Every finding on record at Fairlawn Health and Rehabilitation of Cascadia

Based on observation, interview, and record review it was determined the facility failed to follow infection control precautions for 2 of 3 sampled hallways (north hall and west hall) reviewed for infection control. This placed the residents at risk of acquiring an infection. Findings include:According to the Center for Disease Control and Prevention (CDC) website https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: -Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission. -Use personal protective equipment (PPE) appropriately, including gloves and gowns. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. According to the Centers for Disease Control and Prevention (CDC)'s 6/2021 Consideration for Use of Enhanced Barrier Precautions (EBP) (protective measures taken by nursing home staff for residents with specific germs or medical devices) in Skilled Nursing Facilities (https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html) - EBP is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of multidrug-resistant pathogens. - EBP was recommended for residents with wounds or indwelling medical devices. a. On 3/23/26 at 10:20 AM and 3/24/26 at 12:29 PM, Staff 7 (RN) entered room [ROOM NUMBER], which was on Contact Precautions. Prior to entering the room, Staff 7 did not don PPE. A CDC Contact Precautions sign was prominently displayed on the outside wall, next to the room door with large black letters indicating: NO ENTRY WITHOUT PPE. The sign indicated staff and visitors were to put on a gown and gloves before room entry and discard the gown and gloves before exiting the room. On 3/23/26 at 10:20 AM and 3/24/26 at 12:29 AM, Staff 7 stated individuals were allowed to enter room [ROOM NUMBER] without PPE as long as no care was being provided to the residents. Staff 7 stated no resident in room [ROOM NUMBER] was on contact precautions and he was unsure why a contact precautions sign was posted. On 3/24/26 at 12:31 PM, Staff 10 (CNA) stated lots of people were confused regarding the PPE requirements for room [ROOM NUMBER]. On 3/25/26 at 9:54 AM, Staff 9 (Infection Preventionist) confirmed staff and visitors entering room [ROOM NUMBER] were required to wear PPE because a resident in the room was diagnosed with MRSA (a bacterium responsible for severe infections and resistant to many antibiotics) thus contact precautions were required. Staff 9 stated PPE was required upon entering room [ROOM NUMBER] for any reason. b. On 3/23/26 at 9:59 AM room [ROOM NUMBER] was observed to have a CDC EBP sign attached to the wall outside of the room listing glove and gown use were required with high contact cares. On 3/23/26 at 9:59 AM, 3/24/26 at 8:53 AM, 3/24/26 at 12:24 PM, 3/24/25 at 12:35 PM, and 3/24/25 at 1:43 PM facility staff were observed to have provided high contact care to the residents in room [ROOM NUMBER]. On 3/24/26 at 1:30 PM Staff 11 (CNA) confirmed she had not worn a gown because she did not know she was supposed to wear one. Staff 11 confirmed there was a sign posted outside of the room but had not noticed it. On 3/24/26 at 1:46 PM Staff 12 (Restorative Aide) confirmed she had not worn a gown because she did not believe the resident was on EBP. On 3/24/26 at 3:37 PM Staff 13 (LPN Care Manager) stated PPE would only be needed if the staff was working directly with the gastrostomy tube or wound but after reviewing the CCD EBP sign, she confirmed PPE would be required when providing all high contact care, not just when providing care with the indwelling medical device or wound. On 3/25/26 at 3:42 PM Staff 9 (Infection Preventionist/LPN) confirmed staff were required to wear PPE as outlined on the signage posted outside of the room when providing high contract cares since the residents in this room had an indwelling medical device and wounds. c. On 3/26/26 at 10:05 AM Staff 15 (CNA) was observed in room [ROOM NUMBER] assisting a resident with compression stocking and sock donning for both lower extremities while wearing only gloves. A sign directly outside room [ROOM NUMBER] indicated enhanced barrier precautions (EBP) were to be followed when direct contact care was provided including dressing. On 3/26/26 at 10:09 AM Staff 15 stated she provided lower body dressing care for the resident in room [ROOM NUMBER] without a gown. Staff 15 stated she was instructed to wear a gown only when she cleaned and touched an area near a wound or opening for a resident on EBP. Staff 15 stated gloves were all that were required when other direct contact care was provided. On 3/26/26 at 10:22 AM Staff 9 (Infection Preventionist/LPN) confirmed EBP were to be followed when any direct contact care was provided to the resident in room [ROOM NUMBER], including socks and compression stockings donning.

Based on observation, interview and record review it was determined the facility failed to ensure food was labeled and stored in a manner to avoid spoilage in 2 of 2 kitchens and failed to properly follow dish sanitizing practices and sanitization of food preparation surfaces for 1 of 2 kitchens. This placed residents at risk for food-borne illnesses. Findings include:Review of the US FDA 2022 Food Code indicated the following:-Food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded.-Food must be labeled with a use-by-date if stored for at least 24 hours.-Food could be stored up to seven days.The facility's Food Safety and Storage policy, dated 11/28/2017, indicated the facility stored and handled all food, non-food items and food preparation supplies in a manner that ensured safety, sanitation and compliance with federal, state and local regulations. Practices followed the FDA Food Code (2022). 1. On 3/23/26 between the hours of 9:33 AM and 9:59 AM, a brief tour was completed of both facility kitchens, accompanied by Staff 3 (Dietary Manager) which revealed the following: Freezer in first kitchen: -three open cartons of ice cream were undated.-five popsicles were undated.-1/4 of an angel food cake in a plastic bag was undated. Walk-in refrigerator in second kitchen: -two pans of previously roasted potatoes, dated 3/17/26, were outdated. -one plastic container of broccoli-cheese soup, dated 3/17/26, was outdated. -one large bag of shredded lettuce was wilted. -two, five-pound bags of white cheese were undated. -three, five-pound bags of yellow cheese were undated. Standing refrigerator in second kitchen: -one opened jar of Cesar dressing was undated. -one pitcher of apple juice had a use-by-date of 3/14/26. -one pitcher of iced tea was undated. -one partial pitcher of orange juice was undated. -one opened 12-ounce container of horseradish was undated. Walk-in freezer in second kitchen: -two dozen unbaked biscuit squares in a plastic bag were undated. -one bag of curly fries was dated 12/2025. On 3/23/26 at 9:33 AM and 9:59 AM, Staff 3 confirmed the above items were either undated or expired. Staff 3 stated all items should be dated and any items out-of-date should have been discarded. 2. On 3/26/26 at 9:40 AM, a load of freshly washed and sanitized dishes and trays was observed in the dishwasher. Staff 5 (Dietary Aide) tested the sanitizer level by obtaining a test strip located on the wall and dipped the test strip in the residual water in the dishwasher. The test strip was removed and revealed a white color. Staff 5 then completed a second test which, again, revealed a white color. The white color indicated there were 10 or less parts per million of sanitizer which was less than the required minimum concentration of available sanitizer needed for properly sanitized dishware. Staff 5 then tested the red bucket containing sanitized water used to clean the steam table and food preparation counters. She dipped a test strip into the water which indicated 0 parts per million of sanitizer and stated the water did not meet the required sanitizing requirements. On 3/26/26 at 12:49 PM, Witness 1 (Vendor representative) stated the dishwasher's sanitizing dispenser was not functioning properly and he was unable to determine how long the sanitizing system had not been working. Staff 5 and Staff 6 (Prep Cook) stated they did not test the dishwasher sanitizer prior to washing dishes. Staff 3 stated the dishwasher sanitizing system should be tested prior to starting dishwashing and the sanitizer for the dishwasher and sanitizing buckets did not meet the required sanitizing levels. Staff 3 stated she retested the dishwasher's sanitizing system prior to Witness 1 arriving, and the sanitizer tested a white color which confirmed the system was not properly sanitizing dishes and dishware.On 3/27/26 at 10:00 AM, Staff 4 (Assistant Dietary Manager) verified the red bucket sanitization water should test at 200 to 400 parts per million of sanitizer and the dishwasher should test at 75 to 200 parts per million for effective sanitization.

Based on observation, interview and record review the facility failed to ensure the resident meals were served at an appetizing temperature in hallways for 1 of 1 facility reviewed for food. This placed residents at risk for inadequate nutritional intake. Findings include:Review of the 12/2025, 1/2026 and 2/2026 Resident Council meeting notes revealed the Resident Council expressed food concerns including hot food served cold.Resident 36 was admitted to the facility in 2/2026 with a diagnoses including sepsis (body's extreme response to an infection damaging tissue and organs) and nutritional deficiency.A 2/12/26 admission MDS assessed Resident 36 as cognitively intact. Resident 69 was admitted to the facility in 3/2026 with a diagnoses including occlusion and stenosis of the left posterior cerebral artery (condition where the main vessel supplies blood to the brain).A 3/9/25 admission MDS assessed Resident 69 as cognitively intact.Resident 90 was admitted to the facility 3/2026 with a diagnoses including a fractured tibia (shinbone).A 3/18/26 admission MDS assessed Resident 90 as cognitively intact.On 3/23/26 at 11:17 AM Resident 36 expressed concerns that her/his food was always served cold.On 3/23/26 at 11:52 AM Resident 69 stated her/his food was delivered cold. On 3/25/26 at 12:54 PM Staff 16 (CNA) stated the resident plates were often served without plate warmers and she usually needed to re-heat the meals for residents.On 3/26/26 at 8:32 AM Resident 90's tray was observed to be delivered to her/his room with no plate warmer.On 3/26/26 at 8:34 AM observation of Resident 36's food was delivered to her/his room with no plate warmer. Resident 36 stated her/his food was cold. Resident 36 was observed to request a CNA to re-heat the food.On 3/26/26 at 8:50 AM Resident 90 stated the meal plate was delivered without a plate warmer and the food was often served cold.On 3/25/26 at 12:54 PM Staff 16 (CNA) stated the residents' food was often cold, plates were often served without plate warmers and she usually needed to re-heat the meals for residents.On 3/26/26 at 10:02 AM Staff 6 (Prep Cook) stated the facility used the plate warmers to ensure residents were served meals at appetizing temperatures in the hallways. Staff 6 confirmed the kitchen did not have enough plate warmers to serve all the residents in the hallways.On 3/26/26 at 10:07 AM Staff 3 (Dietary Manager) acknowledged the kitchen used plate warmers to keep the residents' meals at an appetizing temperature when served in the hallways. Staff 3 stated she was unaware the kitchen did not have enough plate warmers to serve all the residents in the hallways. On 3/26/26 at 3:51 PM Staff 1 (Administrator) acknowledged she expected the residents to be served meals at an appetizing temperature and she was unaware the facility did not have enough to provide each resident with plate warmers at meals.

Based on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. The facility's 4/2018 Food Storage: Cold Foods Policy Statement specified, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The facility's 9/2017 Food Storage: Dry Goods Policy Statement specified, All packaged and canned food items will be kept clean, dry, and properly sealed. On 12/2/24 at 9:43 AM during the initial tour of the facility's kitchen, the following was observed: -Three trays of unlabeled and undated cups of milk and juice on the top shelves of the middle and right refrigerators in the food preparation area; -An uncovered and unlabeled large plastic bin of dry oat cereal sitting on the top shelf of a wheeled cart in the dry storage room; -An opened and undated five-pound plastic tub of peanut butter with peanut butter smeared on the top and edge of the lid and on the sides of the tub on the top shelf of a wheeled cart in the dry storage room. The tub was slick and unclean; -An opened and undated bag of salad greens on the top shelf of the refrigerator in the dry storage room; and -A plastic bin containing four eggs, one with a broken shell, on the bottom shelf of the refrigerator in the dry storage room. On 12/2/24 at 9:55 AM Staff 14 (Dietary Manager) stated the lettuce shouldn't be left open as it was observed. She added, It needs to be closed up and wrapped with plastic and labeled with a date. She acknowledged the cracked shell and stated she expected staff to throw out any eggs with broken shells. She added, The peanut butter is definitely not clean like that. It should be wiped down during the process if it gets messy. Staff 14 also stated the bin of oat cereal should was not be uncovered in dry storage storage. She expected the bin to be emptied and taken to the dishwashing station rather than left uncovered in the dry storage room. 2. The facility's 9/2017 Equipment Policy Statement specified, All non-food contact equipment will be clean and free of debris On 12/2/24 at 10:06 AM the gaskets on the interiors of the refrigerator doors were observed to be grimey with solid and liquid food debris collected in the plastic flanges. The gaskets were observed to be pulling away from doors which created an incomplete seal. Staff 14 (Dietary Manager) stated she cleaned the gaskets regularly but they got dirty again because they are old and they don't close well. Stuff drops from above. Staff 14 stated she expected her staff to keep it clean because It shouldn't be like this. Staff 14 stated the facility needed a new refridgerator. 3. On 12/2/24 at 10:07 AM the kitchen was observed to have multiple dirty in-floor drains. The drain opposite the food preparation and steam table area had black grime caked around the inset grate. The drain adjacent to the ice machine was also observed to be caked with so much black grime it was not possible to see the inset grate. Additionally, food debris and other kitchen waste was observed on the floor adjacent to the drain next to the ice machine. Staff 14 (Dietary Manager) confirmed these observations and stated the drains were dirty and needed to be cleaned. On 12/6/24 at 2:14 PM Staff 1 (Administrator) acknowledged these findings and stated she expected the kitchen staff to keep the kitchen clean and sanitary and items should be covered, labeled and dated to prevent spoilage and cross-contamination.

Based on observation, interview and record review it was determined the facility failed to follow catheter care orders for 1 of 1 resident (# 53) reviewed for catheter care. This placed residents at risk for unmet care needs. Findings include: Resident 53 was initially admitted to the facility in 10/2024 with diagnoses including urine retention (difficulty urinating) with the use of a Foley catheter to remove urine from the bladder. A 10/3/24 BIMS indicated Resident 53 had normal cognitive function. A 12/3/24 Neurosurgery Postoperative Visit note included instructions for Resident 53's Foley catheter to be changed after she/he returned to the nursing facility. A 12/3/24 physician order stated the following: Change Foley ASAP, was not changed during hospitalization . On 12/4/24 at 9:53 AM Resident 53 stated she/he returned to the facility after a surgical procedure at the hospital and had orders to have her/his catheter changed immediately. Resident 53 stated her/his Foley catheter was not changed on 12/3/24. On 12/5/24 at 9:50 AM Resident stated her/his Foley catheter was not changed on 12/4/24. Review of the 12/2024 TAR on 12/5/24 revealed Resident 53's Foley catheter change was not completed on 12/3 or 12/4. On 12/5/24 at 10:28 AM Staff 20 (RCM/LPN) stated Resident 53's catheter should have been changed as soon as possible and confirmed that change was not performed as ordered on 12/3/24 or 12/4/24. On 12/5/24 at 11:13 AM Staff 18 (RN) stated she provided care to Resident 53 on 12/3/24 and confirmed she did not change Resident 53's Foley catheter. Staff 18 stated she intended to contact Resident 53's physician for clarification of catheter change orders, but did not contact the physician. On 12/5/24 at 12:03 PM Staff 19 (LPN) stated she provided care to Resident 53 on 12/4/24 and confirmed the Foley catheter change was not completed because she ran out of time. On 12/5/24 at 11:37 AM Staff 2 (DNS) confirmed Resident 53's catheter was not changed as ordered.

Based on observation, interview and record review it was determined the facility failed to ensure safety interventions for fall prevention were followed for 1 of 4 residents (#26) reviewed for accidents. This placed residents at risk for accidents. Findings include: Resident 26 was admitted to the facility on [DATE] with diagnoses including age-related osteoporosis with a current pathological fracture of her/his left femur (a chronic disease that causes bones to become brittle and porous, and a broken upper-leg bone) and severe vascular dementia with agitation (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain). A review of Resident 26's 9/30/24 Quarterly MDS Assessment revealed she/he had severe cognitive impairment. Resident 26's 9/30/24 Quarterly Fall Risk Assessment indicated she/he was at risk for falls related to her/his incontinence, impaired cognition and impaired functional mobility. A review of Resident 26's care plan revealed she/he had a low bed and it was to be against the wall and in the lowest position with a fall mat at her/his bedside to minimize her/his risk of injuries from falls. On 12/3/24 at 10:01 AM Resident 26 was observed to be in bed with a fall mat at her/his bedside. Her/his bed was elevated to a level for transfers and was not in the low position. There were no caregivers in her/his room. On 12/5/24 at 9:24 AM Resident 26 was observed to be in bed, awake and watching television with the head of the bed elevated to approximately 30 degrees. There was a fall mat on the floor beside the bed and the bed was elevated to a height appropriate for wheelchair transfers. The bed was not in the low position and there were no caregivers in the room. On 12/5/24 9:59 AM Staff 13 (CNA) stated Resident 26 was part of the facility's Falling Star program which indicated staff were to look inside Resident 26's room whenever they passed it to make sure she/he had not fallen, there was a fall mat at her/his bedside and her/his bed was in the lowest position. Staff 13 confirmed Resident 26 was in her/his bed and the bed was in wheelchair transfer height. Staff 13 stated Resident 26's bed should be in the lowest position when she/he was in it. On 12/5/24 at 11:23 AM Staff 15 (RN) stated Resident 26 was assessed to be at risk for falls and had a history of falls. She stated she expected CNAs to follow Resident 26's care plan for her/his safety. On 12/6/24 at 10:28 AM Staff 3 (LPN / Infection Preventionist) stated Resident 26 often sat in bed with her/his legs dangling over the edge and it made us nervous. He added this was one of the reasons for Resident 26's fall prevention interventions. On 12/06/24 at 2:23 PM Staff 1 (Administrator) stated she expected staff to follow care planned interventions because Resident 26 was at risk for falls.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 2 sampled residents (#210) reviewed for safe discharges. This placed residents at risk for unmet care needs. Findings include: Resident 210 was admitted to the facility in 7/2024 with diagnoses including periprosthetic fracture around other internal prosthetic joint (a bone fracture that occurs near or around a joint replacement implant). Resident 210's 7/31/24 St. Louis University Mental Status Examination (SLUMS) score indicated the resident experienced dementia. Resident 210's 9/5/24 Discharge MDS Assessment revealed the resident was cognitively intact, had an indwelling catheter, was occasionally incontinent of urine, required setup or clean-up assistance with showering and to put on or take off foot wear and required supervision or touch assistance with car transfers and to go up or down a curb or one step. Resident 210's 9/5/24 Physician Orders directed the resident to receive hydralazine (a medication used to treat high blood pressure) three times daily. The medication was to be held for a systolic (the highest pressure in your arteries when your heart beats) blood pressure less than 110. A review of Resident 210's 9/2024 Progress Notes revealed the following: -A 9/2/24 Progress Note revealed Resident 210 continued to experience episodes of dizziness, unstable blood pressures and urine retention. -A 9/3/24 Physician Order directed the resident to be straight catheterized (a procedure that involves inserting a straight catheter into the urethra to drain the bladder) if her/his post void residual (PVR, the amount of urine left in the bladder after urinating) was more than 300 ml every six hours. If the resident continued to have greater than 300 ml PVR, the resident was to be straight catheterized again. If she/he was straight catheterized three times, a foley catheter (a medical device that helps drain urine from the bladder) was to be inserted. If she/he refused the foley catheter, the resident was to be sent to the emergency department. -A 9/3/24 Skilled Charting Note revealed the resident was concerned about her/his ongoing urine retention and decided the safest thing would be to discharge home with a foley catheter. -A 9/3/24 Social Service Note indicated Resident 210 wanted to discharge on 9/5/24. -A 9/5/24 Social Service Note written at 1:28 PM indicated Witness 2 (Family Member) was called per Resident 20's request to notify Witness 2 of her/his discharge. -A 9/5/24 Health Status Note written at 4:15 PM indicated Resident 210 had a foley catheter re-inserted STAT (immediately) prior to her/his discharge from the facility. Resident 210's 9/5/24 Utilization Review Physical Therapy Progress Section revealed the resident lived with family in a one story home with three steps to enter. The resident required a front wheel walker and supervision with transfers. The Discharge Plan Section indicated the discharge plan was for the resident to go home with Witness 2 and with home health but home health had not been ordered. Resident 210's 9/5/24 Planned Discharge Summary revealed the resident discharged from the facility on 9/5/24 at 2:00 PM, went home as planned and was accompanied home by the driver of a transportation company, needed assistance with lower extremity dressing, personal hygiene and with stairs and was moderately independent for making decisions. In the section of the summary entitled Resident Education Materials Provided, there was no check in the boxes for catheter care or monitor blood pressure. Resident 210's 9/5/24 Physician Discharge Summary indicated the resident discharged home with family on 9/5/24 at 2:06 PM. No evidence was found in Resident 210's clinical record to indicate she/he was could independently administer her/his medications or provide her/his own catheter care, the resident was safe to be alone when she/he experienced on-going episodes of dizziness, the resident's family was notified of her/his discharge from the facility prior to her/his day of discharge, confirmation a family member would be at the resident's house to assist the resident with the stairs or care as needed on the day she/he discharged from the facility or that a family member had received instructions on the resident's medications or catheter care. On 12/5/24 at 11:04 AM Resident 210 stated she/he informed the facility she/he intended to discharge from the facility on 9/5/24 weeks in advance of her/his discharge. Resident 210 stated on her/his day of discharge, everyone was running around to get paperwork done at the last minute. Resident 210 stated she/he did not recall reviewing her/his medication list at the time of discharge or care for her/his catheter. On 12/5/24 at 12:15 PM Witness 2 stated Resident 210's discharge from the facility was really confusing and sad and there was no communication regarding a plan to discharge. Witness 2 stated she was initially informed of Resident 210's discharge from the facility on 9/5/24, just two hours prior to when Resident 210 was anticipated to arrive home. Witness 2 stated when she was informed of the discharge, she told the facility she was out of town and did not know if she would be home at the time Resident 210 arrived. Witness 2 stated she was informed at this time that the resident would be returning home with a foley catheter in place and she had not been trained on the care of a foley catheter. Witness 2 stated she was not informed of what medications the resident was discharged with prior to her/his discharge or if she/he had the necessary supplies for her/his catheter. Witness 2 stated the medication card that contained the resident's blood pressure medication did not match the orders the facility sent home with the resident, and when Resident 210's blood pressure dropped, she/he was not cognitively with it. Witness 2 further stated home health was not set up at the time of Resident 210's discharge, and it was the facility's responsibility to make sure we had the resources available when the resident returned home since we live in a small community where access to resources was limited and home health services were over an hour away. On 12/5/24 at 1:48 PM Staff 13 (CNA) stated Resident 210 was confused and forgetful mostly daily. Staff 13 stated Resident 210 could not independently complete her/his own catheter care at the time of her/his discharge. On 12/6/24 at 11:26 AM Staff 15 (RNCM) stated family was to be notified of a discharge three days ahead of time and throughout the stay. Staff 15 stated residents with a foley catheter required education on catheter care and nurses should document resident abilities in the progress notes. Staff 15 stated residents with medication parameters, such as holding a medication dependent on a blood pressure reading, would need to be trained to take their blood pressure. Staff 15 stated if a resident was determined to discharge home with family, a family member would have to be present when going through all of the patient's medications and she would expect a family member present for catheter care instructions as well. Staff 15 stated Resident 210 had a foley catheter placed the day she/he discharged from the facility because the resident could not straight catheterize on [her/his] own. Staff 15 stated Resident 210 experienced intermittent dizziness, the resident's blood pressure was kind of elevated and staff worked with the resident's provider to change her/his cardiac medication to see what would work. Staff 15 stated the plan was for Resident 210 to discharge home with Witness 2 as the resident required assistance with her/his catheter, needed assistance with transfers for safety reasons and was unable to care for her/himself when dizzy. Staff 15 stated Resident 210's foley catheter was placed at the last minute and the family would have needed some kind of training. Staff 15 reviewed Resident 210's clinical record and confirmed there was no documentation to indicate the family was informed of her/his discharge from the facility prior to her/his date of discharge or that the family was provided any education regarding care of the resident's catheter or medication administration. On 12/6/24 at 12:08 PM Staff 5 (Social Services) stated she was aware of Resident 210's plan to discharge a couple of days prior to her/his actual discharge from the facility on 9/5/24. Staff 5 stated she thought she tried to call Witness 2 to inform her of the resident's discharge on 9/4/24 but she did not connect with Witness 2 or leave her a voicemail. Staff 5 stated she spoke with Witness 2 on 9/5/24 about the resident's discharge and was told Witness 2 may not be home when the resident arrived. On 12/6/24 at 1:26 PM Staff 16 (Physical Therapy Assistant) stated Resident 210 lived with family way far away. Staff 16 stated Resident 210 needed supervision to do the steps at home and needed someone to always be with [her/him] at home. On 12/6/24 at 2:22 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the findings and Staff 2 stated more training and documentation was needed.

Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 2 resident rooms (room [ROOM NUMBER]) reviewed for environment. This placed residents at risk for a lessened quality of life. Findings include: An observation on 12/2/24 at 9:56 AM revealed the cloth recliner chair in room [ROOM NUMBER] was stained with an unknown brown dried residue on the seat of the chair and on the arm rests. On 12/4/24 at 2:14 PM Staff 10 (CNA) stated the chair in room [ROOM NUMBER] was filthy and did not have a cleanable surface. On 12/4/24 at 2:23 PM Staff 3 (Infection Preventionist) stated the chair was very dirty and did not have a cleanable surface. On 12/6/24 at 12:54 PM Staff 12 (Housekeeping) stated she had a monthly cleaning schedule for resident recliners but did not clean the one in room [ROOM NUMBER] because it was cloth. On 12/6/24 at 2:20 PM Staff 1 (Administrator) confirmed the chair was dirty and had a bad odor.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 3 and 4) reviewed for bowel care. This placed other residents at risk for bowel complications. Findings include: On 3/31/24, the Past Noncompliance was corrected when the facility implemented an updated bowel protocol, which included: -Bowel protocol binders are located at each nursing station; -New bowel forms were created for every resident and reviewed daily; -Residents with no documented bowel movement after 72 hours were added to the list, monitored and followed up by nursing staff; -Staff in-serviced on the facility's bowel protocol. -Interviews conducted with nursing staff and confirmed bowel protocol was in place. 1. Resident 3 admitted to the facility in 9/2023, with diagnoses including atrial fibrillation and constipation. Resident 3's physician orders dated 9/28/23 indicated she/he was to be administered bowel medications daily. The bowel protocol on the resident's orders and 10/2023 MAR indicated the following steps were to be taken: -Step 1-Administer 17 grams of Polyethylene Glycol Powder every 48 hours for no bowel movement in two days. -Step 2-Administer Bisacodyl suppository every 72 hours for no bowel movement in three days. If resident refused the suppository, administer two Bisacodyl tablets every 72 hours. -Step 3-Administer a Fleet Mineral Oil enema for no bowel movement in four days. -Step 4-Administer Lactulose Solution, 30 ml every 8 hours as needed if unrelieved by bowel protocols. Resident 3's bowel logs for 10/2023 revealed no bowel movement from 10/22/23 through 10/31/23. Resident 3's 10/2023 MAR revealed she/he was given the following bowel medications and results: -10/25/23 (three days after no bowel movement): Polyethylene Glycol Powder: Results - ineffective -10/25/23: Bisacodyl tablets (3 days after no bowel movement): Results - ineffective -10/30/23: Bisacodyl Suppository (8 days after no bowel movement): Results - ineffective -10/31/23: Fleet Mineral Oil enema (9 days after no bowel movement): Results - ineffective -10/31/23: Lactulose Solution (9 days after no bowel movement): Results - unknown A nursing note dated 11/1/23 stated CMA informed LN that patient is going on day 11 of no BM. Enema was given yesterday with no results. LN performed bowel assessment, abdomen soft and round, bowel tones in all four quadrants. Denies nausea or vomiting, denies any pain, eating and drinking well. Provider aware of lack of bowel movement, per verbal from provider scheduled 30 ml of Lactulose q 8 hrs until BM. Orders updated. Resident 3's 11/2023 bowel log revealed she/he had a large bowel movement on 11/3/23. Resident 3 was not interviewed due to discharging from the facility. On 11/21/24 at 1:08 PM, Staff 2 (DNS) confirmed the resident's bowel protocol was not followed. 2. Resident 4 admitted to the facility in 10/2023 with diagnoses including stroke. Resident 4's physician orders dated 10/20/23 indicated she/he was to be administered bowel medications daily. The bowel protocol on the resident's orders and her/his 10/2023 MAR indicated the following steps were to be taken: -Step 1-Administer 17 grams of Polyethylene Glycol Powder every 48 hours for no bowel movement in two days. -Step 2-Administer Bisacodyl suppository every 72 hours for no bowel movement in three days. If resident refused the suppository, administer two Bisacodyl tablets every 72 hours. -Step 3-Administer a Fleet Mineral Oil enema for no bowel movement in four days. -Step 4-Administer Lactulose Solution, 30 ml every 8 hours as needed if unrelieved by bowel protocols. Resident 4's Nursing Admission assessment dated [DATE] revealed no bowel movement since 10/18/23, when she/he was hospitalized . Resident 4's bowel logs revealed no bowel movement from 10/20/23 through 10/23/23. Resident 4's 10/2023 MAR revealed she/he was not given Polyethylene Glycol Powder from 10/20/23 through 10/23/23 and was not given a Bisacodyl suppository until 10/24/23, six days after her/his last bowel movement. The MAR indicated the suppository administered 10/24/23 was effective. Resident 4 was no longer in the facility and was unable to be interviewed. On 11/21/24 at 3:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were informed of the investigative findings and provided no additional information.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 1 of 3 sampled residents (#1) reviewed for discharge. This placed residents at risk for unmet discharge needs. Findings include: Resident 1 admitted to the facility on ,d+[DATE] with diagnoses including malnutrition. Resident 1's care plan, revised 9/29/23, revealed she/he planned to discharge home and the facility would make referrals for home health, physical and occupational therapy, and other medically related services. On 11/18/24 at 11:05 AM, Staff 4 (Social Services Director) stated she was responsible for resident discharges. She stated she made community referrals including home health, faxed physician orders to community providers and completed discharge summaries as part of the discharge process. She confirmed Resident 1 did not have a discharge summary in her/his clinical record in 2023. On 11/19/24 at 10:16 AM, Witness 1 (Home Health Staff) stated she attended a care conference a couple of days before Resident 1 discharged last year. The facility agreed they would make referrals for home health and send the necessary paperwork to the home health agency. Witness 1 stated she made multiple phone calls to Staff 3 (Previous SSD) requesting physician orders and instructions but did not receive a return call from anyone at the facility. Resident 1's clinical record was reviewed and did not include a discharge summary. Progress notes revealed she/he discharged home on 9/17/23. Staff 3 was no longer working at the facility and unable to be interviewed. On 11/21/24 at 3:30 PM, Staff 1 (Administrator) was informed of the investigative findings and provided no additional information.

Based on interview and record review it was determined the facility failed to follow physician orders for medication administration for 1 of 3 residents (# 501) reviewed for medication administration timeliness. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: Resident 501 was admitted to the facility in 9/2023 with diagnoses including a urinary tract infection (UTI). Physician Orders from 10/2023 included orders for the following medications to be administered at 7:15 AM: - Polyethylene Glycol Power - Give 17 grams in the morning for bowel care. - Potassium Chloride ER - Give half a tablet by mouth in the morning for supplement. - Torsemide 100 mg - Give one tablet by mouth in the morning for heart health. - Cipro 500 mg - Give one tablet by mouth twice a day for UTI for 10 days. (Started 10/10/23). - Nitrofurantoin Macrocrystal 100 mg - Give one capsule by mouth in the morning for UTI prevention. (Started 10/20/23). Review of a 10/2023 Medication Admin Audit Report revealed the following delays in medication administration: - 10/5/23 - Administered at 9:48 AM - 10/7/23 - Administered at 10:54 AM - 10/13/23 - Administered at 9:18 AM - 10/20/23 - Administered at 11:03 AM - 10/21/23 - Administered at 10:11 AM - 10/27/23 - Administered at 9:52 AM - 10/28/23 - Administered at 8:51 AM On 5/23/34 at 2:35 PM Staff 1 (Administrator) stated the administration for medications had a two hour window, which meant medications ordered to be administered at 7:15 AM could be administered between 6:15 AM and 8:15 AM. Staff 1 confirmed Resident 501 received her/his medications outside of this timeframe on the dates listed above.

Based on interview and record review it was determined the facility failed to administer Warfin (blood thinner) as ordered which resulted in a significant medication error for 1 of 3 sampled residents (#1) reviewed for medication administration. The placed the resident at risk for adverse side effects of medications. Findings include: Resident 1 was admitted to the facility in 2023 with diagnoses including heart failure, chronic kidney failure, and atrial fibrillation. Resident 1's Admission MDS identified Resident 1 with a BIMS score of 13 out of 15 which indicated no cognitive impairment. Resident 1's signed Physician Order's revealed Resident 1 was ordered Warfin 2.5 mg by mouth every Monday, Friday, Saturday, and Sunday at bedtime to treat Resident 1's diagnosis of Atrial Fibrillation. A 9/4/23 Incident Note revealed Staff 7 identified and documented that Resident 1 missed 3 doses of Warfin on Friday, 9/1/23, Saturday, 9/2/23 and Sunday 9/3/23. The 9/2023 MAR revealed on Friday 9/1/23, Saturday 9/2/23, and Sunday 9/3/23, Resident 1 was not administered Warfin as prescribed by the provider. On 10/16/23 at 12:47 PM Staff 7 (LPN) acknowledged Resident 1 missed 3 doses of her/his prescribed Warfin order and was required to receive a new medication order as a result. On 10/18/23 at 10:30 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed findings and provided no additional information.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#1) reviewed for respiratory care and bowel care. This placed other residents at risk for unmet needs. Findings include: Resident 1 admitted to the facility in 7/2023 with diagnoses including congestive heart failure, emphysema and muscle weakness related to falls. a. Resident 1's 7/17/23 care plan interventions for her/his respiratory symptoms included wearing a CPAP/BIPAP (a machine that regulates lung airflow and helps with breathing) while sleeping. Physician Orders dated 7/18/23 instructed Resident 1 use a BIPAP one time a day related to sleep apnea. Nursing assessments and notes revealed Resident 1 had a history of hypercapnia (high levels of carbon dioxide in the blood) and had not consistently used her/his CPAP while living at home. Nursing notes dated 8/19/23, 8/20/23 and 8/21/23 revealed the CPAP machine's tubing was missing after she/he moved rooms. There was no documentation until 8/21/23 the facility attempted to replace the tubing. A nursing note revealed on 8/22/23 at 3:06 AM Resident 1 was lethargic and would not wake up with verbal or physical stimuli. The on call physician was notified and the resident was sent to the ED and was found to be hypercapnic. Resident 1 was not interviewed due to discharging from the facility. On 8/29/23 at 11:45 AM, Staff 3 (RCM) confirmed the CPAP tubing was missing from 8/19/23 until Resident 1 was hospitalized on [DATE]. b. The facility's bowel care protocol was to administer laxatives to residents after two days of no bowel movement. Resident 1's physician orders followed this protocol. Resident 1's 7/2023 and 8/2023 bowel records revealed she/he had no bowel movements from 7/19/23 through 7/24/23 and from 8/4/23 through 8/7/23. The 7/2023 MAR revealed no Bisacodly (laxative) was administered to Resident 1 until 7/23/23, four days after her/his last bowel movement. The 8/2023 MAR revealed no Bisacodly was administered until 8/7/23, three days after her/his last bowel movement. On 8/29/23 at 11:45 AM, Staff 3 (RCM) confirmed the facility did not follow the bowel protocol.

1. Based on interview and record review, it was determined the facility failed to follow physician orders for 1 of 3 (#4) residents sampled for physician orders. As a result, Resident 4 missed several doses of an anticoagulant (medication that prevents blood clots, which if not controlled could lead to heart attack or stroke), experienced a stroke and was hospitalized . The facility identified the noncompliance, immediately initiated a plan of correction, initiated in service training for staff providing services and care to residents with similar orders and completed audits to ensure resident safety. This incident was identified as meeting the criteria for past noncompliance. Findings include: Resident 4 admitted to the facility on [DATE] with diagnoses including atrial fibrillation (a medical condition which causes the heart to beat too quickly) and congestive heart failure. Resident 4's 5 Day MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. Resident 4's care plan dated 10/14/22 indicated Resident 4 was prescribed an anticoagulant medication related to atrial fibrillation. The facility submitted a FRI on 10/21/22 which revealed Resident 4 had missed several scheduled doses of the anticoagulant due to an INR (International Normalized Ratio, a blood test that measured blood clotting, which determined how often blood thinners were administered) coding error in her/his TAR. As a result, Resident 4 experienced a stroke on 10/18/22 and required hospitalization . The facility's investigation summary dated 10/24/22 and updated 10/26/22 revealed the following: Staff 5 (Former RN) stated she completed an INR check on Resident 4 on 10/11/22 and the result was 4.5 (a high count that could result in excessive bleeding). Staff 5 notified the physician who ordered the anticoagulant be held for two days and to recheck the INR on 10/15/22. Staff 5 stated while typing in the order she did not change the order type to lab which would have resulted in the order populating into the TAR and the order type was left as other, which did not populate into the TAR. On 10/17/22, Staff 4 (RN) discovered the resident's INR check was not completed as ordered on 10/15/22. Staff 4 completed the lab which resulted in a low INR count (which indicated the blood had clotted and possibly caused a stroke). Staff 4 notified the physician, who ordered the anticoagulant be resumed. On 10/18/22 at approximately 6:30 PM, Resident 4 was observed to have symptoms of stroke and was sent to the hospital. The facility concluded the deficient practice resulted from the miscoded lab order, which prevented instructions to complete INR's to appear on the TAR. Resident 4's medical chart was reviewed and the 10/2022 MAR revealed she/he did not receive anticoagulants from 10/11/22 through 10/17/22. Physician Orders dated 10/11/22 revealed the anticoagulant was ordered to be held for two days and the next INR check be completed on 10/13/22. No INR checks were completed on 10/13/22 or 10/15/22. Hospital records revealed Resident 4 was admitted to the Emergency Department on 10/18/22 with diagnoses of stroke and aphasia (inability to speak). Staff 5 was not interviewed due to no longer working at the facility. On 1/27/23 at 3:42 PM Staff 4 confirmed the facility's investigative findings and provided no additional information. On 1/30/23 at 10:25 AM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the investigative findings and provided no additional information. The incident met the criteria for past non compliance as follows: 1. The incident indicated non compliance for F684. 2. The non compliance occurred after the exit date of the last standard recertification survey on 1/21/20 and before the date of the current survey, 1/25/22. 3. There was sufficient evidence the facility corrected the non compliance and was in substantial compliance with F684 as evidenced by: -No deficient practice was found at F684 with additional sampled residents. -The deficient practice was identified by the facility and the facility took immediate action to provide one on one counseling with the staff responsible for the coding error, provided in service training to all nursing staff for proper coding of orders and provided signature sheets verifying the nursing staff completed the training by 10/24/22. -Daily audits were immediately implemented to ensure proper entries for orders related to anticoagulant medications with no deficient practice found. 2. Based on interview and record review, it was determined the facility failed to follow manufacturer instructions for heat pack application for 1 of 3 residents (#7) reviewed for wound care. This placed residents at risk for developing wounds. The facility identified the noncompliance, immediately initiated a plan of correction, initiated in service training for staff providing services and care to residents with similar orders and completed audits to ensure resident safety. These incidents were identified as meeting the criteria for past non compliance. Findings include: Resident 7 admitted to the facility in 2017 with diagnoses including Multiple Sclerosis (MS) and quadriplegia. Resident 7's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Resident 7's care plan dated 10/20/22 revealed she/he had limited physical mobility related to her/his MS diagnosis and was totally dependent on staff for all ADL's. Resident 7 used an adaptive call light pad due to her/his mobility issues and was able to move her/his head to activate the call light. The facility submitted a FRI on 5/14/20 which revealed on 5/12/20 Resident 7 had a blister on her/his right shoulder which was acquired from a heat pack applied to the shoulder on 5/12/20. The resident's physician was notified, the blister was treated and Staff 2 (DNS) reviewed heat pack procedures with all nurses on duty, with in service training implemented for all other nurses to review the procedure. The facility's investigative summary dated 5/21/20 revealed the following: On 5/12/20 at 10:30 AM Staff 7 (Former RN) applied a heat pack to Resident 7's right shoulder. The call light was located on the resident's chest. At approximately 11:00 AM Resident 7 asked Staff 8 (Former CNA) to look at the shoulder area where the heat pack was applied because it hurt. Staff 8 removed the pack and observed the right shoulder area to be red. Later that evening Staff 9 (Former CNA) discovered the blister on Resident 7's right shoulder and notified Staff 18 (Former RN) who examined Resident 7. A blister was treated at the facility and the resident did not have any further complaints of pain. The facility determined the heat pack was not inspected every five minutes per manufacturer's recommendations due to Staff 7's report she was called away to another resident. Nursing notes from 5/13/20 through 5/19/20 revealed the resident was seen by her/his physician, who ordered the heat pack discontinued. Orders were changed to apply topical cream to the resident's shoulder when she/he experienced pain and new protocols were implemented for all residents with orders for heat packs. On 1/26/23 at 11:56 AM Staff 2 confirmed the facility's investigative findings and provided no additional information. The incident met the criteria for past non compliance as follows: 1. The incident indicated non compliance for F684. 2. The non compliance occurred after the exit date of the last standard recertification survey on 1/21/20 and before the date of the current survey, 1/25/22. 3. There was sufficient evidence the facility corrected the non compliance and was in substantial compliance with F684 as evidenced by: -No deficient practice was found at F684 with additional sampled residents. -The deficient practice was identified by the facility and the facility took immediate action to provide one on one counseling with the staff responsible for not checking the heat pack every five minutes, provided in service training to all nursing staff, therapy staff and restorative aides responsible for heat pack application, provided signature sheets verifying the nursing staff completed the training and new protocols for testing water temperatures were implemented which ensured water temperatures were within manufacturer's recommended range. -Audits of all residents with heat pack application orders were reviewed for safety and appropriateness. Orders were discontinued for any resident deemed inappropriate for continued heat pack use.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 8 sampled residents (#107) reviewed for medications. As a result, Resident 107 received a diabetic medication, she/he did not have a diabetic condition, and experienced [MEDICAL CONDITION] activity due to severe [DIAGNOSES REDACTED] (low blood sugar) with a blood sugar level of 19 upon arrival at the hospital. Resident 107's blood sugar levels did not stabilize and she/he became unresponsive and was transferred to the hospital. Findings include: Resident 107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission did not include a [DIAGNOSES REDACTED]. The 5/13/19 Admission MDS assessment revealed Resident 107 had a BIMS score of 10 (moderately impaired cognition). She/he was not coded for a diabetic condition and did not receive diabetic medication. Resident 107's care plan did not include care and supports for a diabetic condition. A 5/29/19 handwritten physician order [REDACTED]. - Administer glimepiride (diabetic medication used to control high blood sugar levels) 2 mg by mouth one time a day. There was no clinical indication on the order for the glimepiride medication. A 5/30/19 fax request from the facility to Staff 12 requested a clinical indication for the use of the glimepiride medication and .would you like us to check CBGs? (capillary blood glucose). Nursing staff did not question the order for the gliperimide medication in the absence of a diabetic [DIAGNOSES REDACTED]. A 6/1/19 response from Staff 12 revealed the clinical indication for glimepiride as diabetes mellitus. Staff 12 ordered the resident's CBGs to be checked twice a day, once at breakfast and once at dinner. The 5/2019 MAR revealed Resident 107 received the glimepiride on 5/30/19 and 5/31/19. The 6/2019 MAR revealed Resident 107 received the glimepiride on 6/1, 6/2, 6/3 and 6/4/19. Staff checked Resident 107's blood sugars twice a day from 6/1 through 6/3/19. On 6/4/19 the resident's blood sugar levels dropped and her/his blood sugars were not stabilized and documented on the MAR as follows: - 7:00 AM the resident's blood sugar was 49; - 3:00 PM the resident's blood sugar was 55; - 3:24 PM the resident's blood sugar was 40 and insta-glucose was administered - 3:39 PM the resident's blood sugar was 40; - 4:00 PM the resident's blood sugar was 73; - 5:00 PM the resident's blood sugar was 40. On 6/4/19 nursing staff remained in contact with Staff 12 and the monitoring of blood sugar levels were increased. The 6/2019 MAR revealed a physician order [REDACTED]. The 6/19/19 hospital discharge summary revealed Resident 107 was admitted to the hospital on [DATE] as a result of having received glimepiride which was mistakenly prescribed while not a diabetic patient. As a result, Resident 107 had [MEDICAL CONDITION] activity and acute [MEDICAL CONDITION] (brain disease which alters brain function or structure) from severe [DIAGNOSES REDACTED] with a blood sugar level of 19. The facility's 6/10/19 investigation revealed Staff 12 indicated he got Resident 107 mixed up with another resident while talking to staff. Staff 19 transcribed the order and did not notify Resident 107's representative about the new diabetic medication. Resident 107 received the glimepiride in error. On 1/15/20 at 9:22 AM Staff 12 acknowledged he ordered Resident 107 to receive the glimepiride but the resident did not have a diabetic diagnosis. He stated it was a busy day and he remembered talking to a staff about a resident who was going to be admitted to the facility with similar issues as Resident 107 when he wrote the order on the wrong resident's order sheet. Staff 12 stated Resident 107 became hypoglycemic as a result of having received the glimepiride medication. On 1/16/20 at 10:51 AM Staff 2 (DNS) confirmed Resident 107 did not have a diabetic [DIAGNOSES REDACTED]. Staff 2 stated Staff 19 transcribed the 5/29/19 order for the glimepiride medication and Staff 10 (RN) confirmed the order. On 1/17/20 at 6:05 PM Witness 4 (Family) stated Resident 107 did not have diabetes and as a result of being given the diabetic medication experienced a [MEDICAL CONDITION] at the hospital and required admission to the ICU. On 1/21/20 at 9:33 AM Witness 5 (Family) stated Resident 107 was not diabetic. He was in the facility on 6/4/19 and stated he observed Resident 107's eyes rolled to the back of her/his head and she/he became unresponsive. Witness 5 indicated he was informed by facility staff [MEDICATION NAME] had already been administered. Witness 5 insisted staff call 911 and was told to calm down, it would be fine and we have this under control. Witness 5 was unsure of how long it took for medics to arrive and stated Resident 107 had a short [MEDICAL CONDITION] while at the facility and convulsed for about 45 minutes at the hospital.

Based on observation, interview and record review it was determined the facility failed to appropriately prepare, distribute, serve and store kitchen cookware for 2 of 2 kitchens reviewed for food services quality. This placed residents at risk for contaminated food. Findings include: 1. On 1/15/20 at 3:43 PM eight pans in the main kitchen were observed to be stacked wet in the dry storage area. In an interview on 1/15/20 at 3:45 PM Staff 15 (Cook) stated that the pans were not usually stacked wet and the pans needed to be air dried prior to being stacked. On 1/17/20 at 2:19 PM, Staff 1 (Administrator) confirmed she expected pans to be stacked dry. 2. The 7/2018 Employee Hygiene and Dress Code for Good and Nutrition Services revealed hairnets or hair restraints are used when in the food preparation kitchen including dish rooms and storage rooms. Hair is to be covered completely. On 1/16/20 at 7:12 AM through 7:27 AM Staff 16 (Dietary Aide) was observed with her bangs outside the hairnet while handling plates of food in the kitchen. On 1/16/20 at 11:35 AM Staff 16 and Staff 17 (Cook) were observed with bangs not covered by the hairnet while handling plates of food in the kitchen. On 1/16/20 at 12:32 PM Staff 16 confirmed her bangs were out of the hairnet while she was handling plates. On 1/17/20 at 12:14 PM Staff 17 was observed with bangs not covered by the hairnet while handling plates of food in the kitchen. On 1/17/20 at 2:19 PM Staff 1 (Administrator) confirmed she expected staff to have hairnets covering all hair.

Based on observation, interview and record review it was determined the facility failed to ensure meals were palatable, attractive and served at an appropriate temperature for 2 of 3 halls and 2 of 2 sampled residents (#s 45 and 55) reviewed for food quality. This placed residents at risk for unmet needs. Findings include: 1. Resident 55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/2019 Admission MDS revealed Resident 55 had a BIMS score of 15, which indicated she/he was cognitively intact. Resident 55 was assessed to eat independently and she/he did not have any swallowing disorders. On 1/13/20 at 10:48 AM, Resident 55 stated the vegetables were mushy. Resident 55 stated that she/he had been given an inadequate amount of food for breakfast and was still hungry. Resident 55 stated she/he was unaware that snacks or alternative food could be requested. Resident 55 stated she/he had observed the food cart in the hall on dinner shift. She/he stated it took a while for the food to be served and stated she/he observed approximately 35 to 40 minutes to lapse while the staff were doing other tasks. Resident 55 stated when the tray was delivered to her/him, the food was cold. She/he stated that a recent meal had succotash and the vegetables were all mushy except the corn. Resident 55 stated she/he was hungry between meals. The 12/2019 Resident Council notes revealed the residents had expressed concerns of the meal plates and food were not warm enough when served. The 1/10/20 Resident Council notes reported the residents stated the morning's breakfast consisted of english muffins, which were too hard to eat and unripe fruit. The residents stated that food was undercooked (eggs too wet and vegetables too hard) or overcooked (vegetables too soft). On 1/15/20 at 11:07 AM, a Resident Council interview revealed the food was served cold and the plates were cold. The fruit was served unripe. On 1/17/20 at 1:04 PM a meal test tray was delivered to surveyors from the west hall meal cart. The meal consisted of lemon fish with a lemon gravy, rice pilaf, vegetable medley and a piece of pineapple upside down cake. The fish was tepid in temperature, overcooked and was bland in flavor. The rice was slightly warm. The vegetables were slightly warm, the cauliflower and zucchini were visibly and orally mushy. The cake was dry and crumbled when sliced and scooped with a fork. On 1/17/20 at 2:19 PM, Staff 1 (Administrator) stated she expected food to be delivered in a timely manner and for food to be served at an appropriate temperature. 2. Resident 45 was admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. The 12/2019 Quarterly MDS Assessment revealed Resident 45 had a BIMS score of 14, which indicated she/he was cognitively intact. Resident 45 was assessed to eat independently with set up help and she/he did not have any swallowing disorders. On 1/13/20 at 10:53 AM Resident 45, whom resided on the west hall of the facility, stated my food is usually cold. At 3:11 PM Resident 45 indicated her/his lunch was between cold and warm and she/he indicated the meal temperature was not how she/he preferred. On 1/14/20 at 3:50 PM Resident 45 indicated her/his noon meal was not warm when it was delivered to her/his room. On 1/17/20 at 1:04 PM a meal test tray was delivered to surveyors from the west hall meal cart. The meal consisted of lemon fish with a lemon gravy, rice pilaf, vegetable medley and a piece of pineapple upside down cake. The fish was tepid in temperature, overcooked and was bland in flavor. The rice was slightly warm. The vegetables were slightly warm, the cauliflower and zucchini were visibly and orally mushy. The cake was dry and crumbled when sliced and scooped with a fork. On 1/17/20 at 1:24 PM Resident 45 was observed in her/his room with a meal tray in front of her/him. There was a small portion of fish, a large amount of rice and vegetables left on her/his plate. Resident 45 indicated her/his meal was delivered less than warm but not cold. Resident 45 stated the fish was overcooked and the vegetables were soft. She/he indicated her/his coffee was delivered cold. The lid to the resident's cup of coffee was observed to be off and the cup was full.

Based on observation and interview it was determined the facility failed to inform residents of the location of 1 of 1 State survey inspection results and failed to ensure the survey results were readily accessible. This placed residents and public at risk for lack of knowledge regarding quality of care and quality of life concerns within the facility. Findings include: On 1/15/20 at 11:23 AM ten of ten members of the resident council group interview, responded they were unaware of where to access a copy of and what the facility's survey results were without asking facility staff. On 1/15/20 at 11:35 AM no facility State survey results were found on any of the 3 halls, in the prayer lobby and at the nurse's station. On 1/15/20 at 1:34 PM a binder labeled RECENT SURVEY was observed at the front reception desk behind a potted plant, tucked in a gap between the wall and the glass to the reception desk with approximately four inches of the binder exposed from the nook-like gap. The survey binder was not visible or accessible to someone sitting in a wheelchair or walking by. On 1/16/20 at 9:57 AM the State survey inspection binder was observed at the front reception desk behind potted plant in the wall gap. Staff 1 (Administrator) stated the plant was there for the holiday and acknowledged the binder was in a spot which may not be visible to residents. When asked how residents know the survey results binder was available to them without asking Staff 1 stated the facility did not make a public notice for the binder and she indicated she understood how it was a problem for residents to find.

Based on observation, interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 107 out of 107 days reviewed for staffing. This placed residents, public and staff at risk for lack of accurate staffing information. Findings include: On 1/13/20 at 9:02 AM and 1/15/20 at 5:20 PM, the Direct Care Staff Daily Report was observed prefilled with completed information for all shifts and had not been completed at the beginning of each shift on a daily basis. On 1/16/20 at 1:59 PM, the Direct Care Staff Daily Reports were provided by facility from 10/1/19 through 1/15/20. The reports had no corrections made on the sheets and the signatures were of the same person completing all three shifts. On 1/17/20 at 8:25 AM, Staff 1 (Administrator) acknowledged the Daily Staffing reports were not completed at the beginning of each shift and were completed at the start of the day or evening prior.

Based on record review and interview it was determined the facility failed follow up on advance directives for 1 of 5 sampled residents (#20) reviewed for advanced directives. This placed residents at risk for choices not being honored. Findings include: The 4/2016 Advance Care Planning and Advanced Directive policy revealed Purpose: to provide each resident the opportunity to make decisions regarding future medical care and select a proxy .to define a process to assist residents or families and healthcare decision makers in advanced care planning. Resident 20 was admitted in 10/2012 with [DIAGNOSES REDACTED]. The 2/13/19 Advanced Care Planning note revealed an annual review of the POLST (portable orders for life sustaining treatment) form. The resident was unable to comprehend or discuss her/his POLST and the family was not available for discussion. Will continue with the current POLST. No additional documentation was found or provided by the facility to ensure the resident's representative was offered the opportunity to provide information if Resident 20 had an advanced directive. On 1/17/20 at 2:31 PM Staff 1 (Administrator) stated she expected staff to follow up with the resident's family to find out if Resident 20 had an advanced directive. On 1/17/20 at 2:44 PM Staff 2 (DNS) stated staff communicated with the resident's representative on other occasions and should have followed up to find out if Resident 20 had an advanced directive.

1. Based on interview and record review it was determined the facility failed to ensure a personal alarm (alerts staff when a resident attempts to stand) was placed in the resident's wheelchair for 1 of 3 sampled residents (#2) reviewed for falls. Resident 2 fell and sustained a fractured leg. Findings include: Resident 2 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. The resident's 11/9/17 CAAs indicated the resident fell before admission to the facility and sustained a left shoulder injury. The resident had a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. The resident required extensive assistance for most ADLs including transfers. The resident was assessed to have poor safety awareness and due to cognitive decline the resident's safety awareness was not likely to improve. The CAAs indicated personal alarms would not be used for the resident because the alarms might frustrate the resident and increase the risk for falls. The Care Plan initiated on 11/16/17 indicated Resident 2 was at risk for falls. The resident was to wear appropriate foot wear, the wheel chair was to be within reach of the resident and locked and the resident's room was to be clear of clutter. The Progress Note dated 11/19/17 indicated the staff observed the resident attempt to transfer without assistance and staff were not able to reach the resident before the resident fell . The Progress Notes dated 11/25/17 through 11/29/17 indicated Resident 2's personal alarms were in place and worked. On 12/28/17 at 10:26 am Staff 11 (RNCM) indicated when the CAAs were completed the resident was at risk for falls but it was determined a personal alarm in the chair and bed would not be effective fall prevention interventions. Staff 11 indicated at the request of the family the alarms were placed after the resident fell on [DATE]. Staff 11 acknowledged the Care Plan was not updated to indicate the resident was to have personal alarms placed until 12/11/17. The 12/10/17 Progress Note indicated the resident was found on the floor. The resident had pain and was sent to the local hospital. The 12/10/17 fall Investigation indicated the resident was found on the floor next to the closet, the resident's wheelchair was not by the resident. The resident fell on the left hip and reported she/he hit her/his head. An assessment to rule out head injury was initiated and the resident's physician was notified. X-rays were obtained and demonstrated the resident had a left [MEDICAL CONDITION]. The staff interviews attached to the investigation indicated Staff 1 (CNA) did not hear an alarm. Staff 4 (LPN) reported she heard a thump then heard Resident 2 call for help. The resident gripped her/his left leg and reported pain. On 12/21/17 at 12:00 pm Staff 4 (LPN) indicated Resident 2 was to have a personal alarm on when in the wheelchair and bed. On 12/10/17 Staff 4 indicated she was in the hall that Resident 2 resided. Staff 4 heard a thud and then heard Resident 2 call for help. Staff 4 indicated the resident was on the floor on her/his left side with the wheel chair behind the resident. Staff 4 did not hear an alarm before the resident fell . On 12/20/17 at 10:15 am Staff 9 (LPN) indicated Resident 2 was confused and often attempted to self transfer. The resident was to have an alarm in the chair and wheel chair. The personal alarms were initiated shortly after the resident was admitted to the facility. On 12/12/17 at 1:30 pm Staff 5 (DNS) indicated on 12/10/17 when Resident 2 fell Staff 3 (CNA) was on break. Staff 3 left the break room to grab her water bottle. Staff 3 observed Resident 2 to attempt to self transfer. Staff 3 assisted the resident to the wheel chair, informed another staff about the resident's self transfer and went back to the break room. Staff 5 indicated Staff 3 reported she did not place the safety alarm back on the resident. Staff 5 acknowledged the alarm was not placed on the resident, the resident fell and sustained a fracture. 2. Based on observation, interview and record review it was determined the facility failed to supervise a resident at meals for 1 of 3 sampled residents (#2) reviewed for diet orders. This placed residents at risk for aspiration. Findings include: Resident 2 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. The hospital 12/14/17 Assessment and Plan indicated the resident had dysphagia (difficulty swallowing) and the resident choked while drinking fluids. The resident developed a cough after the event. The hospital 12/16/17 Skilled Nursing Facility Transfer Orders indicated the resident's diet could be upgraded or downgraded by the Speech Language Pathologist. The diet was to be dental soft with thin liquids. The order comment indicated PLEASE CONTACT RN WHEN FOOD TRAY DELIVERED; DO NOT LEAVE WITH PATIENT. On 12/18/17 Witness 4 (Family) indicated she was concerned staff left the dinner tray with the resident and did not stay in the room. Witness 4 indicated the resident was to be assisted with meals due to aspiration. On 12/18/17 at 10:10 am Resident 2 was observed in bed with the head of the bed elevated approximately 35 to 45 degrees. The resident had a nutritional shake carton and water in a cup on the bedside table. The drinking containers were within reach of the resident. On 12/18/17 at 10:42 am Staff 14 (CNA) indicated she was assigned to work with Resident 2. Staff 2 indicated she provided the resident the breakfast tray, set up the tray for the resident and left the room. Staff 14 indicated she checked on the resident every five to ten minutes to ensure the resident ate. On 12/18/17 at 10:40 am Staff 11 (RNCM) indicated the resident's new orders were not clear. Staff 11 indicated the orders were for the resident to have a dental soft diet with thin liquids. Staff 11 also acknowledged the diet order was followed by directions in bold font to inform the RN when the food tray arrived and not to leave the tray with the resident. Staff 11 indicated the orders in the computer for the staff did not include instructions for the staff to not leave the resident's meal trays with the resident. Staff 11 removed the fluids from the resident's bed side table.

Based on observation, interview and record review it was determined the facility failed to provide adequate supervision and safe use of a lift for 1 of 1 sampled resident (#1) reviewed for a fall from a lift. As a result Resident 1 sustained a fractured arm. Findings include: Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. The resident's careplan dated 6/18/13 included the resident was to be transferred with a "total lift" with 2 persons' assistance. A procedure and operating instructions for a Total Lift Ultralift (dated 11/23/11) included a "TIME OUT" after raising the lift arm and before the resident left the surface to "Stop, check and verbalize all sling hooks are secure...cross check opposite side and verbally confirm that all straps checked and OK... Continue to observe all sling hooks during transfer to ensure that sling is securely attached." According to Interdisciplinary Progress Notes and an Incident Report dated 7/9/13, Resident 1 fell during a lift transfer (Total Lift Ultralift) and landed across the metal support on the bottom of the lift. Staff 1 and 2, CNAs were assisting with the transfer, when one of the straps on the sling slipped off causing the resident to fall from the sling. The resident had bruises and abrasions across the right waist/back area and pain in the right humerus. An X-ray showed a fractured right humerus and the physician ordered a sling for the right arm. Investigation Notes dated 7/11/13 included that Staff 1 and 2 recreated the procedure of how they performed the lift transfer. It was noted the CNAs did not state they pulled on the loops, but they looked at them before and after raising the resident above the bed. The resident interview included the CNAs were talking between themselves during the procedure, "I don't think they were paying attention." On 8/12/13 at noon Resident 1 was observed seated in a recliner chair in her/his room, with a sling on the resident's right arm. Resident 1 stated at the time of the accident, two CNAs raised the resident up in the sling/lift and started to move the resident when suddenly the loops on the strap came off and she/he fell on top of the metal lift support. The resident stated the CNAs were chatting together while transferring the resident and not looking at the loops (sling attachments). The resident stated "Now I'm scared of the lift." On 8/13/13 at 9:20 am Staff 1 stated she and Staff 2 were providing a lift transfer for Resident 1 on 7/9/13, when the strap loops came loose from the lift and the resident fell . Staff 1 stated they raised the resident in the air with the lift and the straps were checked and were attached. When Staff 1 lifted the resident's feet to clear the edge of the bed, the lift straps came loose and the resident fell . Staff 1 stated when she lifted the resident's feet it must have put slack in the loops, and they came loose. Staff 1 acknowledged the resident was not high enough to clear her/his feet and she was not watching the loops while lifting the resident's feet. Staff 1 did not acknowledge that she and Staff 2 were chatting during the procedure. On 8/13/13 at 9:30 am Staff 2 stated she and Staff 1 were transferring Resident 1 via the lift on 7/9/13. They each checked that sling loops were tight before and after raising Resident 1 in the lift above the bed. Staff 2 stated she was operating the controls on the lift while Staff 1 was bending over to lift the resident's feet enough to clear the bed. The lift sling itself "gets so much slack in it." Lifting the feet likely put enough slack in the straps/sling that the loops became detached. Staff 2 was not looking at the straps/loops when the resident fell . Staff 2 did not acknowledge that she and Staff 1 were chatting during the procedure. A Conclusion to Resident 1's fall investigation dated 7/11/13 indicated "it was determined that the two CNA's (Staff 1 and 2) that were assisting with the lift had operator error in the respect that they did not wait long enough to assure that the straps were secure and taut prior to the lift. They performed the time out in the lift process but did not assure the straps were taut." On 8/14/13 at 10:12 am Staff 4, RN confirmed the lift accident was due to "operator error," because staff (Staff 1 and 2) did not ensure the straps of the sling were secure.

Based on interview and record review it was determined facility staff failed to meet professional standards of care related to a safe lift transfer for 1 of 1 sampled resident (#1) reviewed for a fall from a lift. As a result Resident 1 sustained a fractured arm. Findings include: Review of Oregon State Board of Nursing Standards and Authorized Duties for Certified Nursing Assistants [PHONE NUMBER] Standards of Care for CNAs (6)(j) indicated the CNA shall consistently apply safety concepts in the workplace. Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. A procedure and operating instructions for a Total Lift Ultralift dated 11/23/11 included a "TIME OUT" after raising the lift arm and before the resident left the surface to "Stop, check and verbalize all sling hooks are secure...cross check opposite side and verbally confirm that all straps checked and OK... Continue to observe all sling hooks during transfer to ensure that sling is securely attached." Skills Competency forms dated 2/16/12 for Staff 1, CNA and 2/24/12 for Staff 2, CNA indicated the CNAs were trained and completed a return demonstration of how to use the "Total Lift" for resident transfers. A CNA Agenda dated 3-13-13 indicated there was updated information provided which included lift operation. The resident's careplan dated 6/18/13 included the resident was to be transferred with a "total lift" with 2 persons' assistance. According to Interdisciplinary Progress Notes and an Incident Report dated 7/9/13, Resident 1 fell during a lift transfer (Total Lift Ultralift) and landed across the metal support on the bottom of the lift. Staff 1 and 2, CNAs were assisting with the transfer, when one of the straps on the sling slipped off causing the resident to fall from the sling. The resident had bruises and abrasions across the right waist/back area, pain in the right humerus and X-ray showed a fractured right humerus. Investigation Notes dated 7/11/13 included that Staff 1 and 2 recreated the procedure of how they performed the lift transfer. It was noted the CNAs did not state they pulled on the loops, but they looked at them before and after raising the resident above the bed. The resident interview included the CNAs were talking between themselves during the procedure, "I don't think they were paying attention." On 8/12/13 at noon Resident 1 was observed seated in a recliner chair in her/his room, with a sling on the resident's right arm. Resident 1 stated at the time of the accident, two CNAs raised the resident up in the sling/lift and started to move the resident when suddenly the loops on the strap came off and she/he fell on top of the metal lift support. The resident stated the CNAs were chatting together while transferring the resident and not looking at the loops (sling attachments). The resident stated "Now I'm scared of the lift." On 8/13/13 at 9:20 am Staff 1 stated she and Staff 2 were providing a lift transfer for Resident 1 on 7/9/13, when the strap loops came loose from the lift and the resident fell . Staff 1 stated they raised the resident in the air with the lift and the straps were checked and were attached. When Staff 1 lifted the resident's feet to clear the edge of the bed, the lift straps came loose and the resident fell . Staff 1 stated when she lifted the resident's feet it must have put slack in the loops, and they came loose. Staff 1 acknowledged the resident was not high enough to clear her/his feet and she was not watching the loops while lifting the resident's feet. Staff 1 did not acknowledge that she and Staff 2 were chatting during the procedure. On 8/13/13 at 9:30 am Staff 2 stated she and Staff 1 were transferring Resident 1 via the lift on 7/9/13. They each checked that sling loops were tight before and after raising Resident 1 in the lift above the bed. Staff 2 stated she was operating the controls on the lift while Staff 1 was bending over to lift the resident's feet enough to clear the bed. The lift sling itself "gets so much slack in it." Lifting the feet likely put enough slack in the straps/sling that the loops became detached. Staff 2 was not looking at the straps/loops when the resident fell . Staff 2 did not acknowledge that she and Staff 1 were chatting during the procedure. A Conclusion to Resident 1's fall investigation dated 7/11/13 indicated "it was determined that the two CNA's (Staff 1 and 2) that were assisting with the lift had operator error in the respect that they did not wait long enough to assure that the straps were secure and taut prior to the lift. They performed the time out in the lift process but did not assure the straps were taut." On 8/14/13 at 10:12 am Staff 4, RN confirmed the lift accident was due to "operator error," because staff (Staff 1 and 2) did not ensure the straps of the sling were secure. Refer to F323.