Every finding on record at Mirabella Portland

Based on interview and record review it was determined the facility failed to ensure a resident's fall investigations were completed timely for 1 of 5 sampled residents (#1) reviewed for unnecessary medications. This placed residents at risk for continued falls and injury. Findings include: Resident 1 was admitted to the facility in 8/2022 with a diagnosis of heart disease. The facility Abuse and Incident Reporting Policy and Procedure revised on 5/2024 revealed an investigation was to be completed within five working days after an incident was reported. a. Resident 1's 10/8/25 Unwitnessed Fall investigation revealed on 10/8/25 she/he tried to move a swivel chair, lost balance, and fell. The investigation indicated at the time of the fall Resident 1's care plan was followed and abuse and neglect were ruled out two hours after the incident occurred. The investigation was not completed until 11/1/25. On 3/26/26 at 10:07 AM and 12:55 PM Staff 2 (DNS) stated investigations were to be completed and submitted to her and Staff 1 (Administrator) five days after an investigation was initiated. Staff 2 stated at the time of Resident 1's fall there was no resident care manager and the paperwork was not completed timely. On 3/27/26 at 8:28 AM Staff 1 stated if a resident fell, the nurses were to initiate an investigation, start obtaining interviews with witnesses, implement new interventions if indicated, and notify Staff 2 of the incident. Staff 1 stated the investigation was to be completed within five days, including the root cause analysis, and then submitted to him for a final review.b. Resident 1's 11/21/25 Witnessed Fall investigation revealed she/he fell while being assisted to bed. Staff 2 (DNS) completed the fall investigation on 12/2/25. Staff 1 (Administrator) signed off on the completed investigation on 12/16/25. On 3/26/26 at 10:07 AM and 12:55 PM Staff 2 (DNS) stated investigations were to be completed and submitted to her and Staff 1 (Administrator) five days after an investigation was initiated. Staff 2 stated at the time of Resident 1's fall there was no resident care manager and the paperwork was not completed timely, but the staff ensured Resident 1 needs were met. On 3/27/26 at 8:28 AM Staff 1 stated if a resident fell, the nurses were to initiate an investigation, start obtaining interviews with witnesses, implement new interventions if indicated, and notify Staff 2 of the incident. Staff 1 stated the investigation was to be completed within five days, including the root cause analysis, and then submitted to him for a final review.

Based on observation, interview and record review it was determined the facility failed to ensure the resident was assisted to wear glasses for 1 of 2 sampled residents (#13) reviewed for activities. This placed residents at risk for impaired vision. Findings include:Resident 13 was admitted to the facility in 6/2018 with diagnoses including intracranial injury with loss of consciousness (traumatic brain injury) and aphasia (a language disorder caused by brain damage and resulting in impaired communication and comprehension).Resident 13's care plan dated 1/2/20 indicated staff were to ensure her/his glasses were available to support her/his participation in activities and staff were to provide assistance to place and remove them.Resident 13's 1/21/26 annual MDS revealed she/he had severe cognitive impairment, was dependent on staff for assistance with ADLs including dressing and completing personal hygiene tasks and had adequate vision with the use of glasses.Random observations on 3/23/26 through 3/26/26, between 8:30 AM and 4:03 PM Resident 13 was observed not wearing her/his glasses when she/he was in the living room with other residents, or during group activities or while sitting in her/his room. Resident 13's glasses were observed in their case on the shelf above her/his dresser.On 3/25/26 at 12:21 PM Staff 4 (CNA) stated he referred to Resident 13's care plan to know how much assistance to provide her/him. Staff 4 stated Resident 13 was not able to ask for assistance and was completely dependent on staff assistance for completion of her/his ADLs. Staff 4 stated he never saw Resident 13 wear glasses and he was not sure if she/he had glasses.On 3/25/26 at 3:40 PM Staff 5 (CNA) stated she referred to Resident 13's care plan whenever she worked with the resident because she/he was not able to communicate verbally and was not able to complete any personal care tasks for herself/himself. Staff 5 stated she didn't think Resident 13 wore glasses.On 3/26/26 at 10:08 AM Staff 6 (CNA) stated Resident 13 was completely dependent on staff to provide assistance and was unable to ask for help. Staff 6 stated she referred to Resident 13's care plan to know what assistance to provide for her/him. Staff 6 stated she was not aware Resident 13 needed to wear glasses.On 3/26/26 at 10:33 AM staff 7 (RN) stated Resident 13 was, Totally dependent and did not do anything on her/his own. Staff 7 stated Resident 13 had glasses and he saw her/him wear them occasionally. Staff 7 stated it was important for staff to assist Resident 13 with her/his glasses because she/he needed them and she/he could not ask for anyone to help her/him put them on or take them off.On 3/26/26 at 11:53 AM Staff 2 (DNS) stated Resident 13's spouse wanted her/him to wear her/his glasses. Staff 2 stated she expected staff to assist Resident 13 to use her/his glasses because she/he was not able to place and remove them herself/himself and she/he was not able to communicate requests to her/his caregivers.

Based on interview and record review it was determined the facility failed to ensure the resident / representative was provided the bed hold policy and the State Ombudsman Office was notified of residents' discharge for 2 of 2 sampled residents (#s 4 and 27) reviewed for hospitalization. This placed residents at risk for right to return and lack of advocacy. Findings include: 1. Resident 4 was admitted to the facility in 5/2024 with diagnoses including pulmonary embolism without acute cor pulmonale (a blood clot in the lung artery that does not cause immediate right-sided heart failure) and vascular dementia (a decline in cognitive function caused by conditions that block or reduce blood flow to the brain). Resident 4's 1/21/26 Annual MDS revealed she/he had moderate cognitive impairment. A review of Resident 4's health record revealed she/he was admitted to the hospital on [DATE] due to pain in her/his left flank (side of the torso between the lower ribs and the top of the hip) and decreased blood oxygen saturation. No evidence was found in Resident 4's health record to indicate the facility notified the State Longterm Care Ombudsman of her/his discharge or provided Resident 4 or her/his representative with a copy of the facility's bed hold policy. On 3/26/26 at 3:17 PM Staff 9 (RN) stated she made the decision to send Resident 4 to the hospital because of her pain and low oxygen levels after speaking with her/his provider and family representative. Staff 9 stated she did not provide the resident or her/his family with a copy of the facility's bed hold policy and she did not contact the office of the State Longterm Care Ombudsman. On 3/30/26 at 1:02 PM Witness 1 (family member) stated the facility did not provide him or Resident 4 with a notification of the bed hold policy when she/he was discharged to the hospital. On 3/27/26 at 9:46 AM Staff 1 (Administrator) stated staff did not notify the State Longterm Care Ombudsman of Resident 4's discharge to the hospital nor did they provide Resident 4 or her/his representative with a copy of the facility's bed hold policy when she/he was discharged to the hospital on 1/25/26 because he was unaware this was a requirement. 2. Resident 27 was admitted to the facility in 12/2025 with a diagnosis of left hip replacement. Resident 27's 1/21/26 Progress Note revealed she/he was transported to the hospital. Resident 27's clinical record revealed she/he did not return to the facility and there was no documentation to indicate the State Longterm Care Ombudsman office was notified of her/his discharge. On 3/26/26 at 10:52 AM and 3/27/26 at 8:33 AM Staff 1 (Administrator) stated Staff 3 (Social Services Director) was responsible for notifying the State Longterm Care Ombudsman office when residents were discharged from the facility. Staff 1 also stated the facility did not notify the ombudsman unless a resident was discharged involuntarily. On 3/26/26 at 10:53 AM Staff 3 stated she did not notify the State Longterm Care Ombudsman office when residents were discharged from the facility, including Resident 27.

Based on observation, interview and record review it was determined the facility failed to follow fall prevention techniques for 1 of 4 residents (# 16) reviewed for accidents. This placed residents at risk for falls. Findings include: Resident 16 was admitted to the facility in 7/2020 with diagnoses including dementia. A 10/23/24 Fall Risk Evaluation determined Resident 16 to be at high risk for falls. A 11/18/24 CNA Pocket Guide regarding transfers stated Resident 16 required the assistance of one person with the use of a front wheel walker (FWW) and gait belt with a focus on turning clockwise when available. On 11/19/24 at 12:13 PM Resident 16 was observed being assisted by Staff 4 (CNA) with a standing transfer with the use of a FWW. Resident 16 was observed without a gait belt turning counter-clockwise when she/he was observed falling backwards onto the ground. On 11/19/24 at 12:36 PM Staff 4 stated Resident 16 experienced a fall during a standing transfer. Staff 4 confirmed Resident 16 was not wearing a gait belt and probably should have been wearing one. Staff 4 stated she was not aware of specific instructions regarding fall prevention techniques for Resident 16. On 11/19/24 at 12:38 PM Staff 2 (DNS) confirmed the CNA Pocket Guide was updated daily and was provided to nursing staff at the start of their shifts to provide care need information to staff. Staff 2 stated Resident 16 did not experience a significant injury as result of the fall. Staff 2 stated Resident 16 should have been wearing a gait belt and assisted with turning clockwise to reduce the risk of falls.

Based on interview and record review it was determined the facility failed to complete a Quarterly MDS (Minimum Data Set) assessment in the required time frame for 10 of 14 sampled residents (#s 1, 4, 5, 10, 13, 15, 18, 20, 22, and 23) reviewed for resident assessments. This placed residents at risk for unassessed needs. Findings include: The facility's 6/2022 MDS policy and procedure specified the following: -The facility would complete and maintain MDS assessments on every resident admitted to the facility in accordance with the current Centers for Medicare and Medicaid Services Resident Assessment Instrument manual, Version 3.0. -The purpose of the MDS was to assess residents using a comprehensive process in order to identify care needs and to develop an interdisciplinary care plan. On 8/23/23, Staff 2 (RNCM) provided a list of the following residents with overdue Quarterly MDS assessments: -Resident 4's Quarterly 3 MDS was due 6/15/23 and was 69 days overdue; -Resident 1's Quarterly 3 MDS was due 6/16/23 and was 68 days overdue; -Resident 22's Quarterly 2 MDS was due 6/27/23 and was 56 days overdue; -Resident 20's Quarterly 3 MDS was due 7/5/23 and was 49 days overdue; -Resident 18's Quarterly 2 MDS was due 7/7/23 and was 47 days overdue; -Resident 15's Quarterly 2 MDS was due 7/17/23 and was 37 days overdue; -Resident 23's Quarterly 1 MDS was due 7/19/23 and was 35 days overdue; -Resident 10's Quarterly 1 MDS was due 7/27/23 and was 27 days overdue; -Resident 13's Quarterly 2 MDS was due 8/3/23 and was 20 days overdue; -Resident 5's Quarterly 1 MDS was due 8/10/23 and was 13 days overdue. On 8/23/23 at 11:44 AM Staff 3 stated he was responsible for ensuring each resident's MDS assessment was completed. Staff 2 stated there were multiple residents whose Quarterly MDS assessments were not yet completed and he was working towards getting all of the overdue MDS assessments completed and transmitted. On 8/24/23 at 8:45 AM Staff 2 (DNS) confirmed there were many residents with overdue Quarterly MDS assessments and the nursing staff were working on getting them caught up.

Based on interview and record review it was determined the facility failed to complete an Admission or Annual MDS (Minimum Data Set) assessment in the required time frame for 4 of 14 sampled residents (#s 6, 8, 16 and 77) reviewed for resident assessments. This placed residents at risk for unassessed needs. Findings include: The facility's 6/2022 MDS policy and procedure specified the following: -The facility would complete and maintain MDS assessments on every resident admitted to the facility in accordance with the current Centers for Medicare and Medicaid Services Resident Assessment Instrument manual, Version 3.0. -The purpose of the MDS was to assess residents using a comprehensive process in order to identify care needs and to develop an interdisciplinary care plan. On 8/23/23, Staff 2 (RNCM) provided a list of the following residents with overdue Admission or Annual MDS assessments: -Resident 6's Admission MDS was due 6/23/23 and was 61 days overdue; -Resident 8's Annual MDS was due 6/23/23 and was 61 days overdue; -Resident 16's Annual MDS was due 6/30/23 and was 54 days overdue; -Resident 77's Admission MDS was due 7/13/23 and was 41 days overdue. On 8/23/23 at 11:44 AM Staff 3 stated he was responsible for ensuring each resident's MDS assessment was completed. Staff 2 stated there were multiple residents whose Admission or Annual MDS assessments were not yet completed and he was working towards getting all of the overdue MDS assessments completed and transmitted. On 8/24/23 at 8:45 AM Staff 2 (DNS) confirmed there were many residents with overdue Admission and Annual MDS assessments and the nursing staff were working on getting them caught up.

Based on observation, interview and record review it was determined the facility failed to store drugs and biologicals in locked compartments for 1 of 1 medication carts and 1 of 1 treatment carts observed during this survey. This placed residents at risk for medication diversion and accidents. Findings include: The facility's Medication and Accounting Policy and Procedure dated 7/21 indicated: -It was the policy of the facility to store medications in a safe and locked place that was not accessible to persons other than employees responsible for the supervision of medications. 1. On 8/22/23 at 10:15 AM a treatment cart was observed to be unlocked near the nurses' station. The nurse was not in view of the cart. Staff 9 (RN) verified the cart was unlocked. 2. On 8/24/23 at 8:16 AM a medication cart was observed to be unlocked across from the spa room. The nurse was not in view of the cart. Staff 8 (LPN) verified the cart was unlocked. On 8/24/23 at 10:50 AM Staff 1 (Administrator) stated it was her expectation the carts remained locked when not in use. 32543 3. On 8/24/23 at 11:32 AM a medication cart near the conference room was observed unlocked and unattended by staff. Staff 8 (LPN) exited a nearby resident room and approached the cart. Staff 8 acknowledged the cart was unlocked and it should have been locked.

Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#76) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 76 was admitted to the facility in 2020 with diagnoses including dementia. A Nursing Facility Reported Incident Form dated [DATE] indicated Resident 76 was physically abused by Staff 13 (Former contracted radiology technician). The incident was witnessed by Staff 10 (CNA), Staff 11 (CNA) and Staff 12 (agency CNA). A facility incident investigation report dated [DATE] indicated Resident 76 was in pain and confused on [DATE]. Staff 13 hit the resident's forearm four times, restrained the resident's right arm and was verbally abusive toward the resident. Staff 10, Staff 11 and Staff 12 notified Staff 4 (LPN) who assessed the resident and no injuries were noted. A handwritten signed witness statement by Staff 10 dated [DATE] indicated she, Staff 11 and Staff 12 were assisting Staff 13 to position Resident 76 for x-rays. The resident was in a lot of pain, very agitated, confused and scared and the resident was flailing her/his arms. Staff 13 held the resident's arms down, hit the resident's forearm and told the resident your mother is here and she's not going to like this. Staff 13 seemed flustered and frustrated throughout the process because Resident 76 was not cooperating perfectly even though it was clear the resident was confused and in an immense amount of pain. A handwritten signed witness statement by Staff 11 dated [DATE] indicated she, Staff 10 and Staff 12 were helping position Resident 76 for an x-ray. The resident was positioned but would move out of position several times. Staff 13 became more irritated and physical, pinned the resident's arms down, slapped the resident's forearm and said stop or your mom will be mad at you. A handwritten signed witness statement by Staff 12 dated [DATE] indicated she, Staff 10 and Staff 11 were trying to position and calm Resident 76. The resident was very confused, agitated and in a lot of pain. Staff 13 was frustrated, annoyed and impatient because the resident would not stop moving. Staff 13 tightly held the resident's arm down by the wrist which did not work and the resident touched the x-ray equipment. Staff 13 snapped and said something along the lines of 'you better not break that it's a $100,000' and then started swatting the resident's forearm about four times. Staff 13 then said you better stop moving or your mom will be mad at you!!! Staff 4 entered the room and moved between Staff 13 and the resident. Staff 11 reported the incident immediately. Progress Notes dated [DATE] and [DATE] indicated Resident 76 was on hospice and died at 5:30 AM on [DATE]. A written statement by Staff 13 dated [DATE] was received for review on [DATE] from Witness 2 (Senior Human Resources Business Partner for the contracted diagnostic company). In the statement Staff 13 wrote .due to pain the CNAs and I did have to restrain [the resident's] hands at different times and hold [the resident's] ankles to obtain the exams. and Earlier in the exam the patient started talking to their Mother and Grandmother making them happy they cooperated in completing the exams. (Since my training is to join their world I went along with that line of talk) to get the patient to cooperate and it did work for a bit. On [DATE] at 1:27 PM Staff 10 stated [on [DATE]] around dinner time they were attempting to position and calm Resident 76 for x-rays. The resident was confused and moving around. The resident grabbed at the x-ray equipment and Staff 13 hit the resident's hand out of the way. Staff 13 told the resident to behave or her/his mom would be mad. Staff 11 was crying and Staff 4 entered the room and helped to calm the resident. On [DATE] at 9:56 AM Staff 11 stated the incident occurred [on [DATE]] around dinner time. Staff 4 told her someone needed to go into Resident 76's room with Staff 13. The resident was confused and moving around. Staff 13 held the resident's wrist down, slapped her/his wrist and told the resident to stay still or her/his mom would be mad. Staff 13 slapped the resident's wrist three to four times loud enough to hear the impact. Staff 11 stated Staff 4 entered the room, she left the room, started to cry and called Staff 1 (Administrator) to report the incident. On [DATE] at 10:04 AM the facility's staffing agency was requested to have Staff 12 contact the Surveyor. As of [DATE] Staff 12 had not contacted the Surveyor. On [DATE] at 1:19 PM Staff 4 stated when she came to Resident 76's room it was reported to her the x-ray process was not going well. She entered the room and attempted to calm the resident. Staff 13 was pushing to complete the x-rays but she stopped the process because she was not going to allow the resident to become more distressed. Staff 4 stated she assessed the resident, no injury was noted and the resident was not in additional distress. Staff 4 stated she immediately started an incident report and notified Staff 1. On [DATE] at 9:17 AM Staff 1 (Administrator) confirmed Resident 76 was abused by Staff 13. On [DATE] at 2:05 PM a request was made to Witness 2 for Staff 13 to call the surveyor. No return call was received as of [DATE]. 43690

Based on observation and interview it was determined the facility failed to ensure hand hygiene was performed between tasks for 2 of 2 staff (#s 10 and 17) who were randomly observed for hand hygiene. This placed residents at risk for cross contamination. Findings include: 1. On 7/28/22 at 10:35 AM Staff 17 (Server) was observed to deliver food to room [ROOM NUMBER], left the room, did not perform hand hygiene and then delivered food to room [ROOM NUMBER]. Staff 17 stated she did not usually do hand hygiene when passing snacks. On 8/1/22 at 10:03 AM Staff 2 (DNS) indicated hand hygiene was to be performed upon leaving each resident room. 2. On 8/2/22 at 10:29 AM Staff 10 (LPN) was observed to remove gloves and walk to the medication cart. Staff 10 then made contact with a computer keyboard, opened the medication cart and then started to prepare a resident's medications. Staff 10 did not wash her hands. Staff 10 acknowledged she did not wash her hands after removing the gloves and before starting to prepare a resident's medications.

Based on observation and interview it was determined the facility kitchen staff failed to handle and prepare food in a sanitary manner for 1 of 3 kitchens reviewed. This placed residents at risk for foodborne illness. Findings include: On 7/28/22 at 11:34 AM Staff 18 (Cook) was observed to wear gloves and plate lunch meals for residents in the 2nd-floor kitchen. She opened the refrigerator, removed containers of meat, cheese, spread, and bread, and placed them on the counter while she wore the same gloves. Staff 18 did not change her gloves before she assembled grilled beef and cheese sandwiches. With the same gloves she returned the bread, cheese, and spread to the refrigerator. Staff 18 then changed her gloves without performing hand hygiene, opened a different refrigerator wearing the new gloves, retrieved a salad container to the counter, and used her gloved hands to scoop portions of roasted potato wedges onto plates. She did not use the utensils that were readily available to scoop the potatoes. Throughout this process Staff 18 was observed to place plated meals in the insulated tray carts and returned to handle food without changing gloves and performing appropriate hand hygiene after touching potentially contaminated surfaces. On 7/28/22 at 11:40 AM Staff 18 reported, I can use my gloved hands to pull food out of the fridge and containers and place it on the flat top but then I change gloves when I turn around to the steam table to work with food that has already been cooked. On 8/2/22 at 2:45 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the lack of hand hygiene and appropriate glove use by Staff 18.

Based on interview and record review it was determined the facility failed to discontinue a medication for 1 of 5 sampled residents (#17) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: Resident 17 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 17's 7/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/29/22 at 11:38 AM Staff 8 (RNCM) was asked why there were two different orders for [MEDICATION(S)] eye drops and why they were ordered to be administered one hour apart at 11 PM and 12 AM. Staff 8 stated it was an error but did not clarify which order was in error.

Based on interview and record review it was determined the facility failed to ensure a resident's prophylactic use of an antibiotic was reviewed and a rationale for continued use was documented for 1 of 2 sampled residents (#23) reviewed for antibiotic usage. This placed residents at risk for adverse medication consequences and drug resistant infections. Findings include: Resident 23 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 23's 6/4/21 CAA indicated she/he was incontinent of urine and was at risk for infection. Staff were to monitor the resident for UTIs. There was no information related to the resident's prophylactic use of an antibiotic. A Progress Note dated 7/25/22 indicated Resident 23 was not on antibiotics. A 7/25/22 Physician Visit note indicated the resident had recurrent UTIs, functional incontinence with a decline in mobility and was on prophylactic [MEDICATION(S)] (antibiotic). The note indicated the resident's last [CONDITION(S)] was 10/2021 which was resistant to [MEDICATION(S)]. The plan was to continue the [MEDICATION(S)]. On 8/1/22 at 12:02 PM Witness 4 (Pharmacist) stated there was a risk with any long-term use of antibiotics for the development of bacteria which were resistant to antibiotics. The facility needed to weigh the overall health of the resident and the risk factors which could develop and the benefits of the resident acquiring fewer UTIs. Witness 4 also stated on 5/29/19 the pharmacist consultant's review regarding the [MEDICATION(S)] indicated the resident's kidney function should be monitored and [MEDICATION(S)] was not recommended per Beers list (Potentially Harmful Drugs in the Elderly). The pharmacist recommended an alternative medication, [MEDICATION(S)] (antibiotic), to administer in place of the [MEDICATION(S)]. The physician did not accept the recommendation. Resident 23's 3/7/22 Laboratory results revealed the resident's current creatinine (kidney function) level was 0.79 (normal 0.60-1.10). The resident's records did not have current pharmacy reviews specific to the use of the [MEDICATION(S)]. On 7/29/22 at 12:00 PM Staff 8 (RNCM) stated Resident 23 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 8 reviewed the resident's record and did not find a rationale with risk versus benefits for the continued use of the [MEDICATION(S)] to ensure it was still the best medication for the resident. On 8/1/22 at 10:03 AM Staff 2 (DNS) stated they did not review the residents on prophylactic antibiotic as part of the antibiotic stewardship program. On 8/2/22 at 11:18 AM Staff 1 (Administrator) stated the review of residents on prophylactic antibiotics will be added to the antibiotic stewardship program.

Based on interview and record review it was determined the facility failed to ensure a resident was provided an activity program to meet a resident's needs for 1 of 2 sampled residents (#11) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include: Resident 11 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 11 resided in the Health Center. Resident 11's 2/2/22 Activity History and Personal Preference form indicated it was very important to do things with groups of people. The July 2022 Daily Activity Lists revealed multiple activities in the Memory Care Unit including group exercises. There were no group exercises offered in the Health Center. On 7/29/22 at 1:36 PM group exercise was observed in the Memory Care Unit. Staff 10 (RN) stated all the residents who participated in the activity resided in the Memory Care Unit. On 7/29/22 at 10:47 AM Resident 11 stated she/he would attend most exercise group activities on a daily basis if they were not located in the Memory Care Unit. On 7/28/22 at 9:43 AM Staff 16 (Activity Director) stated there were group activities on the Health Center side a couple times a week but most of the activities were on the Memory Care Unit. Staff 16 stated he was not aware residents, including Resident 11, did not want to go the Memory care unit. Staff 16 acknowledged there were no group exercise programs offered to the residents on the Health Center side of the facility.

Based on interview and record review it was determined the facility failed to provide snacks for 1 of 1 sampled resident (#80) reviewed for meal choices. This placed residents at risk for unintended change in nutritional status. Findings include: Resident 80 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 80's functional nutritional Care Plan included the resident was to be offered snacks three times a day initiated on 10/27/21. A review of daily snack pass sheets, many of which were undated and only went back as far as 1/27/22 through 6/13/22, revealed Resident 80 was not offered three snacks per day. On 8/2/22 Staff 19 (Dietary Manager) confirmed the snack pass sheets indicated Resident 80 was generally only offered one to two snacks daily.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for for 1 of 1 sampled resident (#27) randomly observed. This placed residents at risk for an un-homelike environment. Findings include: Resident 27 was admitted to the facility in 2018 with diagnoses including dementia. On 7/26/22 at 9:19 AM a large brown irregular shaped stained area approximately 12 inches in diameter was observed on the carpet between the foot of Resident 27's bed and bathroom. There was no odor noted in the room. On 7/26/22 at 10:31 AM Witness 3 (Spouse) stated the carpet in the resident's room was dirty and she/he was not sure what caused the stain. On 7/27/22 at 10:18 AM Staff 13 (Housekeeping) stated when carpets were dirty they called maintenance and the maintenance staff cleaned the carpets. On 7/27/22 at 10:20 AM Staff 14 (Housekeeping) stated Resident 27's carpet was dirty for approximately one month and she told Staff 15 (Maintenance) the carpet needed to be cleaned about 15 days ago. On 7/29/22 at 11:09 AM Staff 15 stated housekeeping staff notified him when there was a carpet stain that needed to be cleaned. He was not aware of a stain in Resident 27's room and acknowledged the carpet was stained.

Based on interview and record review it was determined the facility failed to obtain and maintain an advance directive for 2 of 2 sampled residents (# 8 and 23) reviewed for advance directives. This placed residents at risk for not having their health care wishes followed. Findings include: 1. Resident 23 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's 6/2022 MDS indicated the resident was cognitively impaired. Resident 23's record did not include an advance directive or legal documentation for a responsible person to make medical decisions for the resident. A 10/5/21 Care Conference form indicated the resident had an advance directive. The resident's medical record did not indicate the family or responsible party was provided advance directive information. On 7/28/22 at 9:19 AM Staff 9 (Social Service Director) acknowledged Resident 23 did not have an advance directive and there was no documentation to indicate the resident or responsible party was provided advance directive information. 2. Resident 8 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 8's care conference notes from 6/1/20 through 6/13/22 included seven notes indicating Resident 8 had an advance directive and one note indicating she/he did not. No evidence was found in the facility's electronic health record to indicate Resident 8 had a current advance directive. On 7/27/22 at 2:41 PM Staff 9 (Social Services Director) confirmed the facility did not have a copy of Resident 8's advance directive in the resident's record.

Based on interview and record review it was determined the facility failed to ensure a resident was monitored after first developing signs of a [CONDITION(S)] for 1 of 2 sampled residents (#19) reviewed for UTIs and failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This placed residents at risk for delayed care and adverse medication reactions. Findings include: 1. Resident 19 was admitted to the facility in 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Progress Note by Staff 6 (LPN) dated 7/19/22 indicated Resident 19 had increased urination and the symptoms started on 7/16/22. There was no documentation prior to 7/19/22 to indicate the resident was monitored for signs of a [CONDITION(S)]. On 8/1/22 at 8:52 AM Staff 6 stated Resident 19 had mixed incontinence. Staff assisted the resident every two hours during the day, every four hours at night and upon the resident's request. Staff 6 stated he worked on 7/16/22 and Resident 19 had increased urination which indicated a possible [CONDITION(S)] and staff were going to monitor the resident. Staff 6 stated on 7/16/22 he notified the oncoming shift to monitor the resident. Staff 6 indicated he did not work from 7/16/22 until 7/19/22. Staff 6 reviewed the progress notes and acknowledged there were no notes to indicate the staff assessed the resident for signs of a [CONDITION(S)]. On 8/1/22 at 10:19 AM Staff 2 (DNS) stated when a resident had a change in condition, staff were to put the resident on alert charting, monitor and assess the resident and document in the resident's record. Staff 2 acknowledged Resident 6 first developed symptoms on 7/16/22 but there were no assessments until 7/19/22. 2. Resident 18 was admitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 18's 7/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Maximum daily dose 16 grams to all joints. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/29/22 at 9:40 AM Staff 6 (LPN) confirmed two grams of [MEDICATION(S)] administered to all four sites equaled 24 grams per day which was in excess of the maximum 16 grams per day as ordered.

Based on observation, interview and record review it was determined the facility failed to ensure a safe environment free from toxic flowers and plants in 1 of 1 facility and failed to identify the root cause of a resident's fall and implement fall interventions for 1 of 1 sampled resident (#80) reviewed for accidents. This placed residents at risk for injury. Findings include: 1. Resident 80 was admitted to the facility in 2021 with diagnoses including dementia. Resident 80's fall Care Plan initiated on 10/18/21 indicated the resident was a high risk for falls. Interventions included every 15 minute safety checks initiated on 11/1/21. A Progress Note dated 12/5/21 indicated the resident was a high fall risk and was checked on by staff every 25 to 30 minutes. A review of facility incident reports revealed Resident 80 fell eight times between 1/9/22 and 5/3/2022. None of the eight incident reports included an evaluation or analysis to identify specific hazards, risks and trends, or the development of targeted interventions to reduce the potential for additional falls. None of the reports included an analysis and rationale to demonstrate abuse and neglect had been ruled out. The reports included the following: - On 1/9/22 the resident fell with a family member present and incurred abrasions to her/his head and hand. - On 1/9/22 the resident was found crawling on the floor next to her/his wheelchair. No injuries were noted but the report did not indicate when the resident was last assisted or checked on by staff. - On 2/16/22 the resident was found on the floor near her/his bed with a 1 cm by 2 cm laceration to the left brow. The report did not indicate when the resident was last assisted or checked on by staff, however, a Progress Note dated 2/16/22 indicated staff had last assisted the resident 10 minutes prior to the fall. - On 2/26/22 the resident was heard screaming and was found on her/his knees on the floor. The report did not indicate when the resident was last assisted or checked on by staff. - On 3/27/22 the resident was witnessed by staff as she/he slid out of her/his wheelchair onto the floor. - On 4/13/22 the resident was found on the floor near her/his wheelchair. The report did not indicate when the resident was last assisted or checked on by staff. - On 4/30/22 the resident was heard to fall out of bed as staff were entering the resident's room. Staff last assisted the resident 19 minutes prior to the fall. - On 5/3/22 the resident had an assisted fall to the floor. On 8/1/22 at 11:14 AM Resident 80's fall incident reports were discussed with Staff 2 (DNS). Staff 2 acknowledged the lack of root cause analysis and care plan changes related to the resident's falls. She stated they were behind on charting. Staff 2 stated Staff 1 (Administrator) had not signed off on any of the incident reports yet. On 8/1/22 at 11:32 AM Staff 1 stated she had not signed off on any of the incident reports because they were not closed yet and stated they were behind on their documentation. On 8/2/22 at 12:59 Staff 2 (DNS) stated there was no documentation of the care planned 15 minute safety checks. 2. Multiple random observations from 7/25/22 through 8/2/22 between the hours of 8:30 AM and 4:00 PM revealed living plants in numerous resident rooms and common areas of the Health Center and Memory Care Unit of the facility. Residents were frequently observed unsupervised in the Memory Care Unit common living area near plants and residents self-ambulated in the hallways and sat at the nursing station where flowers and plants were readily accessible. On 7/27/22 at 3:11 PM Staff 12 (Memory Care Coordinator) provided a list of living plants accessible to residents in the following areas of the Memory Care Unit: living room, front table, nursing station, dining room, plant table, resident rooms, indoor therapy garden and outdoor therapy garden. There were approximately 38 living plants listed including hydrangea and anthurium. According to the University of California: Safe and Poisonous Garden Plants, Division of Agriculture and Natural Resources, dated 2022 (https://ucanr.edu/sites/poisonous_safe_plants/), two living plants located on the Memory Care Unit were identified as toxic to humans. These included hydrangeas located at the nursing station and resident room 228 and an anthurium plant located in resident room 225. On 7/27/22 at 2:45 PM Staff 12 stated the facility contracted with an organization that provided plants for the facility's indoor therapy garden and those plants were non-toxic; however, the facility did not have a system in place to identify toxic flowers and plants brought into the facility by staff or family members. Staff 12 was unable to state if any flowers and plants in the common areas or resident rooms on the Memory Care Unit were considered toxic to humans. On 7/29/22 at 11:30 AM Staff 1 (Administrator) confirmed the facility did not have a system in place to identify potentially toxic flowers and plants brought into the facility and understood this was a safety concern, especially in the Memory Care Unit. On 7/29/22 at 2:13 PM Staff 12 confirmed hydrangeas and anthurium were toxic to humans.

Based on interview and record review it was determined the facility failed to provide bathing for 1 of 2 sampled residents (#80) reviewed for ADLs. This placed residents at risk for lack of person hygiene and infections. Findings include: Resident 80 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 80's functional mobility Care Plan initiated on 10/18/21 indicated the resident required staff assistance with bathing. A review of Resident 80's bathing record from 10/2021 through 6/2022 revealed the following: - In 10/2021 no baths were provided. - In 11/2021 two baths were provided. - In 12/2021 one bath was provided. - In 1/2022 no baths were provided. - In 2/2022 two baths were provided. - In 3/2022 four baths were provided from 3/3/22 through 3/7/22. - In 4/2022 seven baths were provided from 4/11/22 through 4/27/22. - In 5/2022 nine baths were provided from 5/8/22 through 5/29/22. - In 6/2022 four baths were provided from 6/1/22 though 6/15/22. On 7/29/22 Staff 8 (RNCM) stated Resident 80 was not resistive to bathing and there was no evidence to support the resident received routine bathing cares.

Based on observation, interview and record review, it was determined the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for disposing, cleaning and storing of personal protective equipment (PPE) for 1 of 1 sampled resident (#184) reviewed for infection control related to COVID-19 and failed to follow manufacture's guidance related to use of disinfection products for infection control precautions in relation to COVID-19 prevention. This placed residents and staff at risk for infection and illness related to the COVID-19 virus. Findings include: 1. According to the CDC Strategies for Optimizing the Supply of Isolation Gown, updated 1/21/21: Once personal protective equipment (PPE) supplies and availability return to normal, healthcare facilities should promptly resume conventional practices. Re-use of isolation gowns. The risks to healthcare provider (HCP) and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits. According to CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19 Pandemic): Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. According to Oregon Health Authority guidance: If eye protection is being reused, establish a dedicated area in the facility to clean, disinfect, and store eye protection between uses (preferably near facility entrance/exit). Disinfection should occur immediately after removing eye protection. Social distancing should be observed at and around the disinfection station. Personal protective equipment should not be shared between staff. After cleaning/disinfection/drying, eye protection can be stored in a transparent plastic bag or container, and labeled with the staff member name to prevent accidental sharing between staff. Resident 184 was admitted to the facility in 5/2021 and placed on 14-day droplet precautions that required all staff and visitors wear full PPE. The resident was in a private room. On 5/14/21 at 3:03 PM, the door to Resident 184's room was open. Directly inside the doorway of the room were five hooks placed on the wall, three on the left side behind the opened door and two on the right side. Each of the five hooks had a blue disposable isolation gown hanging on it. Four face shields, three on the left side and one on the right side, were also hanging on the same hooks with the inside of each face shield directly facing the hanging isolation gowns. A PPE cart was located right outside of Resident 184's room. The cart contained new PPE supplies (gloves, blue disposable isolation gowns, masks, and two different containers of disinfecting wipes) and plastic bags. On 5/14/21 at 3:46 PM, Staff 5 (CNA) entered Resident 184's room after donning full PPE (mask, disposable isolation gown, gloves and face shield) to provide care. After providing care, Staff 5 noticed the five hanging isolation gowns and disposed of four of them in a covered trash receptacle in the resident's room, leaving one isolation gown still hanging. Staff 5 left the four face shields hanging on their hooks. Staff 5 then hung up her face shield on one of the hooks without disinfecting or storing it in a plastic bag. Staff 5 exited the room after doffing the rest of her PPE. When asked about the use, storage and disposal of PPE, Staff 5 stated she used the disposable isolation gown once and disposed of it immediately afterwards. She stated this process had recently changed as staff had previously used the same gown for their entire shift. Staff 5 then stated the hanging isolation gowns she disposed of belonged to other staff who had cared for the resident earlier in the day. In regards to her face shield, Staff 5 stated she received a new face shield each shift. Since Resident 184 was the only resident on droplet precautions, Staff 5 used the same face shield throughout her entire shift and stored the face shield in the resident's room. Staff 5 stated she did not disinfect her face shield between uses in the resident's room or store the face shield in a storage bag afterwards. In an interview on 5/13/21 at 12:30 PM, Staff 1 (Administrator) stated the facility had a three months supply of PPE, including disposable isolation gowns. She stated there should not be any reuse of PPE. In an interview on 5/14/21 at 4:41 PM, Staff 3 (Assistant DNS and Infection Preventionist) stated staff should not be reusing disposable isolation gowns and should be disinfecting face shields between use and appropriately storing them. Staff 3 acknowledged this was not done. 2. Centers for Disease Control Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019 (COVID-19) Pandemic revised 7/15/20 instructed facilities to ensure environmental cleaning and disinfection procedures were followed consistently and correctly. The disinfecting solution (Signet Neutral Disinfectant) used within the facility had manufacturer's instructions which stated treated surfaces must remain wet for 10 minutes . allow to air dry. On 5/10/21 at 10:36 AM, Staff 8 (Housekeeping) was interviewed about disinfection of surfaces in residents' rooms and communal areas. Staff 8 stated that Signet Neutral Disinfectant was sprayed on surfaces, left on for five seconds, then wiped away. On 5/12/21 at 10:35 AM, Staff 9 (Housekeeping) was observed using Signet Neutral Disinfectant on surfaces in an isolation precaution room. Staff 9 sprayed the disinfecting product on surfaces and wiped those surfaces dry immediately. Staff 9 was interviewed about use of Signet Neutral Disinfectant. Staff 9 stated they sprayed the product on a surface, waited 30 seconds, and then wiped it off. On 5/12/21 at 1:48 PM, Staff 7 (Housekeeping Supervisor) was interviewed about disinfection products used in the facility. Staff 7 stated the contact time for Signet Neutral Disinfectant was 30 seconds. The concentrate dispenser label was reviewed regarding contact time for the disinfectant with Staff 7 to which she corrected her previous statement, stating that 10 minutes was the correct contact time for that product. On 5/14/21 at 4:05 PM, Staff 1 (Administrator) stated an understanding of the need for a 10 minute contact time with Signet Neutral Disinfectant in order to disinfect surfaces.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's care-planned interventions were followed for 1 of 3 sampled resident (#14) identified with a fall with injury. As a result, Resident 14 sustained [MEDICAL CONDITION], rib fractures and head and elbow lacerations. The facility identified the noncompliance and immediately initiated a plan of correction which included staff education, staff reminders to read residents' care plans daily and implement care planned interventions and no further accidents occurred. This incident was identified as meeting the criteria for past noncompliance. Findings include: Resident 14 was admitted to the facility in 12/2019 with [DIAGNOSES REDACTED]. Resident 14's 12/16/19 Admission MDS Section C: Cognitive Patterns indicated severe cognitive impairment and Section G: Functional Status indicated the need for two person assistance with ambulation. Resident 14's Care Plan identified the resident as a fall risk. The fall prevention intervention directed staff to ensure Resident 14 had two person extensive assistance with gait belt and four wheel walker during in room ambulation. Incident report initiated on 1/2/20, revealed Staff 3 (former Nursing Assistant) failed to follow the care plan to ensure Resident 14 had two staff assistance during ambulation. Staff 3 reported she allowed Resident 14 to ambulate with her/his walker to the bathroom while she gathered clothing for her/him to wear. Resident 14 fell after she/he left her/his walker in the restroom and turned around to walk back toward Staff 3. Staff 3 heard a whoa, whoa and turned to look at the restroom and observed Resident 14 on the floor. The report revealed this was an avoidable event and Staff 3 had not followed the care plan as directed. Resident 14 was sent to the hospital on [DATE]. Hospital records revealed X-ray's were obtained and it was determined Resident 14 sustained a [MEDICAL CONDITION] acetabulum (hip socket), [MEDICAL CONDITION] of the left femur (ball joint of hip) and multiple fractures of the ribs. Bandages to the lacerations to the head and elbow stopped the bleeding. Resident 14 re-admitted to the facility on [DATE] with new orders for pain management and a urinary catheter. Resident 14 discharged the facility on 1/17/20. On 2/12/20 through 2/14/20, observations were made of several residents with fall care plans in place, which were followed as directed. In a phone interview on 2/14/20 at 10:27 AM, Staff 3 acknowledged Resident 14 fell . Staff 3 confirmed she did not follow Resident 14's care plan to have two staff assistance during ambulation. Staff 3 was unwilling to provide further information. In an interview on 2/14/20 at 10:00 AM, Staff 5 (RNCM) stated Resident 14 fell on [DATE] due to Staff 3 not following the care plan as directed. Staff 5 developed a care plan book, which was kept at the nurse station to inform staff of each residents' ambulation status and other care planned interventions. Interviews conducted on 2/13/20 and 2/14/20/20 with Staff 6 (CNA), Staff 7 (CNA), Staff 8 (CNA), Staff 9 (CNA), Staff 10 (CNA), Staff 11 (CNA) and Staff 5 who stated information regarding residents was found in the care plan. Staff stated it was an expectation to read residents' care plans daily and follow the recommended interventions to prevent falls. Staff were aware of places to find the updated care plan interventions. On 2/14/20 at 11:00 AM, Staff 2 (DNS) stated on 1/2/20 Resident 14 was allowed and attempted to walk with out staff assistance, fell and sustained hip and rib fractures. Staff 2 stated a staff in-service was immediately completed which included staff education to read the care plan daily, implement the care planned interventions to prevent falls and to ensure the care plan was used for residents at all times. Staff 2 stated there were no further accidents or incidents of not implementing the care plan since the 1/2/20 incident. This situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F689. 2. The noncompliance occurred after the exit date of the last standard recertification survey (8/30/20) and before the date of this survey (2/12/20). 3. There was sufficient evidence the facility corrected the noncompliance immediately and was in substantial compliance with F689 as evidenced by: -No deficient practice was found at F689 with additional sampled residents; -Evidence the deficient practice was identified by the facility, brought to facility team members and a plan of correction was implemented on 1/3/20 to educate and remind staff to read residents' care plans and implement interventions to prevent falls. -DNS, RN and CNA interviews indicated knowledge and awareness of expectations and protocol to follow the care planned interventions to prevent falls.

Based on interview and record review it was determined the facility failed to ensure residents were free from physical and mental abuse for 1 of 3 sampled resident (#1) reviewed for abuse. This resulted in Resident 1 receiving care against her/his wishes, which resulted in distress and bruising to the resident's right and left wrists and right forearm. This placed residents at risk for physical and mental abuse. Findings include: Resident 1 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Resident 1's 10/2018 Annual MDS revealed the resident was severely cognitively impaired and rarely or never made decisions. The resident required extensive assistance with one person physical assist for toileting and one person physical assist for bathing. The 10/2018 Care Plan revealed the following: -Problem: resistive to care and therapy evidenced by care refusals of ADLs and showers. -Interventions: ask the resident if she/he would allow care. If the resident refused, set a time to return that might be better or return in 30 minutes and re-attempt care delivery. Diversionary activities if she/he would participate. -Problem: cognitive impairments and behaviors related to dementia and [MEDICAL CONDITION] evidenced by delusions, wandering and was territorial. -Interventions: when the resident refuses ADLs allow the resident a few moments alone and reapproach. Provide reassurance of safety and attempt to re-direct her/his thoughts to a pleasant topic. Redirect the resident. Offer to walk with the resident. -Problem: needed assistance with bathing and hygiene. -Interventions: assist the resident with bathing parts she/he is unable to do, give verbal reminders and cues, allow time to perform tasks. Wednesday and Friday bathing with one person extensive assistance. -Problem: needed assistance with toileting. -Interventions: setup assistance for perineal care. Allow the resident to do as much as possible. If visibly soiled with bowel movement two CNAs need to assist as resident had care refusals. A 12/1/18 Interdisciplinary Note stated CNAs (Staff 5 and Staff 6) reported to Staff 3 (LPN) at approximately 12:15 PM that during resident care on 12/1/18 at approximately 8:20 AM the resident was extremely agitated and combative, which lead to the aides grabbing the resident by the wrists to redirect her/him back into the resident's room as the resident attempted to leave when undressed and covered with bowel movement, as well as guide the resident into the shower. The CNAs (Staff 5 and Staff 6) pointed out to Staff 3 the resident had bruising to her/his bilateral wrists and right forearm as a result of the 12/1/18 morning care. Per CNA statements one CNA (Staff 4) entered the room and put on the assist light after finding the resident and bed linens soiled. A second CNA (Staff 6) entered to assist the first CNA (Staff 4) to help provide care. The resident became agitated and combative when the aides (Staff 4 and Staff 6) were trying to remove her/his clothes. A third CNA (Staff 5) entered the room to answer the assist light and per Staff 6's statement, staff had to get the resident's shirt off forcefully and had to pull her/him by the hands to get her/him into the shower. While holding the resident's wrists the CNAs reported the resident tried to pull her/his hands back. The 12/1/18 Skin Evaluation Forms revealed the following: -Red/purple bruising to the right forearm. The bruise was 1.5 cm long by 2.5 cm wide. -Red/purple bruising to the back of the left wrist. The bruise was 3 cm long by 3 cm wide. -Red/purple bruise to the right medial wrist. The bruise was 2.5 cm long by 1.5 cm wide. The 12/2018 Treatment Record revealed on 12/1/18 through 12/11/18 the resident was being monitored each shift for bruises to the right wrist, left wrist and right forearm. Staff were to notify the physician if the bruises worsened. The 12/5/18 Incident report revealed the following: -The 12/1/18 Interdisciplinary Note was included (see above). -Staff 2 (DNS) noted the following: Staff 4 (CNA) stated while she was doing morning rounds, Resident 1 had feces all over and needed to be cleaned up. Staff 4 pressed the call light and Staff 6 (CNA) entered the room to assist. The resident became combative when Staff 4 and Staff 6 tried to remove the resident's clothes. Staff 5 (CNA) entered the room and all three CNAs felt it was best to shower the resident. Staff 4, Staff 5 and Staff 6 stated the resident's wrist were held and the resident tried to pull her/his hands away from the CNAs. Staff 4, Staff 5 and Staff 6 showered and dressed the resident in clean clothes. At 12:15 PM Staff 3 (LPN) was notified who then completed an assessment and the resident had bruising to the bilateral wrists and right forearm following the morning shower incident. -Written Statements: -Staff 4 (CNA) stated she checked on the resident during morning rounds and was able to walk the resident to the bathroom to help clean the resident up since the resident had feces all over her/his body. The resident started refusing care and pushed Staff 4 away. Staff 4 pressed the call light for help. Staff 4 stated she held the resident's hand and helped the resident stand up as Staff 6 cleaned up the resident. Staff 4, Staff 5 and Staff 6 showered, dressed and changed the resident's linens. -Staff 5 stated the resident's call light was on and she entered to assist and saw Staff 4 and Staff 6 trying to clean up the resident in the bathroom. The resident was clearly agitated during the process. Staff 4, Staff 5 and Staff 6 decided the best option was to shower the resident because they did not want the resident to remain soiled. Staff 4, Staff 5 and Staff 6 asked the resident to stand up and led the resident into the shower while she/he was being very combative toward staff. Staff 6 was helping from behind by leading the resident in the shower and Staff 4 and Staff 5 held the resident's hands. Staff 4, Staff 5 and Staff 6 washed the resident up quickly which resulted in holding the resident's arms because Staff 5 was afraid the resident would walk out naked without a brief. At the time Staff 5 did not know what the best decision was so they kept drying the resident and got the resident dressed. The resident was very distressed afterwards and approximately one hour the resident calmed down and sat to finish breakfast. -Staff 6 (CNA) stated she entered the resident's room to help Staff 4 with changing the resident. Staff 4 told her the resident was covered in feces and the bed and the resident needed cleaned. Staff 6 tried to call the resident to the bathroom and the resident said no she/he was not getting up. The resident covered herself/himself with the soiled sheet and attempted to leave the room. Staff 4 and Staff 6 redirected the resident to the bathroom. Staff 5 entered to assist and they all agreed to shower the resident. Staff 4, Staff 5 and Staff 6 had to forcefully take the residents shirt off and had to pull the resident by her/his hands to get the resident in the shower. Staff 6 washed the resident and could not see what Staff 4 and Staff 5 were doing in the front. -The facility terminated Staff 4, Staff 5 and Staff 6. In an interview on 1/8/19 at 10:20 AM Staff 1(Administrator) stated the DNS was the primary investigator but she learned one CNA entered the room, and the resident had feces on herself/himself. The resident was not being complaint about getting cleaned up. The CNA got a second CNA and they still could not get the resident in the shower so they called a third CNA to help shower the resident. The resident was agitated and did not want a shower but staff forced the resident into the shower. The CNAs did not report all the details to nurse until a couple hours later because they started seeing the bruising. The CNAs did not follow the facility dementia process or the care plan. In an interview on 1/8/19 at 1:18 PM Staff 4 verified her written statement included in the investigation. Staff 4 added she noticed a ring of yellow on the bed and believed the resident had been left soiled for a long while. Staff 4 stated the resident was combative when she tried to take the resident's pants off to clean her/him and the resident told Staff 4 no, no, no, no, no. Staff 4 felt it would be neglectful to leave the resident soaked. The resident threw herself/himself back onto the bed and Staff 4 turned on the call light for more assistance. Staff 4 stated she and Staff 6 held the resident's hands and got the resident into the bathroom but the resident was not happy about it. Staff 4 stated the resident was very upset about taking a shower, Staff 4, Staff 5 and Staff 6 let the resident go when the shower was complete and the resident barged out of the room. Staff 4 stated she was trained to leave and come back when the resident was upset and leave the resident alone but she did not do this because she felt the resident might be a danger to herself or others. Staff 4 further stated if the resident was cognitively intact she would have respected her/his wishes. Staff 4 stated she did not attempt to do anything to comfort the resident like do a sponge bath or warm towels instead of forcing the resident in the shower, instead she felt it would be quicker and easier to shower the resident. Staff 4 stated she did not try any other interventions. In an interview on 1/8/19 at 3:02 PM Staff 5 verified her written statement included in the investigation. Staff 5 added the bed looked as if it was soiled from the night and tried to get the resident into the bathroom. The resident was agitated because she/he did not like the cold wipes and got more aggravated. Staff 5 and Staff 4 thought it would be better and quicker to shower the resident. Staff 5 stated she had to hold the resident by the wrist to prevent being hit during the shower and to prevent the resident from falling. Staff 5 stated as a result of holding the resident's wrist, the resident was bruised. Staff 5 stated everything happened so quickly she did not think of a more appropriate intervention. Staff 5 stated the resident told her no to care and showering but completed it anyway. Attempts to reach Staff 6 were unsuccessful. In an interview on 1/9/19 at 9:16 AM Staff 2 (DNS) verified the information contained within the investigation. Staff 2 stated the CNAs should have walked around with the resident because the resident clams down after a walk. Staff should have called the nurse for guidance and could have ensured the resident was safe and walked away and come back. It was never was it acceptable for staff to force care on the resident or hold the resident. In an interview on 1/9/19 at 10:08 AM AM Staff 3 (LPN) verified her Interdisciplinary Note and note contained within the investigation. Staff 3 added the CNAs notified her of the difficulty with the resident when it happened but did not elaborate on the details and she was unaware they held the resident until 2:15 PM when Staff 5 and Staff 6 showed her the bruises. Staff 3 stated when she did the assessment she saw bruises on the right and left wrists and one to the back of the hand. There were definitely bruises around the wrist from being held. Staff 3 stated staff should have come and gotten her or another nurse when two people could not calm the resident.

Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards regarding Oregon State Board of Nursing Conduct related to state and federal rule violation regarding the prevention of abuse for 1 of 3 sampled residents (# 1) reviewed for abuse. This resulted in Resident 1 receiving care against her/his wishes, which resulted in distress and bruising to the resident's right and left wrists and right forearm. This placed residents at risk for physical and mental abuse. Findings include: The Oregon Nurse Practice Act includes: Oregon Administrative Rule [PHONE NUMBER] Standards and Authorized Duties for the Certified Nursing Assistant and Certified Medication Aide. 851-063-0090 Conduct Unbecoming a Nursing Assistant (1) Conduct, regardless of setting, related to general fitness to perform nursing assistant authorized duties: -(a) Demonstrated incidents of violent, abusive, neglectful or reckless behavior. (3) Conduct related to client safety and integrity: -(a) Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities. -(b) Failing to implement the plan of care developed by the registered nurse. (8) Conduct related to other federal or state statutes/rule violations: -(d) Abusing a person. Resident 1 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Resident 1's 10/2018 Annual MDS revealed the resident was severely cognitively impaired and rarely or never made decisions. The resident required extensive assistance with one person physical assist for toileting and one person physical assist for bathing. The 10/2018 Care Plan revealed the following: -Problem: resistive to care and therapy evidenced by care refusals of ADLs and showers. -Interventions: ask the resident if she/he would allow care. If the resident refused, set a time to return that might be better or return in 30 minutes and re-attempt care delivery. Diversionary activities if she/he would participate. -Problem: cognitive impairments and behaviors related to dementia and [MEDICAL CONDITION] evidenced by delusions, wandering and was territorial. -Interventions: when the resident refuses ADLs allow the resident a few moments alone and reapproach. Provide reassurance of safety and attempt to re-direct her/his thoughts to a pleasant topic. Redirect the resident. Offer to walk with the resident. A 12/1/18 Interdisciplinary Note stated CNAs (Staff 5 and Staff 6) reported to Staff 3 (LPN) at approximately 12:15 PM that during resident care on 12/1/18 at approximately 8:20 AM the resident was extremely agitated and combative, which lead to the aides grabbing the resident by the wrists to redirect her/him back into the resident's room as the resident attempted to leave when undressed and covered with bowel movement, as well as guide the resident into the shower. The CNAs (Staff 5 and Staff 6) pointed out to Staff 3 the resident had bruising to her/his bilateral wrists and right forearm as a result of the 12/1/18 morning care. Per CNA statements one CNA (Staff 4) entered the room and put on the assist light after finding the resident and bed linens soiled. A second CNA (Staff 6) entered to assist the first CNA (Staff 4) to help provide care. The resident became agitated and combative when the aides (Staff 4 and Staff 6) were trying to remove her/his clothes. A third CNA (Staff 5) entered the room to answer the assist light and per Staff 6's statement, staff had to get the resident's shirt off forcefully and had to pull her/him by her hands to get her/him into the shower. While holding the resident's wrists the CNAs reported the resident tried to pull her/his hands back. The 12/5/18 Incident report revealed the following: -The 12/1/18 Interdisciplinary Note was included (see above). -Staff 2 (DNS) noted the following: Staff 4 (CNA) stated while she was doing morning rounds, Resident 1 had feces all over and needed to be cleaned up. Staff 4 pressed the call light and Staff 6 (CNA) entered the room to assist. The resident became combative when Staff 4 and Staff 6 tried to remove the resident's clothes. Staff 5 (CNA) entered the room and all three CNAs felt it was best to shower the resident. Staff 4, Staff 5 and Staff 6 stated the resident's wrist were held and the resident tried to pull her/his hands away from the CNAs. Staff 4, Staff 5 and Staff 6 showered and dressed the resident in clean clothes. At 2:15 PM Staff 3 (LPN) was notified and Staff 3 completed an assessment and the resident had bruising to the bilateral wrists and right forearm following the morning shower incident. -Written Statements: -Staff 4 (CNA) stated she checked on the resident during morning rounds and was able to walk the resident to the bathroom to help clean the resident up since the resident had feces all over her/his body. The resident started refusing care and pushed Staff 4 away. Staff 4 pressed the call light for help. Staff 4 stated she held the resident's hand and helped the resident stand up as Staff 6 cleaned up the resident. Staff 4, Staff 5 and Staff 6 showered, dressed and changed the resident's linens. -Staff 5 stated the resident's call light was on and she entered to assist and saw Staff 4 and Staff 6 trying to clean up the resident in the bathroom. The resident was clearly agitated during the process. Staff 4, Staff 5 and Staff 6 decided the best option was to shower the resident because they did not want the resident to remain soiled. Staff 4, Staff 5 and Staff 6 asked the resident to stand up and led the resident into the shower while she/he was being very combative toward staff. Staff 6 was helping from behind by leading the resident in the shower and Staff 4 and Staff 5 held the resident's hands. Staff 4, Staff 5 and Staff 6 washed the resident up quickly which resulted in holding the resident's arms because Staff 5 was afraid the resident would walk out naked without a brief. At the time Staff 5 did not know what the best decision was so they kept drying the resident and got the resident dressed. The resident was very distressed afterwards and approximately one hour the resident calmed down and sat to finish breakfast. -Staff 6 (CNA) stated she entered the resident's room to help Staff 4 with changing the resident. Staff 4 told her the resident was covered in feces and the bed and the resident needed cleaned. Staff 6 tried to call the resident to the bathroom and the resident said no she/he was not getting up. The resident covered herself/himself with the soiled sheet and attempted to leave the room. Staff 4 and Staff 6 redirected the resident to the bathroom. Staff 5 entered to assist and they all agreed to shower the resident. Staff 4, Staff 5 and Staff 6 had to forcefully take the residents shirt off and had to pull the resident by her/his hands to get the resident in the shower. Staff 6 washed the resident and could not see what Staff 4 and Staff 5 were doing in the front. -The facility terminated Staff 4, Staff 5 and Staff 6. In an interview on 1/8/19 at 1:18 PM Staff 4 verified her written statement included in the investigation. Staff 4 stated the resident was combative when she tried to take the resident's pants off to clean her/him and the resident told Staff 4 no, no, no, no, no. Staff 4 stated she and Staff 6 held the resident's hands and got the resident into the bathroom but the resident was not happy about it. Staff 4 stated the resident was very upset about taking a shower. Staff 4, Staff 5 and Staff 6 let the resident go when the shower was complete and the resident barged out of the room. Staff 4 stated she was trained to leave and come back when the resident was upset and leave the resident alone but she did not do this because she felt the resident might be a danger to herself or others. Staff 4 further stated if the resident was cognitively intact she would have respected her/his wishes. Staff 4 stated she did not attempt to do anything to comfort the resident like do a sponge bath or warm towels instead of forcing the resident in the shower, instead she felt it would be quicker and easier to shower the resident. Staff 4 stated she did not try any other interventions. In an interview on 1/8/19 at 3:02 PM Staff 5 verified her written statement included in the investigation. The resident was agitated because she/he did not like the cold wipes and got more aggravated when she was providing care. Staff 5 and Staff 4 thought it would be better and quicker to shower the resident. Staff 5 stated she had to hold the resident by the wrist to prevent being hit during the shower and to prevent the resident from falling. Staff 5 stated as a result of holding the resident's wrist she/he was bruised. Staff 5 stated everything happened so quickly she did not think of a more appropriate intervention. Staff 5 stated the resident told her no to care and showering but completed it anyway. Attempts to reach Staff 6 were unsuccessful. Refer to F600 and F658.

Based on interview and record review it was determined the facility failed to ensure staff implemented appropriate dementia cares and competencies and failed to implement care plan interventions for a resident diagnosed with [REDACTED].# 1) reviewed for abuse. This resulted in Resident 1 receiving care against her/his wishes, which resulted in distress and bruising to the resident's right and left wrists and right forearm. This placed residents at risk for the unmet care needs and physical and mental abuse. Findings include: Resident 1 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. Resident 1's 10/2018 Annual MDS revealed the resident was severely cognitively impaired and rarely or never made decisions. The resident required extensive assistance with one person physical assist for toileting and one person physical assist for bathing. The 10/2018 Care Plan revealed the following: -Problem: resistive to care and therapy evidenced by care refusals of ADLs and showers. -Interventions: ask the resident if she/he would allow care. If the resident refused, set a time to return that might be better or return in 30 minutes and re-attempt care delivery. Diversionary activities if she/he would participate. -Problem: cognitive impairments and behaviors related to dementia and [MEDICAL CONDITION] evidenced by delusions, wandering and was territorial. -Interventions: when the resident refuses ADLs allow the resident a few moments alone and reapproach. Provide reassurance of safety and attempt to re-direct her/his thoughts to a pleasant topic. Redirect the resident. Offer to walk with the resident. -Problem: needed assistance with bathing and hygiene. -Interventions: assist the resident with bathing parts she/he is unable to do, give verbal reminders and cues, allow time to perform tasks. Wednesday and Friday bathing with one person extensive assistance. -Problem: needed assistance with toileting. -Interventions: setup assistance for perinea care. Allow the resident to do as much as possible. If visibly soiled with bowel movement two CNAs need to assist as resident had care refusals. In an interview on 1/8/19 at 10:20 AM Staff 1 (Administrator) stated Staff 4 (CNA), Staff 5 (CNA) and Staff 6 (CNA) failed to follow the facility's dementia care standards learned through ongoing training and failed to follow the resident's care plan. In an interview on 1/8/19 at 1:18 PM Staff 4 (CNA) stated she was trained to leave and come back when the resident was upset or leave the resident alone but she did not do this because she felt the resident might be a danger to herself or others. Staff 4 stated she was able to get the resident to the restroom and everything was fine until Staff 4 told the resident she was going to take off her pants to clean her/him, the resident said no, no, no, no, no. Staff 4 stated she and Staff 6 held the resident's hand to get the resident back in the bathroom but the resident was irritated and was not happy about getting wiped down. Staff 4 stated she and Staff 6 continued to hold the resident while getting the resident into the shower. Staff 4 stated if the resident was cognitively intact she would have respected the resident's right to refuse care but since the resident had dementia she felt it would be neglectful to leave the resident soiled despite the resident's refusals. Staff 4 stated she did not attempt to do anything to comfort the resident as indicated on the care plan, instead she felt it would be quicker and easier to shower the resident. Staff 4 stated she did not try any other care plan interventions. In an interview on 1/8/19 at 3:02 PM Staff 5 (CNA) stated she and Staff 4 and Staff 6 thought it would be better and quicker to shower the resident. Staff 5 stated she had to hold the resident by the wrist to prevent being hit during the shower and to prevent the resident from falling. Staff 5 stated as a result of holding the resident, the resident's wrists were bruised. Staff 5 stated when the resident was upset she/he usually runs out of the room, but Staff 5 could have left the resident unclean and undressed and come back later. Staff 5 stated everything happened so quickly she did not think to use a better intervention. Staff 5 stated the resident said no and acted like she/he did not want care or a shower. Staff 5 stated she never considered doing another intervention or less restrictive bathing technique like a bed bath. Staff 5 stated the maximum a resident should have to care for them is two people. In an interview on 1/9/19 at 9:16 AM Staff 2 (DNS) stated Staff 4, Staff 5 and Staff 6 went through dementia care training, monthly dementia trainings, and were required to complete three to four shifts on the memory care prior to working alone. Staff 2 expected Staff 4, Staff 5 and Staff 6 to have walked around with the resident, ensured the resident was safe and reapproach for cares at a later time and consulted the nurse for assistance. Staff 2 stated during her interviews with Staff 4, Staff 5 and Staff 6 they all admitted they held the resident by the arms to get the resident in the shower and none of them considered getting the nurse for assistance. Staff 2 stated Staff 4, Staff 5 and Staff 6 failed to follow the dementia care trainings and the resident's care plan. Attempts to reach Staff 6 (CNA) were unsuccessful.