This placed the residents at increased risk for unmet bladder needs. Resident 60 was admitted to the facility in 1/2015 with an indwelling catheter and a [DIAGNOSES REDACTED]. Resident 60's Bowel and Bladder Evaluation dated 1/13/15 revealed the resident was identified to be a good candidate for bladder retraining. No documentation could be located in the resident's medical record pertaining to attempts by the facility to initiate restorative bladder services. On 4/6/15 at 1:58 pm, Staff 6 (LPN Resident Care Manager) acknowledged no documentation could be located regarding restorative services for Resident 60's indwelling catheter.