Every finding on record at Reedwood Post Acute

Based on observation, interview, and record review it was determined the facility failed to maintain comfortable temperature levels, and a safe and home like environment for 1 of 1 facility reviewed for comfortable temperatures and homelike environment. This placed residents at risk for an uncomfortable and unhomelike environment. Findings include: 1. On 12/26/23, 1/17/24 and 1/18/24 public concerns were reported to the State Agency which alleged residents had to endure cold temperatures due to heating issues in the facility and many residents had to wear coats, hats and gloves to stay warm. The report indicated the facility had some heat in the hallways so residents gathered in common areas with coats and hats on but individual resident rooms were ice boxes due to the heating system not working properly since 11/2023. The report alledged the facility's temperatures were cruel and inhumane treatment. Multiple observations from 3/4/24 through 3/6/24 between the hours of 8:00 AM and 4:00 PM revealed the following: -Many residents in their rooms and hallways wore extra clothing, coats, shawls and hats; -Many residents in their rooms were covered with two or more blankets; -Cold drafts were felt in some areas of the hallways, common areas and in some residents' rooms; -Some residents opened their room windows to cool off their rooms. On 3/4/24 at 9:46 AM and 3/5/24 at 12:38 PM and 1:06 PM Resident 38 stated in the past, her/his room was really cold but on 3/5/24, her/his room was about 105 degrees and she/he was sweating so she/he opened the window. Resident 38 stated the room was so hot she/he wanted to sleep in the hallway. Resident 38 stated sometimes her/his room was too hot so she/he had to open her/his window or the door to do anything I can to regulate her/his room temperature. On 3/4/24 at 10:47 AM Resident 247 stated she/he was a resident in the facility in 11/2023 through the end of 12/2023. Resident 247 stated during her/his stay, there were periods when the facility had no heat, her/his room was always freezing and during the night her/his room was below 61 F. Resident 247 reported Staff 8 (Maintenance Director) covered the inside of her/his room window with plastic but the room remained cold so Staff 8 placed plastic on the outside of her/his room window. Resident 247 reported she/he continued to be cold so she/he was moved to a different room which was colder and more confining. Resident 247 reported she/he was provided with an electric blanket which then confined her/him to her/his room in order to stay warm and also caused her/him to be too hot, sweat and then freeze. Resident 247 stated the temperatures in the facility fluctuated between cold and hot depending on the location in the building. Resident 247 stated there were many residents that congregated at the end of the hallway where a wall heating/cooling device was mounted and blew warm air and many residents wore coats, hats and gloves to stay warm. Resident 247 reported she/he didn't have real healing until I discharged because of the frigid temperatures she/he had to endure for one month before being discharged home. Resident 247 stated at the time of her/his discharge, the heating system was not yet fixed. On 3/6/24 at 8:10 AM Resident 197 was observed in bed, covered with three blankets. Resident 197 stated her/his room was drafty. A cold draft was evident when standing near Resident 197's bed and in the middle of the room. Resident 197 reported she/he was freezing and she/he usually needed extra blankets to stay warm. Resident 32 shared the room with Resident 197 and reported she/he was also freezing and required extra blankets. Staff 13 (CNA) reported the two residents were always cold and Resident 32 frequently verbalized she/he was freezing. On 3/6/24 at 9:15 AM Resident 98 was observed dressed with a coat, hat and shawl while in the dining room and then sitting in the area surrounding the nurses station. With the assistance of Witness 3 (Interpreter), Resident 98 stated she/he was always cold. On 3/6/24 at 9:17 AM Resident 7 was observed in the dining room and then sitting in the area by the fishtank near the nurses station, wearing two shirts, a wool vest and a crocheted shawl. With the assistance of Witness 3 (Interpreter), Resident 7 stated her/his room was cold which made her/him shake. Resident 7 stated her/his room was especially cold all night long which made it hard to sleep. On 3/6/24 at 1:50 PM Resident 10 stated she/he got cold at night and used an electric blanket to warm up. Resident 10 stated when she/he got cold, her/his bones ache and hurt. On 3/5/24 Staff 8 provided temperature logs from 12/1/23 through 3/1/24. The temperature logs were completed weekly and seven resident rooms were audited for temperature levels, each week. Temperature readings ranged from a low of 67 F to a high of 90 F. On 3/5/24 at 1:06 PM and 3/6/24 at 8:06 AM Staff 8 assessed temperatures of various areas of the facility including common areas such as the dining room, hallways, around the nurses station and multiple residents' rooms. Temperature readings ranged from a low of 66 F to a high of 87 F. On 3/5/24 at 12:26 PM Staff 8 reported in 10/2023, he noted the pilot light for the heater was not working correctly so he contacted a service company. On 10/24/23, the service company partially completed the necessary repairs but additional repairs were still needed. Staff 8 stated, to date, the additional repairs had not been completed. Staff 8 reported there were other parts of the heating system that broke and were serviced in 1/2024 and 2/2024. Staff 8 stated Resident 247 complained about cold temperatures and a draft in her/his room so he covered the room window with plastic and Resident 247 was provided an electric blanket. Staff 8 stated Resident 247 was moved to another room. Staff 8 reported some of the residents' rooms were colder and some were warmer because there was no way to regulate temperatures in the residents' rooms because the heating system was so old. Staff 8 stated he attempted to keep temperatures between 68 F and 75 F. On 3/7/24 at 10:24 AM and 11:57 AM Staff 1 (Administrator) stated temperature issues in the facility related to the heating system were identified in 11/2023. Staff 1 stated he created a PIP (Performance Improvement Plan (a means of measuring a process or procedure then modifying the process or procedure to increase effectiveness)) to address temperature concerns. Staff 1 stated the PIP was ongoing but they had not been completing daily resident audits to ensure residents were warm and the facility was meeting the residents' comfort needs, as outlined in the PIP. Staff 1 stated the facility bought hats, extra blankets, a blanket warmer, moved residents to different rooms and encouraged residents to wear extra clothing, sit in warmer areas of the facility or leave their room doors open for warmth. For rooms that were too hot, the facility provided fans and encouraged the residents to open their room windows to cool their rooms down. Staff 1 stated the heating system was kind of but not really fixed and they continued to wait on parts. Staff 1 reported he was surprised at the number of residents that complained about the temperatures but they had not formally checked in with the residents for awhile. Staff 1 stated his goal was to maintain temperatures at a comfortable level for the residents. 43690 2. Observations of the facility's general environment from 3/4/24 through 3/7/24 identified the following issues: -End cap on the lower wall guard next to the fish tank was broken with sharp and jagged edges. -End cap on the lower wall guard outside the storage room on the south hall was broken with sharp and jagged edges. -End cap on the lower wall guard to the right of the nurses station was broken with sharp and jagged edges. -End cap on the lower wall in the entryway was broken and cracked. On 3/7/24 at 10:15 AM Staff 1 (Administrator) and Staff 8 (Maintenance Director) acknowledged the identified concerns needed to be repaired. 47000 3. On 3/4/24 at 10:19 AM two large patches of dry wall mud (used for repairing cracks and holes in existing drywall and plaster surfaces) were observed on the wall behind Resident 20's bed. Multiple gouges were observed on the resident's wooden baseboard along the wall to the right of the resident's bed which revealed jagged sections in the baseboard. With the assistance of Witness 1 (Interpreter), Resident 20 stated the condition of her/his walls and baseboard had been this way for quite some time, their condition bothered her/him and she/he wanted them repaired. On 3/7/24 at 10:16 AM Staff 1 (Administrator), Staff 8 (Maintenance Director) and Staff 19 (Administrator-in-Training) were present for an interview and facility walk-through. Staff 8 stated staff were expected to add any maintenance concerns to the facility's electronic maintenance system so he could follow up and complete the repairs. Staff 8 stated he was also in resident rooms at least weekly or monthly looking for issues. Staff 1 stated when the facility had resident beds available, he tried to do bed management and move residents around so rooms could be painted and repaired. Staff 1 stated Resident 20's room had not been empty in a long time and was in need of repair. On 3/7/24 at 10:29 AM Staff 1, Staff 8 and Staff 19 observed Resident 20's room. Staff 8 stated he was not aware the resident's baseboards were in need of repair and that he mudded the wall above Resident 20's bed approximately two-to-three months ago but had not been able to return to sand and paint the wall. 4. On 3/4/24 at 10:56 AM light spills were observed on the wall as well as scratches and gouges to the wooden baseboard behind Resident 9's bed. On 3/7/24 at 10:16 AM Staff 1 (Administrator), Staff 8 (Maintenance Director) and Staff 19 (Administrator-in-Training) were present for an interview and facility walk-through. Staff 8 stated staff were expected to add any maintenance concerns to the facility's electronic maintenance system so he could follow up and complete the repairs. Staff 8 stated he was also in resident rooms at least weekly or monthly looking for issues including wall damage. On 3/7/24 at 10:29 AM Staff 1, Staff 8 and Staff 19 observed Resident 9's room. Staff 8 stated he was not aware the resident's baseboards were in need of repair. Staff 8 further stated he was not aware of the condition of Resident 9's wall and acknowledged it needed to be cleaned. 5. On 3/4/24 at 12:37 PM large scrapes were observed on the wall next to Resident 14's recliner. On 3/7/24 at 10:16 AM Staff 1 (Administrator), Staff 8 (Maintenance Director) and Staff 19 (Administrator-in-Training) were present for an interview and facility walk-through. Staff 8 stated staff were expected to add any maintenance concerns to the facility's electronic maintenance system so he could follow up and complete the repairs. Staff 8 stated he was also in resident rooms at least weekly or monthly looking for issues including wall damage. On 3/7/24 at 10:29 AM Staff 1, Staff 8 and Staff 19 observed Resident 14's room. Staff 8 stated he was not aware the resident's wall was damaged and acknowledged it was in need of repair.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 2 sampled residents (#'s 12 and 97) reviewed for resident-to-resident abuse. This placed residents at risk for abuse. Findings include: Resident 12 was admitted to the facility in 8/2019 with diagnoses including dementia with behaviors. Resident 12's 12/31/23 Quarterly MDS indicated a BIMS score of two (severe cognitive impairment) and no behaviors demonstrated. Resident 97 was admitted to the facility in 5/2023 with diagnoses including dementia with mild agitation. Resident 97's 10/23/23 Significant Change of Condition MDS indicated a BIMS score of two (severe cognitive impairment) and yelling behaviors. On 9/30/23 the facility submitted a FRI which indicated Resident 12 hit Resident 97. On 3/5/24 at 11:00 AM Staff 15 (CNA) stated she went to get Resident 12 a sweater and overheard Resident 97 yelling, which was a normal behavior. When she returned, Resident 12 had self-propelled herself/himself over to Resident 97, near the nursing station. Staff 15 witnessed Resident 12 hit Resident 97 on the arm and she separated and redirected the residents. On 3/7/24 at 11:22 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the 9/30/23 incident between Resident 12 and Resident 97.

Based on interview and record review the facility failed to provide the required written notice of a bed hold policy before or upon transfer to the hospital for 1 of 3 residents (#8) reviewed for hospitalization . This placed residents at risk to be uninformed of their rights. Findings include: A facility bed hold policy last reviewed 3/2019 indicated the resident and/or resident representative will be informed of this policy in writing upon admission, transfer or leave of absence. If unable to provide at the time of transfer or leave of absence, the policy will be provided within 24 hours. Resident 8 readmitted to the facility in 1/2024 with a diagnosis of paraplegia (loss of control of motor function). A 1/6/24 progress note indicated Resident 8 was discharged to the hospital for a medical condition. A 1/8/24 progress note indicated Resident 8 was readmitted to the facility. Record review completed on 3/5/24 revealed Resident 8 and her/his family were not provided with a written bed hold policy or a bed hold agreement when Resident 8 discharged to the hospital on 1/6/24 or within 24 hours. Further record review also revealed Resident 8 and her/his family did not receive the facility's bed hold policy and did not sign a bed hold agreement upon admission. On 3/6/24 at 11:15 AM Staff 6 (Social Services Director) confirmed she did not provide a written bed hold agreement or discuss holding Resident 8's bed with her/his family when Resident 8 discharged to the hospital. Staff 6 confirmed there was no record a bed hold policy or agreement was provided to Resident 8 or her/his family upon admission.

Based on observation, interview and record review it was determined the facility failed to accurately assess 3 of 7 sampled residents (#s 6, 20 and 297) reviewed for unnecessary medications and accidents. This placed residents at risk for unassessed needs. Findings include: 1. Resident 6 admitted to the facility in 2015 with diagnoses including mood disorder. A 6/5/21 physician order indicated Resident 6 received Seroquel (antipsychotic) BID for bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Resident 6's 12/2023 MAR revealed she/he was administered Seroquel from 12/1/23 through 12/31/23. The 12/31/23 Annual MDS indicated the resident did not receive Seroquel during the MDS look back period from 12/24/23 through 12/31/23. On 3/5/24 at 3:14 PM Staff 2 (DNS) acknowledged Resident 6's MDS was inaccurate. 43690 2. Resident 297 was admitted to the facility in 12/2018 with diagnoses including diabetes and osteoporosis (disease that causes bones to become weak). On 11/26/23 a Fall Investigation revealed the resident had an unwitnessed fall in her/his room which resulted in the resident having a fractured nose. The 12/17/23 Annual MDS indicated Resident 297 had two or more non-injury falls since admission. On 3/6/24 at 10:20 AM Staff 4 (RNCM) stated she was responsible for completing Resident 297's Annual MDS related to falls. Staff 4 confirmed Resident 297 had a fall with injury and the 12/17/23 Annual MDS was inaccurate. On 3/7/24 at 9:45 AM Staff 2 (DNS) acknowledged Resident 297's MDS was inaccurate for falls. 47000 3. Resident 20 was admitted to the facility in 7/2019 with diagnoses including left-sided hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness). Resident 20's Left Arm and Leg Pain Care Plan, initiated 7/18/19, indicated the resident had a left hand contracture. Resident 20's 7/9/23 Annual MDS indicated the resident had upper extremity impairment on one side, needed or wanted an interpreter to communicate with health care staff and the resident's preferred language was Chinese. Resident 20's 10/8/23 and 1/7/24 Quarterly MDS Assessments indicated the resident did not have an upper extremity impairment. On 3/4/24 at 10:19 AM and 3/5/24 at 11:17 AM Resident 20 was observed in her/his room in bed. Resident 20's left elbow was tightly bent in towards her/his chest and her/his left hand rested on the top of her/his chest. The fingers of the resident's left hand were tucked into the palm of her/his hand. With assistance from Witness 1 (Interpreter), the resident demonstrated she/he could not fully straighten her/his left arm or fingers on her/his left hand. On 3/6/24 at 11:35 AM Staff 4 (RNCM) stated Resident 20 had an upper extremity impairment and the 10/8/23 and 1/7/24 Quarterly MDS Assessments were inaccurate. On 3/6/24 at 1:08 PM Staff 2 (DNS) was informed of the findings and stated Resident 20's upper extremity impairment was inaccurately assessed on her/his 10/8/23 and 1/7/24 Quarterly MDS Assessments.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#14) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity. Findings include: Resident 14 was admitted to the facility in 3/2020 with diagnoses including dementia. Observations from 3/4/24 through 3/6/24 between the hours of 8:00 AM and 4:00 PM revealed Resident 14 had numerous hairs, up to approximately 1.5 inches long, on the lower portion of her/his chin. Resident 14's 12/24/23 Quarterly MDS indicated the resident had moderate cognitive impairment and required the substantial to maximal assistance of one staff for personal hygiene care which included shaving. Resident 14's 3/2024 Care Plan revealed the resident required the assistance of one staff with hair, make-up and shaving. On 3/4/24 at 12:26 PM Resident 14 stated she/he did not like hair on her/his chin and wanted the hair removed. On 3/5/24 at 2:34 PM Staff 14 (CNA) stated she was frequently assigned Resident 14 and never shaved the resident's chin hair. On 3/5/24 at 2:43 PM Staff 20 (CNA) reported she did not shave Resident 14's chin hair because she did not know how. Staff 20 stated she did not ask Resident 14 if she/he wanted her/his chin hair removed because I would not point that out. On 3/6/24 at 10:16 AM Staff 3 (RNCM) confirmed Resident 14 had long chin hairs present. Resident 14 told Staff 3 she/he wanted her/his chin hair removed. On 3/7/24 at 8:24 AM Staff 2 (DNS) stated she expected staff to shave Resident 14's chin hairs if the resident wanted them removed.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 3 sampled residents (#9) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: Resident 9 was readmitted to the facility in 9/2023 with diagnoses including dementia. Resident 9's 12/12/23 Activity Assessment indicated the resident's favorite activities included exercise groups, socials and performers. Resident 9's 12/30/23 Annual MDS revealed the resident was severely cognitively impaired. The MDS Staff Assessment of Daily and Activity Preferences indicated the following activities were important to Resident 9: -Listening to music; -Doing things with groups of people; -Participating in favorite activities; and -Participating in religious activities or practices. Resident 9's 2/22/23 Care Plan revealed the following related to the resident's activity goals and interventions: -The resident was to receive one-to-one visits from staff two-to-three times per week for sensory stimulation. -The resident previously spoke Chinese, was non verbal at this time and was hard of hearing. Staff must write in Chinese to communicate. -The resident enjoyed watching television and reading Chinese newspapers and books. -Ensure adaptive equipment was provided, including paper and pen. -Invite the resident to scheduled activities. -The resident needed assistance/escort to activity functions. -The resident was to be up in her/his wheelchair daily and offered daily activities. Resident 9's 2/6/24 through 3/5/24 Activity Daily #1 and #2 Task Records revealed the resident participated in an independent activity on a daily basis, participated in music/singing on 2/17/24 and 2/22/24, participated in a special event on 2/23/24 and refused an activity on 3/5/24. Resident 9's 2/7/24 through 3/5/24 Activity Task Record revealed the resident received regular one-to-one visits which consisted of socializing/conversing. The facility's 3/2024 Activity Calendar revealed the following scheduled activities: -3/4/24: 9:45 AM Exercise 10:30 AM Playdough 3:30 PM Bingo 6:15 PM News -3/5/24: 9:45 AM Exercise 10:00 AM Youtube Videos 3:30 PM Crafts 6:15 PM Dice No evidence was found in Resident 9's clinical record to indicate the resident participated in her/his identified favorite and preferred activities of exercise and religious activities/practices from 2/6/24 through 3/5/24 or that the resident refused activities outside of the single instance on 3/5/24. Resident 9's clinical record identified socials and doing things with groups of people as important to the resident. Resident 9's clinical record indicated she/he participated in a group activity on three occasions from 2/6/24 through 3/5/24. Observations of Resident 9 conducted on 3/4/24 and 3/5/24 between 8:38 AM to 3:43 PM revealed the resident to be in her/his room either in bed or in her/his wheelchair with the television on. No paper, pens or Chinese newspapers or books were observed in the resident's room. On 3/5/24 at 9:57 AM Resident 9 was observed in her/his wheelchair in her/his room. The resident opened her/his eyes in response to the surveyor greeting. The facility's exercise group occurred at this time in the dining room. On 3/6/24 at 9:20 AM Staff 16 (CNA) stated Resident 9 enjoyed being involved and social. Staff 16 stated the resident enjoyed being out of her/his room and being around people or sitting by the window near the front entrance. Staff 16 stated the resident did not actively participate in activities, including exercise, but she/he still liked to watch. Staff 16 stated Resident 9 did not read newspapers or books and she communicated with her/him by talking, not by writing. On 3/6/24 at 9:27 AM Staff 17 (CNA) stated it had been a little while since [Resident 9] had been at a group activity and she noticed a decline in the resident's out-of-room activity participation when the resident received a feeding tube. Staff 17 stated she had never seen the resident read either newspapers or books, use writing and reading to communicate or have music on in her/his room. On 3/6/24 at 12:31 PM Staff 18 (Life Enrichment Assistant) stated Resident 9 enjoyed card games, music, socials and group activities. Staff 18 stated it had been a long time since they wrote on paper to communicate with the resident and she/he no longer read the newspaper or books. Staff 18 stated the resident did not go to exercise group often and it had been a while since she/he last attended the facility's church service. Staff 18 stated she completed one-to-one visits with Resident 9 one-to-two times per week which consisted of her asking the resident how she/he was doing, if she/he felt better or if she/he needed help. Staff 18 stated she would sometimes bring music to these visits but had never attempted additional sensory activities with Resident 9 during these visits outside of talking and music, on occasion. Staff 18 further stated she recorded the resident as participating in an independent activity any time she saw the resident in her/his room with her/his eyes opened and the television on. On 3/6/24 at 2:41 PM Staff 1 (Administrator) and Staff 19 (Administrator-in-Training) acknowledged the findings of this investigation. Staff 1 stated he expected Resident 9 to receive different types of sensory activities outside of those that were verbal and Resident 9's care plan was in need of revision.

Based on observation, interview and record review it was determined the facility failed to prepare and handle food in a sanitary manner in 1 of 1 kitchen reviewed for food service. This placed residents at risk for foodborne illness. Findings include: On 12/1/22 at 11:14 AM Staff 18 (Dietary Aide) walked out of the kitchen and into the hallway while wearing gloves. Staff 18 unlocked a food storage door, retrieved a beverage cart, and returned to the kitchen without performing hand hygiene or changing her gloves. Staff 18 proceeded to the back of the kitchen to the sink/dishwasher area and wiped down the countertops then walked towards the front of the kitchen and began handling clean coffee cups to prepare drinks for lunch. On 12/1/22 from 11:44 AM through 12:18 PM, the following observations of the resident lunch tray service were made: - Staff 19 (Cook) used her gloved hand and grabbed noodles from one bowl to add to another bowl then added beef soup to both bowls after having touched various other surfaces and utensils with the same gloves. -After completing hand hygiene, Staff 19 (Cook) dried her hands with paper towels and placed her used paper towels on the stove top next to the clean plates and scoops. -Staff 20 (Dietary Aide) and Staff 21 (Cook) placed their fingers in the inner surface of bowls prior to placing them on the food tray after touching other potentially unclean surfaces. On 12/5/22 at 10:20 AM Staff 3 (Dietary Manager) confirmed he was made aware of the concerns and was already planning staff training.

Based on observation, interview and record review it was determined the facility failed to develop and follow practices to sanitarily transport, store and handle laundry for 1 of 1 laundry cart and 1 of 1 laundry room reviewed for infection control. This placed residents at risk for receiving contaminated laundry and infection. Findings include. 1. On 11/29/22 12:06 PM Staff 7 (Laundry) was observed delivering clean resident laundry using a small uncovered metal cart. On 11/30/22 and 12/1/22 between 8:45 AM and 9:03 AM Staff 7 was observed delivering clean resident laundry using a plastic cart with shelving. The cart had a cover; however, one side remained open and uncovered for the duration of laundry delivery. Staff 7 was observed to leave the laundry cart parked in a resident hallway with the uncovered side of the cart open to the hallway. On 12/1/22 at 10:31 AM Staff 7 stated she never used the small metal cart without a cover to deliver resident laundry. She stated she was unaware she needed to use the covers on the clean laundry cart during the transportation and delivery of clean laundry. On 12/2/22 at 12:25 PM Staff 1 (Administrator) was informed of these findings. He did not express any concerns about resident laundry being delivered uncovered and provided no additional information. 2. On 12/1/22 at 10:31 AM observations of the facility's laundry room revealed a small metal cart used to move laundered linen from the washing machine to the dryer placed in the soiled utility room of the laundry area directly next to the sink used to rinse overly soiled linen. On 12/1/22 at 10:31 AM Staff 7 (Laundry) was asked about the use and location of the small metal cart. At this time, Staff 7 moved the small metal cart from the soiled utility room of the laundry area and positioned it next to the washing machines in the clean portion of the laundry area and loaded it with freshly washed laundry from the washing machine without cleaning the cart. She stated the cart should never be left in the soiled portion of the laundry area but nursing staff had access to the laundry room and moved items around. On 12/2/22 at 12:25 PM Staff 1 (Administrator) was informed of these findings. He stated he was unaware of any issues related to laundry and no additional information was provided. 3. The facility's 12/2021 Soiled Laundry and Bedding Policy and Procedure specified the following procedure when handling and transporting laundry: *Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. *Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items. *Anyone who handles soiled laundry wears protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely). *Environmental services and nursing staff will place and transport contaminated laundry that is wet enough to potentially leak or soak through the bag or container in double bags or leak-proof bags or containers. CNA interviews regarding the process for handling overly soiled resident laundry revealed the following: *On 12/1/22 at 11:26 AM Staff 9 (CNA) stated she wiped resident bowel movements off of resident clothing using incontinence wipes in the resident room. She stated she placed the wiped off clothing in a plastic bag and placed the plastic bag containing the contaminated linen in the bin in the soiled utility room. She stated she never used the sink in the soiled utility room to rinse overly soiled resident clothing. *On 12/1/22 at 11:42 AM Staff 8 (CNA) stated she cleaned overly soiled laundry in the sink in the soiled utility room wearing only gloves and a mask. *On 12/1/22 at 3:49 PM Staff 10 (CNA) stated he rinsed bowel movements out of resident clothing in the soiled utility room and then put the rinsed clothing in the resident's mesh laundry bag located on a hook inside of each resident's closet. He stated he placed these laundry bags in the bin in the soiled area of the facility's laundry room at the end of his shift. He stated he never wore any personal protective equipment when rinsing overly soiled linen outside of gloves and a mask. *On 12/2/22 at 4:04 PM Staff 11 (CNA) stated she washed resident laundry containing bowel movements in the resident's personal sink. Once rinsed, she stated she placed the laundry in the resident's mesh laundry bag located on the hook inside of each resident's closet and placed the laundry bag into the bin in the soiled utility room. On 12/2/22 at 12:25 PM Staff 1 (Administrator) was informed of these findings. He stated he was unaware of any issues related to laundry and no additional information was provided.

Based on observation, interview and record review it was determined the facility failed to update a care plan to reflect changes in care needs for 2 of 3 sampled residents (#s 24 and 40) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: 1. Resident 24 was admitted to the facility in 2019 and readmitted in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 24's 10/6/19 care plan included interventions to apply a left foot boot while in bed and apply a left arm sling. An intervention was added to apply a left palm protector on 6/6/2020, and re-initiated in 7/7/2021 when the resident was readmitted from the hospital. On 11/30/22 between 12:40 PM and 3:16 PM, 12/1/22 between 8:57 AM and 3:23 PM, and 12/2/22 between 8:49 AM and 10:30 AM, Resident 24 was observed in bed without the left palm protector, left arm sling, and left foot boot. On 11/30/22 at 1:22 PM Staff 14 (CNA) stated she did not recall Resident 24 using a palm protector, left arm sling, and left foot boot. On 12/1/22 at 9:21 AM Staff 15 (CNA) stated Resident 24 did not have a palm protector, arm sling or boot. Staff 15 checked the Kardex (a brief care plan for staff providing direct care) and stated she did not place a palm protector in the resident's hand and had not seen one in the resident's room Staff 15 was unable to locate the devices in the resident's room. On 12/2/22 at 10:32 AM Staff 5 (LPN) stated the resident's care plan was updated quarterly at care conferences with the resident, family, and interdisciplinary team. Staff 5 stated each item on the care plan was reviewed at care conferences. Staff 5 stated the left palm protector, arm sling and boot were trialed during the resident's initial 2019 admission but were discontinued and were not removed from the care plan. 2. Resident 40 was admitted to the facility in 8/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 40's 7/29/22 physician's diet order indicated the resident was ordered pureed texture. Resident 40's Diet Order and Communication changed to minced and moist texture on 11/22/22. Review of Resident 40's care plan on 11/30/22 provided no information of resident's current diet texture. On 11/29/22 at 1:17 PM Witness 1 (Family) expressed concern about Resident 40's weight and stated the family requested a diet upgrade from puree texture to minced and moist diet texture in early 11/2022 to improve the resident's nutritional intake. On 12/1/22 at 9:27 AM and 12/1/22 at 2:38 PM Staff 13 (CNA) and Staff 14 (CNA) stated the resident's diet texture was pureed. On 12/1/22 at 3:20 PM Staff 17 (LPN) stated the resident's diet was minced and moist, then Staff 17 looked in the resident's health record and stated it was puree. On 12/2/22 at 1:54 PM Staff 5 (LPN) confirmed the care plan and health record was not updated.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing activities program designed to meet the individual interests and needs of residents for 1 of 4 sampled residents (#29) reviewed for activities. This placed residents at risk for diminished physical, emotional and psychosocial well-being. Findings include: Resident 29 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/18/21 Activities Initial Interview revealed Resident 29 used to go to church, read the Bible, watched some TV and wished to participate in activities. The activity participation section revealed it was unknown if the resident wanted to participate in group activities, go on outings, wanted one-to-one visits or liked independent activities. It was indicated Resident 29's activities needed to be modified to accommodate for the resident's cognitive and communication deficits and communication needed to be kept to simple yes/no questions. The 1/16/22 Annual MDS revealed Resident 29 had severe cognitive deficits and her/his preferred activities included snacks between meals, staying up past 8:00 PM, reading books/newspapers/magazines, doing things in groups of people, spending time outdoors and participating in religious activities or practices. The 7/11/22 Activity Assessment-Annual and Quarterly indicated Resident 29 attended some group activities and participated at times, the resident enjoyed reading and activity related focuses remained appropriate as per current care plan. The 10/11/22 Activity Assessment-Annual and Quarterly indicated due to a cognitive decline, Resident 29 showed little interest in doing things and spent most of her/his time sleeping. Resident 29 enjoyed holding a stuffed animal/cat. The resident interacted some during one-to-one visits and the resident used to like to read but primarily slept now. The plan indicated activity related focuses remained appropriate per the current care plan and the interventions were partially effective in attaining goals. The 10/11/22 Social Service Quarterly Assessment indicated Resident 29 had no significant change in cognition, the resident was directable by staff and staff could typically entertain the resident by providing her/him with reading materials. Resident 29's current care plan indicated the following: -Dependent for activities; -Ensure activities the resident is attending are compatible with physical and mental capabilities, compatible with known interests and preferences, adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), compatible with individual needs and abilities and age appropriate; -Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: books, although the resident does not read, having books around her/him is comfort for her/him; -Play classic jazz music from Frank Sinatra for the resident. The resident's favorite song is Blue Sky by Frank Sinatra; -Likes to read her/his Bible. Please offer it to her/him and -Offer activity apron, coloring and snacks. Resident 29's Daily Activity logs from 11/3/22 through 12/2/22 indicated the following: 11/3: exercise group; 11/9: exercise group; 11/16: exercise group; 11/22: movies; 11/29: exercise group and music and 12/2: exercise group. Resident 29's Independent Daily Activity logs from 11/3/22 through 12/2/22 indicated the resident participated in independent activities on 28 out of 30 days. Resident 29's One-to-One Activity log from 11/3/22 through 12/2/22 indicated the resident had no one-to-one visits prior to 12/2/22. Observations of Resident 29's activities included the following: -11/30/22 at 12:28 PM Resident 29 was sitting at the nursing station staring ahead. The resident did not have a stuffed animal/cat, books around her/him, her/his Bible or coloring materials. No residents or staff were interacting with Resident 29. -11/30/22 at 12:50 PM, 2:27 PM and 3:35 PM Resident 29 was in bed with her/his TV on and the volume was inaudible. Resident 29 did not have music playing, a stuffed animal/cat or books around her/him. There was no Bible available. -12/1/22 at 8:38 AM and 8:57 AM Resident 29 was dressed and sitting at the nursing station with her/his eyes intermittently closed and other times looking around. At one point, Resident 29 was holding her/his head in her/his hands, slouched forward. The resident did not have a stuffed animal/cat, books around her/him, her/his Bible or coloring materials. No residents or staff were interacting with Resident 29. -12/1/22 at 9:07 AM Resident 29 was taken to the Vietnamese church group by a staff member. On the way to the activity, Resident 29 asked the staff member if she/he could go outside and the staff member responded no and placed the resident in the Vietnamese church activity. At 9:26 AM the resident remained in the Vietnamese church activity with the activity being conducted in Vietnamese (Resident 29 spoke English). Resident 29 was slouched over. -12/1/22 at 10:44 AM Resident 29 was observed in a fingernail grooming activity group leaning on her/his right hand with her/his eyes closed, positioned in the group. The staff member was painting a different resident's nails while speaking Chinese. -12/1/22 at 3:55 PM Resident 29 was sitting in the hallway at the nursing station. The resident did not have a stuffed animal/cat, books around her/him, her/his Bible or coloring materials. No residents or staff were interacting with Resident 29. -12/2/22 at 8:30 AM and 9:25 AM Resident 29 was dressed and sitting at the nursing station. Resident 29 was alert and talking to herself/himself. Resident 29 did not have a stuffed animal/cat, books around her/him, her/his Bible or coloring materials. No residents or staff were interacting with the resident. -12/2/22 10:34 AM Resident 29 was in a badminton group. Staff 4 (Activities Director) batted a balloon at Resident 29 and the resident made no attempt to respond to the balloon coming directly towards her/him. -12/2/22 at 2:08 PM Resident 29 was in bed with her/his TV on and the volume was inaudible. Resident 29 did not have music playing, a stuffed animal/cat or books around her/him. No Bible was available. On 12/1/22 at 9:34 AM Staff 12 (CNA) reported Resident 29 liked to drink tea, liked the facility's interactive toy cat, coloring, someone sitting next to her/him and talking, enjoyed music, singing and getting her/his nails done. Staff 12 stated Resident 29 was unable to complete independent activities and required assistance for everything. She stated Resident 29 used to enjoy reading, especially the Bible but the resident could no longer read. Staff 12 stated Resident 29 went to exercise groups but usually did not participate. On 12/1/22 at 11:08 AM Staff 13 (CNA) reported Resident 29 enjoyed reading especially large printed materials such as signs around the facility. Staff 13 stated Resident 29 liked to interact with the facility's interactive toy cat. Staff 13 stated Resident 29 was not able to complete independent activities and rarely participated when in the exercise group. Staff 13 stated she did not observe Resident 29 interacting with the TV. On 12/2/22 at 8:50 AM Staff 4 (Activities Director) stated with dementia residents she made activities more simple like relaxing touch and massage, music and sensory activities such as putting fragrant lotion on resident's hands. Staff 4 stated music was powerful with the dementia population and she offered music in the resident's rooms and in groups. Staff 4 stated Resident 29 enjoyed music, eating, one-on-ones and the facility's interactive toy cat. Staff 4 stated Resident 29 used to read but Resident 29's reading skills had declined over the past month. She stated Resident 29 was dependent for activities and unable to complete independent activities. Staff 4 reviewed Resident 29's activity logs and confirmed the majority of the activities documented were independent activities (which the resident was incapable of performing) and no one-to-one activities were completed in the past 30 days. Staff 4 stated she was unsure if music played in the resident's room and Resident 29 used to have books in her/his room but was not sure what happened to them. Staff 4 reported Resident 29 did not watch the TV when it was on in her/his room. Staff 4 stated it was not appropriate to have Resident 29 in the Vietnamese church group and she was unsure why the resident was brought to that activity.

Based on interview and record review it was determined the facility failed to provide timely laboratory services for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed resident at risk for delayed treatment. Findings include: Resident 24 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Note to Attending Physician/Prescriber dated 2/25/22 identified the need for a [MEDICATION(S)] (an anti-convulsant) level at the next convenient blood draw day per CMS regulatory compliance. On 2/28/22 Staff 22 (Nurse Practitioner) checked Agree and wrote will check [MEDICATION(S)] ([MEDICATION(S)]) at next blood draw. A review of Resident 24's health record revealed the resident had blood draws for basic metabolic panels on 9/17/22 and 10/14/22. The resident's [MEDICATION(S)] level blood draw was not completed until 11/9/22, which was over eight months after the pharmacy recommendation was made. On 12/2/22 at 10:28 AM Staff 5 (LPN) stated to minimize discomfort, when a non-urgent lab was ordered, it was added to the next scheduled routine blood draw. Staff 5 acknowledged the resident had routine labs drawn in 9/2022 and 10/2022. Staff 5 confirmed Resident 24's [MEDICATION(S)] level lab was not drawn until 11/2022. On 12/05/22 at 10:02 AM Staff 2 (DNS) confirmed facility's policy of combining non-urgent lab draws with the next routine blood draw. Provided no additional information.

Based on observation, interview and record review it was determined the facility failed to store food, prepare food, and follow sanitizing protocol in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for food services. This placed residents at risk for foodborne illness. Findings include: 1. During a tour of the kitchen with Staff 2 (Dietary Manager) on [DATE] at 9:18 AM the following items were observed in the refrigerator and dry storage area: - A plate of cooked food, undated. - A container of salted black beans, undated. - Browning sauce, opened in 2018, expired in 2019. - Red wine vinegar, opened in 2018, expired in 2019. - Yellow food coloring, opened in 2019. Staff 2 indicated the identified items were old and discarded the items. 2. During a tour of the kitchen on [DATE] at 10:51 AM frozen raw chicken was observed in the kitchen sink with water running over it. Two uncovered containers of chemical sanitizer with rags were observed in the same sink adjacent to the raw chicken. On [DATE] at 11:36 AM Staff 2 acknowledged chemical sanitizer was not to be stored in the same sink with food as it presented a risk for cross contamination. 3. During a tour of the kitchen on [DATE] at 10:51 AM a ,d+[DATE] chlorine sanitizer concentration log for the dishwasher was observed posted next to the dishwasher. The log indicated measurements of ,d+[DATE] parts per million were recorded three times per day. The container of test strips indicated increments of 50 from 0 to 200. The form indicated parts per million was to be between 50 and 100, and to inform the dietary manager if it was outside that range. On [DATE] at 10:51 AM Staff 2 was asked what the documentation of ,d+[DATE] represented and he said he did not know. Staff 2 was asked to test the sanitizer concentration and he determined the concentration was between 100 and 200. Staff 2 acknowledged there was no way to obtain a measurement of ,d+[DATE] from the test strips and staff did not monitor the sanitizer concentration appropriately.

Based on observation, interview and record review, the facility failed to provide care and services to ensure residents were free from physical abuse for 2 of 3 sampled residents (#s 4 and 5). This placed residents at risk for abuse by another resident. Findings include: The facility abuse policy, Abuse screening, training, identification, investigation, reporting and protection-Oregon revised 2/2019, revealed it was the facility's policy to identify types of abuse, investigate and report allegations of abuse and protect residents from abuse. 1.Resident 3 admitted to the facility in 5/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3's Annual MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. Resident 5 admitted to the facility in 1/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5's Annual MDS dated ,d+[DATE] had no BIMS score as the resident was unable to answer questions and was rarely/never understood. A Nursing Facility Reported Incident Form was submitted to the State Agency on 9/19/20 and reported the following: On 9/19/20, Resident 3 was in the hallway outside her/his room and saw Resident 5 approach Resident 3's doorway. Resident 3 became upset, walked to Resident 5 and struck her/him in the face. Resident 3 advised Staff 11 (Charge Nurse) she/he did not want Resident 5 blocking the door which was why she/he struck Resident 5. A 9/19/20 SNF Root Cause - Resident to Resident form revealed Resident 3 was in her/his wheelchair in the hallway. Staff 5 (CMA) saw Resident 3 approach Resident 5 with her/his fist raised and ran toward the residents to intervene but was unable to reach the residents in time. Resident 5 was unable to move her/his wheelchair out of Resident 3's way due to the progression of her/his disease. Resident 5 was interviewed via translator and indicated pain to her/his left cheek, which was red where she/he was struck. Resident 3 initiated the contact and contributing factors were disease, behavioral changes which included physically abusive behaviors. Resident 3's care plan revised in 11/2019 revealed she/he was monitored after attempting to touch her/his spouse while in the spouse's room. Resident 3's spouse was uncomfortable with the attempted contact and inteventions were put in place. Resident 3's behavior monitor was revised on 4/7/20 due to behaviors which included attempting to touch other residents, verbal and physical aggression toward staff and others. Resident 5's care plan revised 9/23/20 revealed she/he had mobility issues related to [CONDITION(S)], was at risk for injury related to anticoagulant therapy and had a psychosocial well being problem related to being hit by Resident 3. The care plan noted Resident 5 was upset as a result of the incident on 9/19/20. Progress notes reviewed from 9/1/20 through 9/30/20 revealed on 9/3/20, Resident 3's behavior monitor was updated due to a display of threatening behaviors. On 9/19/20, Resident 5 was struck by Resident 3. Resident 5 pointed to her/his left cheek to indicate where she/he was struck and reported pain. Staff 11 spoke to Resident 3, telling her/him it was inappropriate to hit other residents but she/he continued yelling it was necessary because Resident 5 had blocked her/his doorway. Resident 5's progress notes revealed there was no psychosocial harm as a result of the incident. On 8/2/21 at 11:28 AM, Staff 4 (RCM) stated Resident 5 was placed in front of Resident 3's room where she/he was struck. Staff 5 saw Resident 3 approaching Resident 5 in a threatening manner but could not get to the resident in time. Staff 4 acknowleged there was a behavior monitoring note added to the care plan on 9/3/20 due to Resident 3's threatening behavior. On 8/2/21 at 3:20 PM, Staff 5 (CMA) stated he observed Resident 3 hit Resident 5 in the face on 9/19/20. Staff 5 attempted to intervene, ran to the residents but was unable to intervene on time. On 8/6/21 at 11:28 AM, Staff 11 stated she was the unit charge nurse on 9/19/20. Staff 11 revealed Resident 3 had dementia and often had angry outbursts. Resident 5 was non verbal but mumbled and this possibly irritated Resident 3, who hit Resident 5 in the face. Staff 11 recalled being told by staff in 2019 Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/9/21 at 12:42 PM, Staff 2 (DNS) stated Resident 3 was care planned for the loss of her/his spouse in 9/2020. Staff 2 stated the resident only had minor behaviors up to that point and was not aggressive toward residents or staff. On 8/10/21 at 2:00 PM, Staff 2 confirmed it was an expectation of the facility for residents to be free from abuse. On 8/10/21 at 2:00 PM, Staff 1 (Administrator) confirmed it was an expectation of the facility for residents to be free from abuse. 2. Resident 3 admitted to the facility in 5/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3's Annual MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. Resident 4 was admitted to the facility on ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4's Annual MDS dated [DATE] had no BIMS score as the resident was unable to answer questions and was rarely/never understood. A Nursing Facility Reported Incident Form was submitted to the State Agency on 9/8/20 and reported the following: On 9/5/20, Resident 4 was yelling in her/his native language while lying in bed. Resident 3 became upset by the yelling, walked to Resident 4's bed and struck her/him on the arm. Staff 6 was in the room, witnessed the abuse and separated the residents. Resident 4 was moved to a new room. A 9/5/20 SNF Root Cause - Resident to Resident form revealed Resident 3 told staff she/he hit Resident 4 because she/he was noisy. Resident 3 initiated the contact. The contributing factors were disease, behavioral changes which included physically abusive behaviors and a history of aggression. Resident 3's care plan revised in 11/2019 revealed she/he was monitored after attempting to touch her/his spouse while in the spouse's room. Resident 3's spouse was uncomfortable with the attempted contact and inteventions were put in place. Resident 3's behavior monitor was revised on 4/7/20 due to behaviors which included attempting to touch other residents, verbal and physical aggression toward staff and others. Resident 4's 7/25/20 care plan revealed she/he was on a behavior monitor which included physically striking others, screaming and using offensive language in her/his native language, which Resident 3 understood. Progress notes reviewed from 4/2019 through 12/2020 revealed Resident 3 pushed another resident on 4/6/19, causing the other resident to fall forward and bump her/his head on the door. This resulted in the other resident sustaining an injury to her/his head. A 9/3/20 progress note revealed the resident's behavior monitor was updated due to a display of threatening behavior. A 9/5/20 progress note revealed Staff 6 (CNA) witnessed Resident 3 walk to Resident 4's bed and strike her/him on the arm due to Resident 4 being noisy. On 8/4/21 at 11:28 AM, Staff 4 (RCM) stated Resident 3 was not physically abusive and never tried to hit anyone prior to the 9/5/20 resident to resident altercation. Staff 4 acknowledged there was a behavior monitoring note added to the care plan on 9/3/20 due to the resident's threatening behavior. On 8/4/21 at 11:28 AM, Staff 2 (DNS) stated Resident 3 hit Resident 4 in their room due to Resident 4 cursing. Staff 2 stated all interventions were in place when the altercation occurred. On 8/4/21 at 11:53 AM, Staff 9 (CNA) stated Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 9 revealed Resident 3 was physically aggressive toward staff prior to 9/5/20. On 8/4/21 at 12:20 PM, Staff 8 (CNA) stated Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 8 reported she witnessed the resident grab other residents' chest area without their consent and said this occurred more than once prior to 9/5/20. On 8/4/21 at 4:25 PM, Staff 6 (CNA) stated she could not recall the incident. On 8/6/21 at 1:18 PM, Staff 10 (CNA) stated she was struck by Resident 3 in 2019 when attempting to change her/his incontinence brief. On 8/10/21 at 2:00 PM, Staff 2 confirmed it was an expectation of the facility for residents to be free from abuse. On 8/10/21 at 2:00 PM, Staff 1 (Administrator) confirmed it was an expectation of the facility for residents to be free from abuse.

Based on interview and record review it was determined the facility failed to ensure allegations of abuse or neglect were reported to the state agency within mandated timelines for 1 of 3 sampled residents (#4) reviewed for abuse. This placed residents at increased risk for abuse. Findings include: Resident 4 was admitted to the facility in 2/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility abuse policy, Abuse screening, training, identification, investigation, reporting and protection-Oregon revised 2/2019, revealed it was the facility's policy to identify types of abuse, investigate and report allegations of abuse and protect residents from abuse. Facility staff mandated to immediately report the abuse were identified as the Facility Administrator, Director of Nursing or Charge Nurse. A Nursing Facility Reported Incident Form was submitted to the State Agency on 9/8/20 at 4:37 PM and reported the following: On 9/5/20, Resident 4 was yelling in her/his native language while lying in bed. Resident 3 became upset by the yelling, walked to Resident 4's bed and struck her/him on the arm. Staff 6 was in the room, witnessed the abuse and separated the residents. On 8/11/21 at 2:00 PM, Staff 2 (DNS) was unable to recall why the abuse was not reported within the mandated timelines. On 8/11/21 at 2:00 PM, Staff 1 (Administrator) was unable to recall why the abuse was not reported within the mandated timelines.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and infections. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. The facility failed to follow manufacturer's instructions for HDQC2 cleaning/disinfecting solution used for high-touch items in 1 of 1 resident (R) (R4) rooms observed by Housekeeper (HK)1 . HK1 cleaned all 27 rooms in the facility for residents who were not on transmission-based precautions. This failure increased the risk for the spread of infection and its associated discomfort and decline in physical condition. Findings include: Observation on 12/8/20 at about 11:20 AM showed Housekeeper (HK)1 enter Resident (R)4's room. R4 sat on bed and stated that she was cold. HK1 bagged trash, placed new trash bag, picked up green microfiber cloth towel from bucket of liquid solution, squeezed liquid from cloth and wiped room, bathroom, and closet door knobs and sink. HK then cleaned bathroom toilet. With another green cloth placed in solution, HK1 squeezed cloth of liquid and wiped overbed table, ipad, bedside table, and dresser handles with cloth. HK1 repeated steps with new cloth and wiped walker handles, seat and frame, window sill, tv remote control, bed control, chair arm and back, wall mounted safety bars, call light and infusion pump and pole. Each item was wiped quickly and then HK1 wiped next item. Wall mounted safety bars was touched about 40 seconds after HK1 wiped bars and it was wet. Wall mounted safety bars was touched about 60 seconds after HK1 wiped bars and it was dry. During an interview on 12/8/20 at about 11:25 AM HK1 stated that the liquid solution that she used to clean items in resident rooms with green cloth was Q2 and items in room are wiped because they kill bacteria. When asked how long items wiped needed to stay wet, HK1 stated 2 minutes. Observation on 12/8/20 at 11:30 AM in housekeeping closet HK1 showed surveyor Q2 solution. Container showed product label as HDQC2 Clean on the Go cleaner/disinfectant/detergent/fungicide against pathogenic fungi/deodorizer/virucidal activity. The label showed to disinfect inanimate hard non-porous surfaces, add 2 ounces of HDQC2 per gallon of water. Apply solution with a mop, cloth, sponge, hand pump trigger spray to wet all surfaces thoroughly, allow to remain wet for 10 minutes, then remove excess liquid. The EPA registration number shown for HDQC2 was 1839-169. During an interview on 12/8/20 at 11:54 AM HK1 stated that items wiped with Q2 stayed wet for about 2 to 3 minutes. HK1 stated that items did not remain wet for 10 minutes. During an interview on 12/8/20 at 1:10 PM Administrator stated that Q2 was the product directed to use and staff should definitely be following manufacturer's instructions on disinfectant's use. Regional support nurse and DON joined the conversation and nodded in agreement that disinfectant's manufacturer's instructions for use should be followed and the facility did not have a policy outlining this but this was general principle followed by the facility. Administrator stated that the rooms for residents who were on transmission-based precautions were taken care of by nursing staff and not housekeeping. Nursing staff cleaned up any large spills and daily room cleaning such as high-touch surfaces, sweeping, and mopping were not routinely done. During an interview on 12/8/20 at 1: 35 PM Administrator stated that facility will start using Pure product instead of Q2. Pure had a dwell time of 30 seconds. Review of CDC Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, dated 6/25/20, accessed 11/17/20, under Environmental Cleaning and Disinfection showed Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment Ensure HCP (healthcare personnel) are appropriately trained on its use. Record review showed R4 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. R4 was receiving antibiotics through a peripherally inserted central catheter (PICC) which is a long thin tube that's inserted through a vein in the arm and passed through to the larger veins near your heart. Review of facility's COVID19 case log, undated with last entry dated 12/4/20, received by email on 12/8/20 at 10:03 AM and facility daily census, dated 12/9/20 showed facility census of 37 with 10 residents with COVID-19. Review of Centers of Disease Control and Prevention (CDC) cases and deaths by county, https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/county-map.html, dated 12/2/20, accessed 12/7/20, showed Multnomah County (the county where the facility was located) had 10.6 percent positivity rate indicating high level of community COVID-19 activity/red zone positivity classification.

Based on interview and record review it was determined the facility failed to ensure nursing staff adhered to professional standards of practice to follow physician orders [REDACTED].#s 2, 3, 4, 5, 6, 7, 8 and 12) administered an incorrect dosage of medication for 1 of 7 sampled residents (#25) reviewed for medications. 83 medication dosage errors occurred over a 28 day period. This placed residents at risk for decreased medication efficacy. Finding include: Oregon Administrative Rule [PHONE NUMBER] Scope of Practice Standards for All Licensed Nurses included: (1) Standards related to the licensee's responsibility for safe nursing practice. The licensee shall: (b) Ensure competency in the cognitive and technical aspects of a nursing intervention or a nursing procedure to its performance and; (c) Self-regulate one's professional practice by: (A) Adhering to professional practice and performance standards; (4) Standards related to the licensee's responsibility for documentation of nursing practice. The licensee shall document nursing practice in a timely, accurate, thorough, and clear manner. (5) Standards related to the licensee's responsibility to accept and implement orders for client care and treatment. Resident 25 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. A 6/20/18 physician order [REDACTED]. A 7/29/18 physician order [REDACTED]. The 7/2018 and 8/2018 MAR indicated [REDACTED]. An 8/26/18 Medication Error incident report written by Staff 3 (RNCM) revealed a physician's orders [REDACTED]. Staff 3 could not find the [MEDICATION NAME] 25/250 mg tablets and ordered the medication on 8/25/18. The incident report revealed the pharmacy did not receive the [MEDICATION NAME] 25/250 mg order until 8/26/18 (28 days after the 7/29/18 dosage change). The report indicated the pharmacy delivered [MEDICATION NAME] 25/100 mg tablets to the facility on [DATE]. A facility root cause analysis of the incident revealed nurses and CMAs did not check the resident's current [MEDICATION NAME] order (8 nursing staff did not check the current [MEDICATION NAME] order against the medication card from which the medication was being dispensed). This placed the resident at risk for decreased medication efficacy in regards to her/his [MEDICAL CONDITION] diagnosis. On 9/14/18 At 1:20 PM Staff 3 acknowledged the facility had a process for entering new physicians orders and indicated a nurse or RNCM entered the new physician's orders [REDACTED]. Orders were to be double checked for name, dose, medication via eMAR (electronic Medication Administration Record) and nursing staff did not check the medication card or how the medication was to be administered. Staff 3 acknowledged the pharmacy delivered [MEDICATION NAME] 25/100 mg TID on 8/10/18. She confirmed Resident 25 should have received [MEDICATION NAME] 25/250 mg TID starting 7/29/18 but received [MEDICATION NAME] 25/100 mg TID for the 28 days, following the 7/29/18 dosage change. Staff 3 acknowledged she and 7 other nursing staff administered the incorrect dose of [MEDICATION NAME] medication to the resident from 7/29/18 to 8/25/18. On 9/14/18 at 1:32 PM Staff 5 (LPN) acknowledged she administered the incorrect dosage of the [MEDICATION NAME] medication to Resident 25. Staff 5 stated we just did not check the dosage. On 9/14/18 at 2:40 PM Staff 1 (DNS) confirmed she was aware Resident 25 was administered a lower than ordered dosage of the [MEDICATION NAME] medication to manage her/his [DIAGNOSES REDACTED]. Refer to F684

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].#s 2, 3, 4, 5, 6, 7, 8 and 12) administered an incorrect dosage of medication for 1 of 7 sampled residents (#25) reviewed for medications. 83 medication dosage errors occurred over a 28 day period. This placed residents at risk for decreased medication efficacy. Finding include: Resident 25 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. The facility's policy and procedures on Medication and Treatment Orders - eMAR (electronic MAR), last revised in 2/2018, indicated Physician orders [REDACTED].if the order is a change to an existing order, a new order will be entered into the software and the old order will be discontinued in the software .orders will be reviewed for completeness and accuracy during medication administration cross check (MACC) process . A 6/20/18 physician order [REDACTED]. This medication dose was discontinued on 7/29/18. A 7/29/18 physician order [REDACTED]. The 7/2018 and 8/2018 MAR indicated nursing staff administered the [MEDICATION NAME] Tablet 25/250 mg dosage three times a day from 7/29/18 to 8/25/18 (28 days following the 7/29/18 dosage change). An 8/26/18 Medication Error incident report written by Staff 3 (RNCM) revealed a physician's orders [REDACTED]. Staff 3 could not find the [MEDICATION NAME] 25/250 mg tablets and ordered the medication on 8/25/18. The incident report revealed the pharmacy did not receive the [MEDICATION NAME] 25/250 mg order until 8/26/18 (28 days after the 7/29/18 dosage change). The report indicated the pharmacy delivered [MEDICATION NAME] 25/100 mg tablets to the facility on [DATE]. A facility root cause analysis of the incident revealed nurses and CMAs did not check the resident's current [MEDICATION NAME] order (nursing staff did not check the current [MEDICATION NAME] order against the medication card from which the medication was being dispensed). On 9/14/18 At 1:20 PM Staff 3 acknowledged the facility had a process for entering new physicians orders and indicated a nurse or RNCM entered the new physician's orders [REDACTED]. Orders were to be double checked for name, dose, medication via eMAR and nursing staff did not check the medication card or how the medication was to be administered. Staff 3 acknowledged the pharmacy delivered [MEDICATION NAME] 25/100 mg TID on 8/10/18. She confirmed Resident 25 should have received [MEDICATION NAME] 25/250 mg TID starting 7/29/18 but received [MEDICATION NAME] 25/100 mg TID for the 28 days following the 7/29/18 dosage change. Staff 3 acknowledged she and 7 other nursing staff administered the incorrect dose of [MEDICATION NAME] medication to the resident from 7/29/18 to 8/25/18. On 9/14/18 at 1:32 PM Staff 5 (LPN) acknowledged she administered the incorrect dosage of the [MEDICATION NAME] medication to Resident 25. Staff 5 stated we just did not check the dosage. On 9/14/18 at 2:40 PM Staff 1 (DNS) confirmed she was aware Resident 25 was administered a lower than ordered dosage of the [MEDICATION NAME] medication to manage her/his [DIAGNOSES REDACTED].

Based on observation and interview it was determined the facility failed to ensure proper hand hygiene was maintained and food storage practices were followed for 1 of 1 central facility kitchen reviewed for food storage and infection control. This placed residents at risk for food-borne illness and infection from improper hand hygiene practices. Findings include: 1. On [DATE] at 9:30 AM an initial kitchen tour revealed the following food items were located in the kitchen walk-in and reach-in refrigerator units or the dry storage area; -A tray of approximately 20 small cups of fiber not labeled or dated; -A bin of approximately 10 pre-packaged baked treats with no labels and no dates; -Two opened gallons of milk not marked with opened on dates; -Three open cans of whip cream with no opened by dates; -Six open boxes of honey thickened milk and juice not marked with opened on dates; -One tub of water chestnuts with an expiration date of ,[DATE] and one tub of fruit salad expired ,[DATE]; -Two packages of deli meat unlabeled and with no dates; -One plastic zip lock bag of an orange flaky food product with no label or date; -One package of seaweed with an expiration date of [DATE]; -One gallon of open cooking wine not marked with an opened by or pull by date. -One bag of seaweed wraps dated 7/ with no additional identifiable date. On [DATE] at 9:30 AM and [DATE] at 9:54 AM Staff 10 (Dietary Manager) acknowledged any items which were not labeled or dated should have been discarded and he disposed of all the items. 2. On [DATE] at 11:59 AM approximately 12 serving trays were used to serve food to residents. Staff reused the serving trays without washing or sanitizing the trays. On [DATE] at 12:05 PM approximately 21 serving trays were used to serve food to residents. Staff reused the serving trays without washing or sanitizing the trays. In an interview on [DATE] at 12:33 PM Staff 10 (Dietary Manager) stated it was the facility's normal tray line process to have staff serve the residents using the trays and then reuse the trays without washing and sanitizing before reusing the trays. Staff 10 acknowledged this practice had the potential for concerns with cross contamination. 3. On [DATE] at 11:53 AM Staff 11 (Dietary Aide/Cook) touched the trash can lid with gloved hands, and served lunch, touched serving scoops and one plate on the eating surface without conducting hand hygiene. On [DATE] at 12:12 PM Staff 11 touched the contaminated serving scoops with gloved hands then directly touched three rolls with the same gloved hands. In an interview on [DATE] at 12:27 PM Staff 11 verified he touched the trash can lid with his gloved hands, did not complete hand hygiene and returned to meal service. Staff 11 stated he was unaware he should not touch food items directly after touching other kitchen items. In an interview on [DATE] at 9:41 AM Staff 10 (Dietary Manager) stated he expected staff to conduct hand hygiene after touching a trash can lid. Staff 10 expected staff to use tongs or complete hand hygiene and use new gloves when directly contacting food.

Based on observation, interview and record review it was determined the facility failed to ensure resident care was provided in a manner that maintained dignity for 1 of 1 sampled resident (#8) reviewed for nutrition. This placed residents at risk for lack of dignity. Findings include: Resident 8 admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. The 3/23/18 Comprehensive Care Plan indicated Resident 8 refused medications and staff were to reapproach as needed and respect the resident's choice of care. On 9/12/18 at 11:59 AM Staff 3 (RNCM) was observed to place a clear plastic cup filled with a clear liquid in front of Resident 8 in the main dining room during lunch. Staff 3 was observed to speak to Staff 9 (Life Enrichment Assistant) and motioned towards the cup. Staff 9 spoke to Resident 8 in the resident's language in a loud voice, while she stood next to the resident and made a motion to her stomach. Resident 8 was observed to shake her/his head and took a sip from a cup of juice. Staff 3 was observed to attempt to pour the clear liquid into the almost empty cup of juice. Resident 8 placed her/his hand over the cup and shook her/his head. Staff 3 grabbed the cup of juice and placed it out of reach of Resident 8 and placed the clear liquid cup in front of the resident. Staff 3 stood behind the resident and poured the clear liquid from the plastic cup into a dining room cup. Staff 3 placed the full cup of clear liquid in front of Resident 8 at the dining room table and told the resident it was water. On 9/12/18 at 12:23 PM Staff 11 (RN) picked up the cup of clear liquid and placed the cup to Resident 8's mouth. The resident pounded on the table until Staff 11 put the cup back on the table. On 9/12/18 at 12:27 PM Staff 9 and Staff 11 stood over Resident 8, pointed at the cup of clear liquid and spoke to the resident in her/his language. During lunch observations on 9/12/18 two alert and oriented residents who speak the same language as Resident 8 were observed to be sitting in the dining room. In an interview on 9/12/18 at 1:01 PM Staff 11 stated the liquid in the cup was [MEDICATION NAME] (a medication for constipation) and she explained to Resident 8 in her language that the medicine would help her since she had not had a bowel movement in over three days. On 9/14/18 at 2:47 PM Staff 1 (DNS) stated if a resident refused a medication she expected staff to reapproach the resident at a later time. Staff 1 acknowledged the verbalization of Resident 8's need for [MEDICATION NAME] in the dining room was inappropriate.

Based on interview and record review it was determined the facility failed to complete a baseline care plan for 1 of 1 sampled resident (#1) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 1 was admitted to the facility in 3/2018 and was discharged on [DATE] with return not anticipated. Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Comprehensive Care Plan dated 8/27/18 revealed the sentence MUST USE THE 'EDIT' BUTTON AND ADD RESIDENT SPECIFIC INFORMATION. The sections titled physician's orders [REDACTED]. A Care Plan intervention dated 4/6/18 revealed Resident 1 required limited assistance with eating and a Care Plan intervention dated 8/27/18 indicated the resident required extensive assist of one staff for eating. A Care Plan intervention dated 4/12/18 revealed Resident 1 was weight bearing and a Care Plan intervention dated 8/27/18 indicated the resident was not weight bearing. On 9/14/18 at 11:12 AM Staff 3 (RNCM) reported sections of Resident 1's Care Plan were dated 4/2018 because the resident was previously admitted and the care plan areas were not discontinued. She confirmed those sections remained on the current Care Plan. Staff 3 acknowledged Resident 1 had uncontrolled high blood pressure when she/he admitted and the Care Plan did not include information related to high blood pressure and should have. On 9/14/18 at 1:31 PM Staff 1 (DNS) confirmed the discrepancies on the care plan related to Resident 1's weight bearing status and need for assistance with eating. Staff 1 acknowledged the Comprehensive Care Plan was not complete.

Based on observation, interview and record review it was determined the facility failed to implement care planned safety interventions for 2 of 3 sampled residents (#s 1 and 2) who had injuries. As a result, Resident 1 sustained a fractured ankle and experienced pain. Findings include: 1. Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. An 8/3/14 annual comprehensive assessment indicated the resident had impaired mobility and "difficulty bearing (weight)." An 8/5/14 care plan indicated the resident required two-person assistance for transfers with a mechanical lift. According to an incident investigation and NN, on 8/21/14 Staff 1, CNA, transferred the resident to bed alone and did not use the mechanical lift. The resident "bumped" the top of her/his foot while moving from the wheelchair to bed. An RN heard the resident "yelling." The RN arrived to the resident's room and noted the resident was holding the left leg "screaming in bed." The resident had pain in the left ankle. The resident had no swelling or bruising. The resident was placed on alert for left ankle pain. Between 8/21/14 - 8/27/14 the resident had left ankle pain daily and was given PRN medication each day for pain. On 8/27/14 an x-ray was obtained which showed the resident had an "acute fracture of distal left 2nd, 3rd and 4th metatarsals." On 9/9/14 at 11:00 am the resident was observed sitting in the wheelchair with a support boot on the left foot. The resident stated her/his ankle was injured during a transfer to bed. The resident couldn't remember if a mechanical lift was used but she/he was usually transferred with a mechanical lift. The resident couldn't provide any additional details about the incident. In an interview on 9/9/14 at 10:20 am Staff 5, RNCM, stated Staff 1, CNA, did not look at the care plan before transferring the resident. Staff 1 had not worked with the resident before 8/21/14 In an interview on 9/9/14 at 11:50 am Staff 4, DNS, stated Staff 1, CNA, transferred the resident by himself. Staff 1 did not look at the resident's care plan before the transfer and took responsibility for the resident's injury. In an interview on 9/9/14 at 1:00 pm Staff 1, CNA, stated a nurse asked him to transfer the resident to bed; the resident's assigned CNA was on break. Staff 1 had not worked with the resident before. Staff 1 used a gait belt and transferred the resident to bed. During the transfer the resident's leg bent and the resident yelled out. Staff 1 did not look at the resident's care plan before transferring the resident. Staff 1 knew care plans were kept in the resident's closet. Staff 1 always reviewed the care plans for the residents assigned to him. 2. Resident 2 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. A 7/17/14 quarterly assessment indicated the resident preferred to be on the floor in her/his room and had a mattress on the floor next to the wall, with a mat beside. The resident moved about the room by scooting on the floor. In the care plan updated 7/24/14, it was directed the resident needed two-person extensive assist with a Hoyer lift for transfers. According to Progress notes on 8/19/14, the resident was found with bruising and swelling of the right upper shoulder. The resident was given Oxycodone for right arm and shoulder pain that day. An initial x-ray did not identify an injury; however x-ray results on 8/20/14 revealed a fracture of lateral mid scapula with mild displacement. A facility investigation of the resident's injury indicated that the resident had been transferred twice on 8/18/14 without the use of the Hoyer lift as care planned. At 5:30 pm Staff 2, CNA independently transferred the resident from the floor to the wheelchair without use of the Hoyer lift as care planned. There was no evidence found that the resident was injured. At 8:30 pm Staff 3, CNA independently transferred the resident from wheelchair to mattress without using the Hoyer lift. There was no evidence of injury. In an interview on 9/12/14 at 11:20 am Staff 2 said she transferred the resident independently with the use of a gait belt. There was nothing remarkable about the transfer and the resident showed no signs of injury. She said she knew the care plan directed use of the Hoyer. It was not used because the resident was on the floor in a place that she could not get the Hoyer into. In an interview on 9/9/14 at 2:20 pm Staff 3 said she transferred the resident with a student. There was no problem with the resident's shoulder at the time of the transfer. Staff 3 said she didn't know that the resident's care plan had been changed to include use of the Hoyer lift for transfers. In an interview with Staff 4, DNS on 9/9/14 at 10:10 am, she said the resident would sometimes fall backwards and at times was found lying on the back, on the floor. Staff 4 believed this behavior could have caused the fracture.