The findings of the re-licensure survey conducted 10/16/23 through 10/19/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 10/19/23, conducted 01/29/24 to 02/01/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 10/19/23, conducted 05/28/24 through 05/29/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third revisit to the re-licensure survey of 10/19/23, conducted on 03/12/2025, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate administrative oversight and to ensure the quality of services rendered in the facility, which posed a risk to the safety of residents. Findings include, but are not limited to:

During the re-visit survey, conducted 01/29/24 through 02/01/24, oversight to ensure resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations, new citations and severity of citations.

Refer to deficiencies in the report.

1.The community team put immediate plans of correction in place during the survey. Each citation listed in the Statement of Deficiency was reviewed and immediate action steps were completed as detailed in this plan of correction.

2.The community team will review systems and corrections at clinical meeting and 1:1 meetings with department heads and Executive Director no less that twice weekly. The District Director of Operations and District Director of Clinical Services or their designees will connect with the community team a minimum of twice weekly via in person visits, training/support calls, and/or remote documentation review. This additional monitoring will continue for the next 30 days, then move to weekly for the following 30 days, and then monthly for the next 30 days.

3. Systems and corrections will be reviewed by community team at least twice weekly and by District team as described above.

4.The community has entered into an agreement with a department-approved Registered Nurse Consultant.  The District Director of Operations and District Director of Clinical Services or their designees will be responsbile for verifying that the corrections are made.

Based on observation and interview, it was determined the facility failed to ensure a copy of the most recent re-licensure survey, including all revisits and plans of correction, was available to residents and visitors. Findings include, but are not limited to:

A tour of the facility conducted on 01/29/24 identified an outdated copy of the facility re-licensure survey from 12/15/21. The most recent re-licensure survey was conducted on 10/19/23.

The need to ensure a copy of the most recent re-licensure survey, including all revisits and plans of correction, was discussed on 02/01/24 with Staff 1 (ED). She acknowledged the findings.

1. Survey results from Kitchen inspection dated 4/4/2023, relicensure survey dated 10/19/2023, and 1st revisit survey dated 2/1/2024 were placed in a binder in the lobby, accessible to residents, families, and visitors.

2. The Executive Director or designee will be responsible to update the binder with survey results upon receipt.

3. Survey results will be updated as needed with each new inspection.

4. Executive Director or designee

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 10/12/23 with diagnoses including Type 2 diabetes, seizure disorder, and hypertension.

The resident's facility records were reviewed. Resident 1 and staff were interviewed. The following was identified:

The move-in documentation, dated 09/28/23, identified the resident as administering his/her medications.

A review of Resident 1's physician's orders revealed s/he took medications for mood, gout, cholesterol, blood pressure, pain, seizures, edema, and chest pain. The resident was an insulin dependent diabetic, and had both scheduled and PRN inhalers prescribed for breathing issues.

Observations of Resident 1 on 10/16/23 at 3:12 pm and on 10/17/23 at 10:04 am, noted the resident was well groomed, dressed appropriately, cognitively intact, and able to hold a conversation.

On 10/17/23 at 10:04 am, Resident 1 confirmed s/he had not had his/her medications since move in. The resident reported s/he was a retired nurse and stated s/he would call staff if s/he was not "feeling right" and needed to go to the hospital. There were 31 sealed moving boxes observed in the resident's room. Resident 1 stated s/he did not know if the medications were in the boxes as the movers "packed all of my belongings." The resident confirmed that s/he was unable to go through the boxes due to his/her health conditions.

On 10/17/23 at 10:55 am, Staff 1 (ED) reported staff had contacted her on 10/14/23 stating the resident was requesting the facility to "take over [his/her] medications." She was contacted again the next evening on 10/15/23 at approximately 9:30 pm by another staff member, stating the resident wanted the facility to "do [his/her] meds" as the resident "didn't have any medications with [him/her]."  

Staff 1 confirmed the process for new admissions. The facility used a checklist that addressed what staff were to do prior to move in, day before move in, and once resident was in the community. The section directing staff on what to do once the resident was in the community addressed the following:

* "All medications counted upon receipt and form signed by family";

* "Medications reconciled with [medication list]. Are all medications on hand?" and

* "Follow up for medications not on hand".

Both Staff 1 and 2 confirmed the facility failed to implement the checklist for Resident 1 and they were not aware the resident did not have his/her medications upon admission.    

The need for reasonable precautions to be exercised against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 and Staff 2 on 10/18/23. They acknowledged the findings.

1. Resident #1's medications were obtained from Kaiser pharmacy Long Term Care Pharmacy on 10/19/2023.

2. Resident's medications will be reviewed to confirm that resident/family has all resident's prescribed medications for resident to self administer or to provide community staff for associate administration. Medications that are not provided from resident/family will be ordered from resident's pharmacy, provided by the family, or ordered from community preferred pharmacy. Medications for all admissions within the last 30 days will be reviewed to ensure all medications are on hand.

3. This process will be completed with each new admission.

4. The Health and Wellness Director/designee will complete each review.

Based on observation, interview, and record review, it was determined the facility failed to provide a homelike environment for 1 of 1 sampled resident (#9) and multiple unsampled residents. Findings include, but are not limited to:

1. During the survey from 01/29/24 through 02/01/24, pervasive odors were observed throughout the third-floor corridor. The facility windows were opened at each end of the 3rd floor corridor on 01/29/24 - 01/31/24. The outdoor temperatures during the survey ranged between 40's and 50's in the late afternoon hours. The indoor ambient air temperature on the third floor was cold and a draft was felt throughout the third floor.

During the survey multiple unsampled residents residing on the third-floor verbalized complaints about the odor.  

The need to provide a homelike environment for residents was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

2. Resident 9 was admitted to the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease (COPD) and Type 2 diabetes mellitus.

Resident 9's evaluation and service plan dated 01/12/24 noted the resident required staff assistance with bladder and bowel incontinence care which often resulted in additional assistance related to hygiene and housekeeping. The resident was dependent on two caregivers for all transfers and used a manual and/or electric wheelchair for mobility.

During an interview with Resident 9 in his/her apartment, the carpet was observed to be sticky when walked on, had multiple large stains that covered much of the floor, and the apartment had a pervasive odor. During the interview Resident 9 stated the carpets had "not been cleaned since [s/he] moved in." The resident further stated "I wouldn't live this way if it was my house. I'm one of those fussy old [gender reference] that likes things clean."

The need to provide a homelike environment for residents was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. Resident 9 was voluntarily relocated to an apartment on the same floor of the same size that had new flooring. The carpet in the old apartment will be replaced.

2. Carpet cleaning for common areas and resident apartments has been scheduled. Community walkthroughs will be completed including visual inspections of each resident apartment and common areas. As needed vaccuming or shampooing of carpets will be added as a work order with the front desk.

3. Common areas will be inspected weekly and each resident apartment will be inspected monthly.

4. Executive Director, Maintenance Technician, or Designee

Based on interview and record review, it was determined the facility failed to ensure an injury of unknown cause was promptly investigated and reported to the local SPD office when abuse and/or neglect could not reasonably be ruled out, for 1 of 3 sampled residents (# 4) with incidents that were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 06/2023 with diagnoses including anemia and history of falling.

A review of the resident's clinical record, including progress notes, between 07/15/23 and 10/16/23, temporary service plans, and staff interviews identified the following:

09/26/23 - A bruise on the resident's upper back on the right side.

During an interview on 10/18/23 at 10:30 am, Staff 11 (MT/CG) confirmed Resident 4 was alert and oriented, and s/he would be able to answer questions regarding the cause of the injury.

There was no documented evidence the bruise had been investigated to rule out abuse or suspected abuse, nor evidence the local SPD was immediately notified.

The need to investigate resident incidents to rule out abuse or suspected abuse, notify the local SPD if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

1. Bruise for Resident #4 identified on 9/26/23 was investigated by Health and Wellness Director and abuse and neglect ruled out. Resident denied abuse and reasonable explination for bruising was determined so injury was not reported to Adult Protective Services (APS).

2. At daily clinical meeting skin report cards will be reviewed for new skin issues. New issues will be investigated and documented. APS will be notified when appropriate. Training provided to new Resident Care Coordinator (RCC) for skin report cards and reporting on new skin issues. Skin report cards reviewed for the last 30 days for any new skin issues; documentation and reported completed as needed.

3. This will be evaluated daily at clinical meeting.

4. Health and Wellness Director and Executive Director, or designee.

Resident 1 was admitted to the facility in 10/2023 with diagnoses including Type 2 diabetes and a seizure disorder.

The facility used an "Addendum Questionnaire" and a "Personal Service Assessment" document to evaluate residents prior to admitting to the facility. The resident's documents, dated 09/28/23, were reviewed and lacked the following required elements:

* Customary routines including eating;

* List of current diagnoses;

* List of medications and PRN use;

* Visits to health practitioner(s), ER, hospital or Nursing Facility in the past year;

* Mental health issues including effective non-drug interventions;

* Personality including how the person copes with change or challenging situations;

* Ability to use call system;

* Housework and laundry;

* Pain including non-pharmaceutical interventions and how a person expresses pain or discomfort;

* Emergency evacuation ability;

* History of dehydration or unexplained weight loss or gain;

* Unsuccessful prior placements; and

* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature.

On 10/16/23 at 3:13 pm, Staff 1 (ED) confirmed there was no additional information relating to Resident 1's move-in evaluation.

The need to ensure newly admitted resident evaluations included each required element was discussed with Staff 1 and Staff 2 (Health and Wellness Director) on 10/18/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements for 1 of 1 sampled resident (# 1) whose evaluation was reviewed. Findings include, but are not limited to:

1. Resident evaluation with customary routines and preferences completed for Resident #1 on 10/16/2023.

2. At move in, evaluation will be completed to include but not limited to, areas noted in statement of deficiencies. Quarterly evaluation checklist will be completed with each service plan update to ensure all ancillary evaluations are completed at the time of review. Evaluations reviewed and completed for all resident's admitted in the last 30 days.

3. Review will occur daily at clinical meeting and as part of the quarterly care planning process.

4. Health and Wellness Director and Executive Director, or designee.

Based on observation, interview, and record review, it was determined the facility failed to evaluate and gather data that was relevant to the needs and current condition of the resident following a significant change of condition, and ensure the evaluation was used as the basis of the resident's service plan for 1 of 4 sampled residents (#9) whose evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes mellitus. During the acuity interview on 01/29/24 it was reported the resident was admitted to hospice.

Observations, interviews with staff, and review of the most recent evaluation and service plan dated 01/12/24, identified the evaluation wasn't reflective of the resident's current status and condition, and was not utilized as the basis of the resident's service plan in the following areas:

* Bathing and level of assistance needed;

* Pain and how pain was expressed, including non-pharmacological interventions;

* Skin issues, type, treatment and wound care location;

* Transportation assistance;

* Complex medication regimen;

* Falls; and

* Outside service providers, including hospice.

The need to ensure evaluations were updated, included relevant data related to the resident's current needs and condition with sufficient information to be used to update the service plan was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

1. Resident 9's evaluation was reviewed and updated on 2/23/24 to be consistent with her current needs including: addressing her bathing assistance, detailing her pain and how she expresses pain and non-pharmacological interventions specific to the resident, description of her skin deficits including treatment needs, her transportation needs, her complex medication regimen, her fall history and interventions, and her outside service providers. Additionally, resident evaluations will be reviewed for current needs and preferences and completed by 3/17/24.

2. Evaluations will be reviewed at each service plan meeting and updated with the service plan. The service plan will be reviewed to verify that the plan is consistent with the current level of resident need and aligns with resident's current preferences. Evaluations will also be brought to care conferences to be reviewed by the care planning team and attached to the signed service plan.

3. Evaluations will be updated with each service plan at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition.

4. Executive Director, Health and Wellness Director and/or Designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, and provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 3 of 6 sampled residents (#s 2, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted in 06/2023 with diagnoses including sleep apnea, mild neurocognitive disorder, and depression.

The resident's 07/15/23 service plan and Temporary Service Plans (TSPs) were reviewed. Resident 6 and staff were interviewed. The following areas were either not reflective on the resident's service plan or lacked clear direction to staff:

* The use of a CPAP (continuous positive airway pressure) machine;

* How environmental factors impact the resident's behavior;

* Behavior interventions relating to the timeliness of medications; and

* Where the resident preferred to eat his/her meals.

The need to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 01/2021 with diagnoses including hypertension.

The resident's 08/01/23 service plan and Temporary Service Plans (TSPs) were reviewed and were not reflective of the resident's current needs and lacked clear instruction to the staff in the following areas:

* ADL assistance provided by hospice providers;

* Assistive mobility devices, use of manual wheelchair;

* Treatments, oxygen use; and

* Toileting, use of urinal.

The need to ensure service plans were reflective of resident needs and included clear instructions to the staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 04/2023 with diagnoses including chronic kidney failure stage 4 (severe), Type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder.

Observations were made of the resident's care on 10/17/23. Interviews with facility staff and the resident were conducted. The current service plan dated 10/03/23 was reviewed.

Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Presence of depression and history of treatment; and

* Instructions for signs and symptoms of infection to report when providing care to the suprapubic insertion site.

The resident's current service plan, dated 10/03/23, was filed in their medical record, which was locked in the medication room and was not readily available to staff.

The need to ensure the service plan reflected residents' current needs, provided clear instructions to staff regarding delivery of services, and was readily available to staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings. No further information was provided.

1. Care Plan for Resident 6 was updated 11/10/23  to include use of CPAP, behaviors and contribution of enviromental factors, and eating preferences. Care plan for Resident 2 updated 11/3/23 to include presence of depression and history of treament as well as instructions for monitoring and providing care for suprapubic insertion site. Care plan for Resident 5 was updated 10/23/23 to include ADL assistance provided by hospice, current use of manual wheelchair, oxygen use, and toileting needs.

2. All care plans will be reviewed by care plan team and resident/family to ensure accuracy and updates will be made as needed. Temporary Service Plans (TSPs) and Outside Provider notes will be reviewed at clinical meeting and written onto care plans as appropriate.

3. Daily at clinical meeting and with each care plan update.

4. Health and Wellness Director and Executive Director, or designee.

2. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition.   

Resident 8's service plan dated 01/18/24 was reviewed. Observations and interviews with the resident and staff were conducted during the survey.

The service plan was not reflective and did not provide clear caregiving instruction in the following areas:

* Nutrition: Weight loss and interventions;

* Dressing and grooming: One-versus-two person dressing assistance, oral care, no longer could stand to be weighed, and no longer wore compression socks;

* Bathing: Shower assistance vs. bed bath from hospice providers;

* Bathroom: one-versus two-person assistance for brief changes and frequency of staff checks per shift;

* One-versus two-person transfer assistance;

* Skin care: interventions and wound care; and

* Hospice comfort care interventions.

The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans reflected the resident's needs as identified in the evaluation and provided clear direction to staff, which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 2 of 4 sampled residents (#s 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 moved into the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes mellitus.

The resident's service plan dated 01/12/24 and Temporary Service Plans (TSPs) were reviewed. Observations and interviews with the resident and staff were conducted during the survey.

The following areas were not reflective of the resident's current care needs and/or lacked clear direction to staff:

* Bathing: Shower assistance vs. bed bath from hospice providers;

* Dressing: No indication of who was to assist the resident and how;

* Bathroom tasks: No indication of who was to assist the resident and how;

* Reluctance to accept care: "was evaluated for hospice but declined admission"; and

* Skin care and who provided the wound care treatments.

The need to ensure service plans reflected the resident's current care needs and status, provided clear direction to staff, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.  

1. Resident 9's service plan was updated to reflect resident's needs and provide clear direction to care staff in the following areas: shower assistance, dressing, bathroom tasks, reluctance to accept care, and skin care. Resident 8's service plan was updated on 1/31/24 to reflect her current nutrition needs including staff assistance with feeding, nutritional supplements, and weekly weights. Resident 8's service plan was also updated in the follow areas: dressing and grooming, shower assistance, bathroom assistance, transfer assistance, skin care, and hospice coordination and care. Additionally, service plans will be reviewed by 3/17/24 to confirm they provide clear direction to staff regarding how assistance will be provided and who is responsible to provide it.

2. Service plans will be reviewed and updated as required. Heath and Wellness Director will sign off on service plans at review. Additionally, service plans will be reviewed at care conferences with the entire care planning team to verify the services align with resident's personal preferences. Signatures will be obtained from care planning team at that meeting acknowledging service plans are reflective of resident's current needs/preferences.

3. Care Plans will be updated at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition.

4. Executive Director, Health and Wellness Director and/or Designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's needs and preferences, provided clear direction regarding the delivery of services, and was implemented for 1 of 3 residents (#12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 12 was admitted to the facility in 04/2019 with diagnoses including depression, stroke, and arthritis.

The resident's 04/28/24 service plan and temporary service plans dated 04/16/24 to 05/28/24 were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas:

* Nectar-thick liquids;

* Meal assistance;

* Nutritional supplement;

* Bed positioning;

* Suicidal ideation;

* Hearing aids; and

* Heel boots.

The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) on 05/29/24. She acknowledged the findings.

1. Resident #12 service plan was updated with the information found in the Statement of Deficency as well as reviewed for any further updates as needed. An audit was performed on service plans to identify residents that had recent changes in condition and/or high levels of care. These care plans were reviewed for accuracy in care performed, staff direction, and addition personalized information regarding the resident.

2. Service plans will be reviewed and updated as required with input from resident, care planning team, and community staff as needed to ensure that they are reflective of resident's current needs, have clear staff direction for cares, and are personalized to suit resident preference and needs.

3. Care Plans will be updated at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition.

4. Executive Director, Health and Wellness Director and/or Designee.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 7, 9 and 10). Findings include, but are not limited to:

Resident 7, 9 and 10's current service plans were reviewed during the survey.

The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) on 02/01/24. She acknowledged the findings.

1. Care conferences were scheduled for Resident 7 (2/23/24), Resident 9 (2/23/24), and Resident 10 (2/27/24) to review their current service plans. Letters were provided to the residents and family was notified. Residents were encouraged to invite anyone they chose to participate in their care planning process.

2. Executive Director will be responsible for scheduling care conferences and communicating them to residents and families. Residents will be encouraged to invite anyone they'd like to participate in their care planning process.

3. Care conferences will occur with each service plan update including: at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition.

4. Executive Director and/or Designee.

2. Resident 1 was admitted to the facility in 10/12/23 with diagnoses including Type 2 diabetes, seizure disorder, and hypertension.

The resident's facility records were reviewed. Resident 1 and staff were interviewed. The following was identified:

The move-in documentation, dated 09/28/23, identified the resident as administering his/her medications.

A review of Resident 1's physician's orders revealed s/he took medications for mood, gout, cholesterol, blood pressure, pain, seizures, edema, and chest pain. The resident was an insulin dependent diabetic and had both scheduled and PRN inhalers prescribed for breathing issues.

On 10/17/23 at 10:04 am, Resident 1 confirmed s/he had not had his/her medications since move in.

On 10/17/23 at 10:55 am, Staff 1 (ED) reported that staff had contacted her on 10/15/23 at approximately 9:30 pm by staff, stating the resident wanted the facility to "do [his/her] meds" as the resident "didn't have any medications with [him/her]."

On 10/17/23 at 10:55 am, Staff 1 and 2 (Health and Wellness Director) confirmed the resident had not been monitored for missing his/her medications since the time of the move in.

The need to ensure changes of condition were evaluated, actions or interventions were determined, those actions or interventions were communicated to staff on each shift, and documented on through resolution was discussed with Staff 1 and Staff 2 on 10/18/23. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 06/2020 with diagnoses including sleep apnea, mild neurocognitive disorder, and depression.

The resident's progress notes, dated 07/17/23 through 10/14/23, and Temporary Service Plans (TSPs) were reviewed. Staff were interviewed. The following changes of condition were identified:

* 09/21/23 - new medication, docusate (for constipation), was started and staff were directed to monitor for nausea, vomiting, abdominal pain, cramps, diarrhea, and loose stools;

* 10/03/23 - suicide ideation's were documented and staff were directed to monitor and report for increased isolation, and hallucinations (both auditory and visual); and

* 10/04/23 - new medication, fexofenadine (for allergies), was started and staff were directed to monitor for rash, dizziness, nausea, vomiting, diarrhea, loose stools, hives, and trouble breathing or swallowing.

There was no documented evidence Resident 6 was monitored with weekly progress noted through resolution.

The need to ensure changes of condition were documented on at least weekly with progress noted until the conditions resolved was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. No additional information was received.

Based on observation, interview, and record review, it was determined the facility failed to determine what actions or interventions were needed, ensure actions or interventions were communicated to staff on each shift, and documented at least weekly with progress noted until the condition resolved for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6), who experienced changes of condition. Resident 5 experienced ongoing falls. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 01/2021. The resident had a diagnoses of hypertensive heart failure and was admitted to hospice in 07/2023.

a. Interviews and reviews of the resident's progress notes dated 07/09/23 through 10/19/23, 08/01/23 service plan, temporary service plans, Hospice Provider Collaboration notes and incident reports revealed the following:

* On 08/10/23, Resident 5 experienced a fall in his/her unit resulting in pain to his/her back. There was no documented evidence the facility determined and documented any actions or interventions related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution;

* On 08/11/23, the resident experienced a non-injury fall in his/her unit. There was no documented evidence the facility determined and documented any actions or interventions were needed related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution;

* On 09/01/23 a Hospice Provider Collaboration Note noted the resident self-reported a non-injury fall to the provider. The note was transcribed to the resident's clinical record. There was no documented evidence the facility determined and documented any actions or interventions needed related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution;

* On 09/04/23 the resident experienced a fall in his/her unit, sustaining a laceration to the forehead. There was no documented evidence the facility determined and documented any actions or interventions needed related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution;

* On 09/09/23 the resident experienced a fall in a common area of the facility, sustaining an abrasion to the right elbow. There was no documented evidence the facility determined and documented any actions or interventions needed related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution;

* On 09/11/23 the resident experienced a non-injury fall in his/her unit. Staff reported the resident's oxygen saturation levels were 82% immediately after the fall. Hospice was notified and the resident received an order for PRN oxygen at two liters. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution;

* During an 10/19/23 interview with Staff 2 (Health and Wellness Director) s/he stated the oxygen was an intervention for the resident's falls as they determined Resident 5's oxygen saturation levels were often low, effecting his mobility;

* On 09/15/23 the facility scheduled daily housekeeping for Resident 5 as an intervention to aide in the prevention of falls;

* On 09/25/23 the resident experienced a non-injury fall in his/her unit. There was no documented evidence the facility evaluated previous fall interventions to determine if they were effective or if new interventions needed to be developed and communicated to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution;

* On 09/30/23 the resident experienced a non-injury fall in his/her bathroom after tripping over oxygen tubing. There was no documented evidence the facility evaluated previous fall interventions to determine if they were effective or if new interventions needed to be developed and communicated to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; and

* On 10/06/23 the resident experienced a non-injury fall in the facility dining room. There was no documented evidence the facility evaluated previous fall interventions to determine if they were effective or if new interventions needed to be developed and communicated to staff on each shift.

In an 10/19/23 interview with Staff 2 (Health and Wellness Director), she confirmed the facility lacked documented evidence each of the resident's falls were evaluated to determine if interventions were needed or if previously implemented interventions needed to be re-evaluated for effectiveness.

Resident 5 was identified to be at risk for falls and experienced multiple non-injury and injury falls.  The facility failed to review each fall to determine what action or intervention was need to help minimize falls and/or failed to  determine if service planned interventions were in place and effective. Resident 5 continued to fall.

b. Review of the records revealed Resident 5 also experienced the following short-term changes of condition:

* 07/25/23 - Emergency room visit/shortness of breath;

* 07/30/23 - Medication change, start lorazepam 0.5 mg give one tablet by mouth every six hours PRN;

* 09/04/23 - Laceration to forehead;

* 09/09/23 - Abrasion to right elbow; and

* 09/11/23 - New order, start oxygen two liters PRN.

There was no documentation the facility developed actions or interventions, communicated the actions or interventions to staff on each shift, and monitored each condition with progress noted at least weekly through resolution for Residents 5's medication and treatment orders and emergency room visit.

The need to ensure the facility had a system to monitor each resident, determine and document what actions or interventions were needed for the resident's short term changes of condition, ensure actions or interventions were communicated to staff on each shift and documented, at least weekly, until the conditions resolved was discussed with Staff 1 (ED) and Staff 2 on 10/19/23. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 07/2022 with diagnoses including Parkinson's disease.

The resident's clinical record, including progress notes, temporary service plans, and incident reports were reviewed, and interviews were conducted. The following was identified:

An 08/08/23 progress note entry stated, "Resident refused to go down to lunch today because [s/he] is upset that some other residents are being homophobic, or saying homophobic things...Will continue to monitor."

There was no documented evidence this incident had been evaluated, actions or interventions had been determined and implemented, or interventions monitored for effectiveness.

The need to evaluate, determine actions or interventions for, and monitor interventions for effectiveness was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

5. Resident 4 was admitted to the facility in 11/2015 with diagnoses including cervicalgia (neck pain) and heart failure.

The resident's clinical record, including progress notes, temporary service plans, and incident reports were reviewed, and interviews were conducted. The following was identified:

* 09/13/23 - A change in warfarin (for anticoagulation) dosage;

* 09/26/23 - New medications, including ferrous sulfate (for supplement) and ascorbic acid (for supplement);

* 09/26/23 - A change in hydrocodone-acetaminophen (for pain) from PRN medication to scheduled; and

* 09/29/23 - A change in Lasix (for edema) dosage.

There was no documented evidence these changes of condition had been monitored through resolution.

The need for short-term changes of condition to be monitored through resolution, with progress documented at least weekly, was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

6. Resident 2 was admitted to the facility in 04/2023 with diagnoses including chronic kidney failure stage 4 (severe) and Type 2 diabetes mellitus with diabetic chronic kidney disease.

Review of clinical records, including the service plan dated 10/03/23, progress notes from 07/17/23 through 10/15/23, and interviews with facility staff and the resident revealed the following:

a. On 07/18/23 the resident was identified as having a left heel pressure ulcer, stage two. There was no documented evidence staff notified the facility nurse of the significant change of condition.

b. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved:

* 07/18/23 - Foley catheter changed;

* 07/26/23 - Flu vaccination;

* 07/28/23 - ER visit related to new onset of chest pain;

* 07/31/23 - ER visit related to cramps and numbness in hands and legs and chest pain;

* 07/31/23 - ER visit related to bleeding from Foley catheter site and pain 8/10;

* 08/31/23 - Foley catheter changed;

* 08/31/23 - '' 'Home Health/Hospice/Third Party Provider Collaboration Notes' ...Pt has sore in [right genital area] due to [Foley catheter] rubbing ..."; and

* 09/29/23- " 'Home Health/Hospice/Third Party Provider Collaboration Notes' [Genital area] is very red and swollen, red rash in groin."

The need to ensure the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed for a significant change of condition, and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings. No further information was provided.

1. Resident #5 fall interventions for incidents listed in the Statement of Deficiency (SOD) were developed and communicated to staff then added to the care plan. Additional items listed in the SOD for Resident 5 including ER visit, medication changes, skin issues, and oxygen use were reviewed and appropriate interventions were communicated to staff and added to resident's care plan. Resident #1 was placed on monitoring on 10/16/23 related to missing medications and was monitored until medications were received on 10/20/23. Resident #6 was reviewed for medication changes and suicidal ideation. Interventions were developed as appropriate and added to resident's care plan. Resident #3 was reviewed for concerns regarding dining room and potentially homophobic speech that upset resident. Intervention developed and added to resident's care plan. Resident #4 was reviewed for medication changes and interventions were developed as needed and added to the care plan. Resident #2 was reviewed for hospital visits, skin issues, and catheter care. Interventions were developed and added to the care plan.

2. Daily at clinical meeting, resident changes, including but not limited to medication and skin changes, hospital/ER visits, fall interventions and behavioral changes will be reviewed and followed up on as appropriate. Community wil also complete a collaborative care review each month in which every resident will be reviewed by department head team. Medication Techs (MT), RCCs, and Health and Wellness Director were provided with training regarding TSPs, change of condition and monitoring, and staff log. All residents were reviewed for changes in condition and interventions were developed and added to care plans as needed.

3. Daily for any resident changes and monthly for all residents

4. Health and Wellness Director and Executive Director, or designee.

3. Resident 10 was admitted to the facility in 10/2023.

Resident 10's clinical record and charting notes, reviewed from 12/18/23 through 01/29/24, revealed the following:

On 12/23/23, staff reported the resident had a bed bug infestation. S/he was immediately relocated to another apartment until the infestation was resolved. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.

Additional information was requested on 01/31/24.

On 01/31/24, Staff 1 (ED) reported she reviewed the resident's record and concluded the short-term change in condition had not been monitored until resolved. No further information was provided.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24 at 2:40 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents with changes of condition were evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and the conditions were monitored through resolution for 3 of 4 sampled residents (#s 8, 9 and 10) who were reviewed with changes of condition. Resident 8 experienced a significant and ongoing decline in his/her ability to eat independently and had a severe weight loss. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition.

Review of clinical records, including the resident's evaluation and service plan dated 01/18/24, progress notes, observations of the resident, and interviews with staff and the resident revealed the following:

The resident's evaluation dated 01/18/24 indicated the resident was on a regular diet with thin liquids, had natural dentition and reported no problem chewing. The resident was able to cut up his/her own food, had a history of malnutrition, and ate all meals in his/her apartment. Staff were to unwrap his/her meal tray and cue the resident to eat. If s/he did not eat at least 50% of the meal, staff were instructed to report to LN/RCC for additional monitoring as needed.

The resident's service plan dated 01/18/24 directed staff to uncover and set-up meal trays and offer a "Mighty Shake" (nutritional supplement) with meals.

Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated hospice providers left the following information and instructions for nutrition and hydration for the facility:

* 09/29/23 - "Patient with difficulty at times bringing food to mouth."

* 09/30/23 - "Patient appears to be declining. Please keep an eye on patient for signs of decline and call hospice when needed."

* 10/02/23 - "Increased swallowing difficulty, more frequent checks, especially during meals due to difficulty swallowing."

* 10/06/23 - "Patient very drowsy, uneaten breakfast before them, began eating banana peel, patient appearing more thin. Patient is more thin in face and eating less."

* 11/22/23 - "Patient unable to focus, uneaten lunch on the over the bed table.

* 12/12/23 - "Patient unable to focus, unable to bring food to mouth. Assisted with one bite of food, patient took a long time to chew and swallow one bite."

* 12/29/23 - "Patient's breakfast untouched and out of reach."

* 01/23/24 - "Patient attempting to eat Jell-o, drizzled all down front, same with chocolate candy."

* 01/24/24 - "Less alert/oriented."

Observations of the resident at morning and noon meals between 01/29/24 through 01/30/24 showed the resident was bed bound, weak with decreased strength, and fluctuating levels of alertness. The resident demonstrated difficulty managing the utensil, scooping the food and bringing it to his/her mouth, and difficulty chewing and swallowing. The resident had difficulty grasping a water bottle and bringing it to his/her mouth to drink. The resident had dry, chapped lips and a dry oral cavity. The resident was observed to eat less than 50% of meals.

Interviews with the resident, staff and Witness 1 (hospice RN) between 01/29/24 through 01/31/24, showed the following:

* Resident 8 stated, "Softer foods might be nice...I could use some help with eating."

* Staff 9, 23, 25, and 27 (MT/CGs) stated they did not provide one-to-one feeding assistance, staff did not provide a nutritional supplement drink and did not document or monitor Resident 8's meal intakes.

* Witness 1 stated she spoke to Staff 1 (ED) and Staff 2 (Health and Wellness Director) on multiple occasions and requested the facility to provide one-to-one feeding assistance for Resident 8 and was informed the facility did not provide feeding assistance.

On 01/30/24, the previous six months of weight records were requested and identified the following:

* On 06/21/23, the initial move-in weight for Resident 8 was 72 pounds. The facility was unable to provide additional weight records.

* On 01/31/24 at 2:20 pm, the surveyor requested a current weight for the resident. The surveyor observed Staff 29 (CG) obtain the resident's weight. The resident weighed 60 pounds, indicating a 12 pound weight loss, which constituted a 16.6% loss of body mass within six months. This constituted a severe weight loss.  

There was no documented evidence the facility evaluated and monitored Resident 8's ability to eat independently and consume adequate nutrition/hydration to determine resident-specific actions or interventions that were needed to prevent weight loss, communicated the actions or interventions to staff on each shift, and reviewed the interventions for effectiveness. This put the resident at risk for weight loss.

On 01/30/24, two surveyors and Staff 28 (Regional RN) observed the resident at the noon meal. Staff 28 acknowledged the resident was unable to independently feed him/herself. Staff 28 stated she would develop interventions to ensure the resident received the assistance needed to ensure his/her nutritional needs were met. On 02/01/24, the facility provided a temporary service plan (TSP) with the following interventions and staff instructions:

* Sit the resident upright in bed at a 90 degree angle;

* Place a chair at the side of the bed facing the resident to assist the resident during the meal;

* Allow the resident to feed herself when possible, engage the resident in conversation;

* If it is necessary to assist the resident with eating, try cueing. If more assistance is needed, show the resident how to eat by demonstrating the hand over hand technique;

* If complete assistance with eating is needed, offer small bites of food and offer fluids frequently and alternate food with a beverage; and

* Do not rush the resident. Allow the resident adequate time to chew and swallow before introducing or assisting the resident with the next bite of food or drink of fluid.

On 02/01/24 the need to ensure Resident 8's weight loss and ADL decline was evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, documentation of staff instructions or interventions was resident specific and was made part of the resident record was discussed with Staff 1 (ED) and Staff 6 (RCC). They acknowledged the findings.

b. Review of the Assisted Living Open Area Flow Sheet dated 12/08/23, identified a left shin skin tear.

The resident's December 2023 and January 2024 MARs and TARs did not reflect any hospice instructions for wound care treatment.

There was no documented evidence the facility updated the resident's service plan with the hospice instructions or communicated the new instructions to staff.

The facility failed to ensure Resident 8's skin tear was evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, documentation of staff instructions or interventions was resident specific and made part of the resident record with weekly progress noted until the condition resolved.

The skin tear, observed on 02/01/24 at 11:50 am with Staff 6 (RCC), revealed the left lower leg was bruised and the skin was scabbed. Staff 6 and the surveyor agreed the skin tear warranted further monitoring.

The facility's failure to ensure Resident 8's skin tear was evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and monitoring of the wound at least weekly through resolution was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

2. Resident 9 moved into the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes mellitus.  

The resident's clinical record, including progress notes, was reviewed, and interviews were conducted.

The following change of conditions lacked documentation of resident specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and documentation of progress noted, at least weekly, through resolution:

a. Review of "Open Area Flow Sheet" identified redness in the groin area with onset date 11/27/23.

On 01/19/24, Staff 2 (Health and Wellness Director) noted the skin was intact, macerated and redness persists. Will continue to monitor weekly or until resolved.

Review of the December 2023 MAR identified MT's were initialing the MAR for administration of barrier cream one time per day.

Observation of the medication cart on 01/30/24 at 12:45 pm, identified there was no barrier cream in the medication cart. Staff 9 (MT) reported, "I think the caregivers are applying it."

There was no documented evidence the facility provided written communication of the resident's skin issue and any required interventions, for caregivers on each shift and documentation the facility monitored the skin issue with progress noted at least weekly through resolution.

b. Review of "Open Area Flow Sheet" identified a skin injury to the left side of the coccyx bone with onset date 12/26/23.

On 01/19/24, Staff 2 noted wound measurements for the left side of coccyx were 1.7 x 1.1 x 0 cm, skin was pink and intact. No signs of infection, cleansed area and covered with Opi-foam. Will continue to monitor weekly or until resolved.

There was no documented evidence the facility monitored the resident's left side of coccyx bone with progress noted at least weekly through resolution.

c. Review of "Open Area Flow Sheet" identified a skin injury to the right side of the coccyx bone with onset date 12/26/23.

During an interview and observation of the medication cart on 01/30/24, with Staff 9 (MT), reported "hospice does wound care. We do it if it comes off." Staff 9 was unable to explain the wound care that was needed if the bandage came off and was not able to locate any bandages or other wound care supplies in the medication cart for the resident.  

Review of the MAR for December 2023 and January 2024 provided no instructions for unlicensed staff to provide the wound care and there was no documented evidence the wound care instructions were added to the service plan and/or were communicated to staff.

There was no documented evidence the facility provided written communication of the resident's skin issue and any required interventions for caregivers on each shift, and documentation the facility monitored the skin issue with progress noted at least weekly through resolution.

The need to ensure resident specific actions or interventions were determined and documented, communicated to staff on each shift, and the conditions were monitored, consistent with the resident's evaluated needs, with progress noted, at least weekly, until resolved was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

Refer to C 280, example 2b.

1. Resident 8's service plan was updated to reflect nutritional needs including feeding assistance, nutritional shakes, and coordination with hospice. Resident is on a nutritional monitoring plan which includes monitoring food intake, providing nutritional supplement shakes and weekly weights. The gathered information will be reviewed by Executive Director, Health and Wellness Director, and/or Designee regularly to monitor resident's progress. Interventions will be evaluated for effectiveness ongoing and updated as needed. Re-education was provided during the staff meeting on 2/1/2024 regarding resident's nutritional plan. Additional clarification regarding delivery of resident's nutritional supplement shakes was provided to Medication Technicians on 2/8/2024. Dining Services Coordinator is also provided a weekly Nutrition Tracker, which has updated details of resident's nutritional needs for her to share with dining staff. Resident 9's orders for wound treatment were updated on 1/31/24 to reflect current hospice orders. Additionally, a Temporary Service Plan was initiated to communicate these treatments to care staff. For Resident 10, chart note was completed recording date resident returned to his apartment, closing the monitoring for relocation.

2. Changes in condition including, but not limited to weight changes, changes in Activities of Daily Living, skin changes, will be discussed on weekdays at clinical meeting and communicated to staff via Temporary Service Plans. Alert Charting will be completed at least once per day by community staff and then closed by Executive Director, Health and Wellness Director, or designee. If temporary changes are significant or ongoing, an assessment will be completed by Health and Wellness Director or nurse designee and updated on resident's service plan as needed.

3. Temporary changes will be monitored on week days during clinical meeting, daily charting to be completed, and service plan changes to be made as necessitated by resident changes.

4. Executive Director, Health and Wellness Director, and/or Designee

2. Resident 5 was admitted to the facility in 01/2021 and had a with diagnosis of hypertensive heart failure.

During a 10/18/23 interview, Staff 2 (Health and Wellness Director) reported  Resident 5 underwent heart surgery including placement of a pacemaker in 06/2023. According to Staff 2 the resident continued to experience a decline in health including weakness and began to require staff assistance with ADL's after the surgery. The resident was admitted to hospice on 07/09/23. This constituted a significant change in condition requiring an RN assessment.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

During a 10/18/23 interview, Staff 2 (Health and Wellness Director) acknowledged an RN assessment had not been completed for Resident 5's hospice admission.

The need for the facility RN to conduct an assessment when a resident experienced a significant change of condition, was reviewed with Staff 1 (ED) and Staff 2 on 10/19/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and/or completed timely for 2 of 3 sampled residents (#s 2 and 5) who experienced a significant change of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2023 with diagnoses including chronic kidney failure stage 4 (severe) and type 2 diabetes mellitus with diabetic chronic kidney disease.

A review of the resident's clinical record dated between 07/17/23 and 10/15/23 identified the following:

a.  An after-visit summary from the outside provider group, dated 10/02/23, stated Resident 2 "had a left ureteroscopy, laser lithotripsy and stent placement. [Resident 2] also had a suprapubic tube placement today."

The suprapubic tube placement constituted a significant change in condition requiring an RN assessment.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

b. Home Health Third Party Provider Collaboration Notes dated 07/18/23 indicated the presence of a pressure ulcer stage II. The facility RN completed an assessment of the pressure ulcer on 07/26/23, 8 days after the wound was identified and was not timely.

The need to ensure an RN assessment was completed and/or completed timely for residents who experienced a significant change of condition was reviewed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings. No further information was provided.

1. RN completed assessment for Resident 2 regarding change of condition related to suprapubic cathereter placement and on current skin deficits on 11/3/23. RN completed change of condition assessment for Resident 5 on 10/23/23 related to admission to hospice and care changes.

2. Resident health changes will be reviewed and discussed daily at clinical meeting.  All residents will be reviewed monthly by department head team at collaboritive care review. All residents reviewed for change of condition then nursing assessments and service plan updates were completed as needed

3. Daily for resident changes and monthly for all residents.

4. Health and Wellness Director and Executive Director, or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 8 and 9) who experienced significant changes of condition. Resident 8 experienced a decline with ADLs and a severe weight loss. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition.

Observations of the resident, staff interviews, progress notes, and the 01/18/24 evaluation and service plan were reviewed during the survey.

The evaluation and the service plan dated 01/18/24 identified the following:

* The resident was on a regular diet with thin liquids;

* The resident had natural dentition and had no problems chewing;

* The resident was able to cut up his/her own food;

* Ate all meals in his/her apartment;

* Staff were to unwrap his/her meal tray and cue the resident to eat;

* If the resident did not eat at least 50% of his/her meal, staff were instructed to report to LN/RCC for additional monitoring as needed; and

* Staff to offer the resident a "Mighty Shake" (nutritional supplement) with meals.

Observations of the resident 01/29/24 through 01/30/24 morning and noon meals identified the following:

* The resident was bed bound, weak with decreased strength, and fluctuating levels of alertness;

* Demonstrated difficulty managing the utensil, scooping the food, difficulty grasping his/her water bottle and bringing it to his/her mouth to eat and drink;

* Difficulty chewing and swallowing;

* The resident had dry, chapped lips and a dry oral cavity;

* The resident was observed to eat less than 50% of meals; and

* There was no nutritional supplement provided to the resident.

Interviews with the resident, staff and Witness 1 (hospice RN) on 01/29/24 through 01/31/24, showed the following:

* Resident 8 stated, "Softer foods might be nice...I could use some help with eating."

* Staff 9, 23, 25, and 27 (MT/CGs) stated they did not provide one-to-one feeding assistance, did not provide the resident with a nutritional supplement and did not document or report Resident 8's meal intakes.

* Witness 1 stated she spoke to Staff 1 (ED) and Staff 2 (Health and Wellness Director) on multiple occasions and requested the facility to provide one-to-one feeding assistance for Resident 8 and was informed the facility did not provide feeding assistance.

On 01/30/24, the previous six months of weight records were requested and identified the following:

* On 06/21/23, the initial move-in weight for Resident 8 was 72 pounds. The facility was unable to provide additional weight records.

* On 01/31/24 at 2:20 pm, the surveyor requested a current weight for the resident. The surveyor observed Staff 29 (CG) weigh the resident. The resident's weight at that time was 60 pounds, indicating a 12-pound weight loss, which constituted a 16.6% loss of body mass within six months. This constituted a severe weight loss.  

The resident's decline in ADLs to eat independently and maintain adequate nutrition and hydration, constituted a significant change of condition, requiring an RN assessment.

There was no documented evidence the RN completed an assessment of the resident's ADL decline, which documented findings, resident status, and interventions made as a result of the assessment. This put the resident at risk for severe weight loss.

On 01/30/24, two surveyors and Staff 28 (Regional RN) observed the resident at the noon meal. Staff 28 acknowledged the resident was unable to independently feed him/herself. Staff 28 stated she would develop interventions to ensure the resident received the assistance needed to ensure his/her nutritional needs were met.

The facility's failure to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment for Resident 8's ADL decline in his/her ability to eat independently and the severe weight loss was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

Refer to C 270 example 1a, C 290 example 1b.

2. Resident 9 moved into the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease (COPD) and Type 2 diabetes mellitus. During the acuity interview it was reported the resident recently had a rapid decline in ADL ability and had admitted to hospice.

Review of the resident's clinical record, including charting notes and current evaluation and service plan dated 01/12/24 identified the following:

a. The resident had a significant decline in ADL ability and admission to hospice on 01/12/24. This constituted a significant change of condition that required an RN assessment.

There was no documented evidence of an RN assessment which documented findings, resident status and condition, and any interventions needed as a result of the assessment.

b. The resident had multiple chronic reoccurring pressure wounds on the left and right side of coccyx bone with onset date 12/26/23.

Review of the MAR for December 2023 and January 2024 provided no instructions for unlicensed staff to provide the wound care and there was no documented evidence the wound care instructions were communicated to staff.

During an interview on 01/29/24, Witness 3 (hospice RN)  reported the resident had Stage 2 wounds on his/her buttocks area and upper leg area near the skin folds where his/her upper leg and buttock joined.

During an interview on 01/29/24 with Staff 1 (ED) and Staff 2 (Health and Wellness Director), it was reported s/he doesn't have any open wounds. Staff 1 stated "there is discrepancies in the documentation from HH and what hospice is reporting to us." Staff 1 requested Staff 2 "take a look at it and report back to her."

On 01/29/24 at 3:30 pm, Staff 2 reported "There is no open area on [his/her] thighs. I didn't look at the coccyx, or that area, I didn't remove[his/her] brief."

Upon review of the resident's clinical record there was no documented evidence the RN completed an assessment of the wounds which documented findings, resident status and condition and any interventions needed as a result of the assessment, and there was no update to the service plan to include the above wound care instructions.

At the request of the survey team, the RN surveyor and Staff 28 (Regional RN) made observations of the resident's coccyx, buttocks, left and right posterior upper thigh area. Staff 28 completed a skin assessment and determined the resident's skin status required continued skin monitoring. Staff 28 also initiated the following skin care interventions: repositioning three to four times per shift, hospice will provide a new order for zinc oxide, an air alternating mattress and a new hospital bed.

The need to ensure the RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. Significant change in condition assessment was completed on 1/31/24 for Resident 8 in regards to her ability to feed herself. Changes and instructions for staff were communicated via a Temporary Service Plan.  Service plan was updated with resident's current needs and staff instruction. Significant change in condition assessment was completed on 1/31/24 for Resident 9 on regarding her skin condition and catheter. Changes and instructions for staff were communicated via Temporary Service Plan and nursing orders updated in the Medication Administration Record. Service plan was updated to reflect the resident's current needs and staff instruction.

2. When a change of condition is identified, Heath and Wellness Director or nurse designee will complete a nursing assessment. Any staff instruction or ongoing monitoring needs will be communicated to staff with Temporary Service Plans, on the Medication Administration Record, and with Service Plan updates as needed. Executive Director will review a significant change in condition with Health and Wellness Director to verify each step is completed.

3. The assessment will be completed with each significant change in condition as needed.

4. Executive Director, Health and Wellness Director, and/or Designee

2. Resident 5 was admitted to the facility in 01/2021 and was admitted to hospice in 07/2023.  

The resident's 07/16/23 through 10/16/23 "Home Health/Hospice/Third Party Provider Collaboration Notes", progress notes, Temporary Service Plans (TSP's) and 08/01/23 service plan were reviewed. The records indicated Resident 5 received hospice services from an outside provider for concerns including hypertensive heart failure.

Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated hospice providers left the following instructions for the facility:

* 09/11/23 - "Staff to offer stand by assist with ambulation ...continue to keep head of bed elevated"; and

* 10/07/23 - "Encourage patient to wear oxygen."

There was no documented evidence the facility updated the resident's service plan with those instructions or communicated the new instructions to staff.

The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided for 2 of 3 sampled residents (#s 4 and 5) who received on-site health services. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 06/2023 with diagnoses including history of falling and congestive heart failure.

The "Home Health/Hospice/Third Party Provider Collaboration Notes," dated 07/12/23 through 08/30/23, were reviewed and revealed the following recommendations:  

* 08/08/23 - "Please encourage activity engagement of walking with assist.";

* 08/09/23 - "Order has been send for stool collection to be placed on ice. Please call...if stool is collected.";

* 08/18/23 - "Please ask [him/her] about pain before bed.";

* 08/23/23 - "Please check [resident's] pain level every shift. Fax to follow.";

* 08/30/23 - "Assist patient with Dermafit [compression stockings]. Don in am, off in pm. Should have order to check pain level."

Resident 4 was observed without Dermafit donned throughout the morning and daytime hours on 10/17/23 and 10/19/23.

There was no documented evidence the facility updated the resident's service plan as necessary after being informed of the new interventions.  

The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

1. By 11/15/23, recomendations from Outside Providers reviewed for Resident #4 and #5 and commuicated to staff via TSPs and eMAR as needed.

2. Outside provider notes will be reviewed at daily clinical meeting and updates will be made to resident records as appropriate. Outside Provider notes for the last 30 days were reviewed and interventions developed as needed.

3)  Daily at clinical meeting.

4)  Health and Wellness Director and Executive Director, or designee.

Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside service providers to ensure staff were informed of new interventions and the service plan was adjusted as necessary for 2 of 2 sampled residents (#s 8 and 9) who received outside services. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved  into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition. During the acuity interview, staff reported the resident received hospice services.

Observations of the resident, the resident's 12/08/23 through 01/24/24 "Home Health/Hospice/Third Party Provider Collaboration Notes", progress notes, and 01/18/24 service plan were reviewed. The records indicated Resident 8 received hospice services for concerns including difficulty swallowing and wound care.

a. Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated hospice providers left the following wound care instructions for the facility:

* 12/08/23 - "The patient has a wound on his/her left shin. Hospice orders included: cleanse with wound cleanser, pat dry with gauze, apply skin prep, spray or wipe to intact skin surrounding the wound, cover with bandaid bordered gauze, change every seven days or PRN soilage or coming off, ok to discontinue once area is healed."

* 12/30/23 - "The bandage on the resident's left shin was removed to be open to air and to keep the resident clean, dry and apply barrier cream."

There was no documented evidence the facility updated the resident's service plan or December 2023 MAR with the hospice instructions or communicated the new instructions to staff.

b. Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated hospice providers left the following information regarding nutrition and hydration for the facility:

* 12/12/23 - "Patient unable to focus, unable to bring food to mouth. Assisted with one bite of food, patient took a long time to chew and swallow one bite."

* 12/29/23 - "Patient's breakfast untouched and out of reach."

* 01/23/24 - "Patient attempting to eat Jell-o, drizzled all down front, same with chocolate candy."

* 01/24/24 - "Less alert/oriented."

In an interview on 02/01/24 at 11:05 am, Staff 1 (ED) stated there was no facility follow-up on the information from hospice's notes.

There was no documented evidence the facility nurse reviewed the above outside service provider notes that were left in the facility and adjusted the resident's services and service plan, as applicable.

The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

2. Resident 9 moved into the facility in 03/2017 with diagnosis including chronic obstructive pulmonary disease (COPD) and Type 2 diabetes mellitus.

During the acuity interview it was reported the resident was receiving home health services and recently admitted to hospice.

The resident's 12/18/23 through 01/29/24 "Home Health/Hospice/Third Party Provider Collaboration Notes", progress notes, Temporary Service Plans (TSP's) and 01/12/24 service plan were reviewed.

Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated home health providers left the following instructions for the facility:

* 12/22/23 - home health recommendation: manual wheelchair needs to be replaced for a larger wheelchair due to the wheelchair causing skin injury;

* 12/22/23 - home health recommendation: Assess patients pain every four hours;

* 01/09/24 - home health recommendation: Delegation to MT to change posterior right thigh wound dressing and coccyx wound dressing every Tuesday and PRN to keep wounds covered until healed.

On 01/30/24 at 12:16 pm the surveyor observed the resident's wheelchair had not been replaced and the resident confirmed s/he had not received a new wheelchair.

On 02/01/24 at 9:45 am the surveyor and Staff 9 (MT) observed wound care supplies were not in the medication cart.

There was no documented evidence the facility updated the January MAR or updated the resident's service plan with those instructions or communicated the new instructions to staff.

The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. For Resident 8, a skin assessment was completed by the nurse on 1/31/24 to identify any current skin issues and to coordinate with hospice regarding reccomendations for wound care as needed. Additionally, a nutritional plan was developed in collaboration with hospice to include feeding assistance, food intake monitoring, nutritional shakes, and weekly weight monitoring. Third Party Notes for January and February 2024 will be reviewed by 3/17/24 to verify that recommendations were appropriately communicated to staff via Temporary Service Plan.  The Executive Director or Health and Wellness Director or designee, will follow up to verify that these recommendations were implemented along with their effectiveness. For Resident 9, the Executive Director coordinated with hospice regarding resident's wheelchair.  A progress note was completed, and instructions for staff were communicated via a Temporary Service Plan. Skin assessment was completed for Resident 9 on 1/31/24 by RN to identify current skin concerns and coordinate with hospice regarding necessary wound care. Wound care orders were communicated to staff via Temporary Service Plan and in the Medication Administration Record.

2. Executive Director or designee will review each third party collaboration note and provide to Health and Wellness Director any which note changes in the resident's condition. The Executive Director, Health and Wellness Director, and/or designee will complete Temporary Service Plans, update Medication Administration Record, and document skin changes as needed based on third party coordination.

3. Notes will be reviewed Monday through Friday at clinical meeting with updates and assessments completed as needed.

4. Executive Director, Health and Wellness Director, and/or Designee.

Based on interview and record review, it was determined the facility failed to carry out medication and treatment orders as prescribed and ensure written, signed physician orders were documented in the resident's facility record for all medications the facility was responsible to administer for 4 of 6 sampled residents (#s 3, 4, 5, and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including depression and high blood pressure.

Physician's orders and MARs dated 09/01/23 through 10/16/23 were reviewed. The following medications were identified as not being available to staff for administration:

* Citalopram (for major depression), 10 mg once daily, was not available from 09/22/23 through 09/30/23;

* Docusate (for constipation), 100 mg once daily, was not available on 09/22/23, from 09/27/23 through 09/29/23, and from 10/01/23 through 10/08/23;

* Lisinopril (for high blood pressure), 20 mg once daily, was not available on 09/23/23; and

* Loratadine (for allergies), 10 mg once daily, was not available from 09/21/23 through 10/12/23.

On 10/19/23 at 11:14 am, Staff 1 (ED) confirmed the facility purchased docusate and loratadine for Resident 6, and s/he was recently enrolled in a monthly auto-fill program with the resident's pharmacy for physician-ordered medications.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 1, Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

4. Resident 5 was admitted to the facility 01/2021 with diagnoses including Type 2 diabetes and heart disease.

The resident's MARs, dated 09/01/23 through 10/16/23, and physician's orders were reviewed. The following were identified:

Resident 5 had a physician order to administer metoprolol succinate (for hypertension) 50 mg once daily. Hold for systolic blood pressure (SBP) less than or equal to 110 and hold for heart rate less than or equal to 60.

a. The MARs showed Resident 5 was administered the medications when the resident's SBP was within the "hold" parameters and should have been held, as follows;

* 09/01/23 - SBP reading was 103, metoprolol was administered; and

* 09/11/23 - SBP reading was 103, metoprolol was administered.

b. Resident 5's Humalog orders (insulin) directed the facility to notify the RN and the physician when the residents's blood sugar level exceeded 350.

The resident's blood sugars levels exceeded 350 on 09/01/23, 09/02/23, 09/16/23, 09/20/23, 09/22/23, 09/24/23, 09/27/23, 09/29/23, and 09/30/23. There was no documented evidence the RN and physician were notified as ordered.

c. Resident 5's physician order, dated 09/15/23, directed staff to "add oxygen to the plan of care at [two liters], PRN for saturations below 88%."

In an interview with Staff 2 (Health and Wellness Director) on 10/18/23, she acknowledged the order was received but not updated on the MARs.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including hypertension and orthostatic hypotension.

Resident 3's MARs, dated 09/01/23 through 10/16/23, and corresponding progress notes and prescriber orders were reviewed and revealed the following:

The resident had an order for Midodrine HCl 5 mg (for orthostatic hypotension) to be administered one tablet three times daily. If blood pressure was greater than 135/60, order stated to hold medication dose one time a day.

* Midodrine HCl was held on 12 occasions in September and on two occasions in October when orders were to administer; and

* Midodrine HCl was administered on three dates in September when blood pressure was greater than 135/60 and no medication dose was held on those dates.

The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings,

3. Resident 4 was admitted to the facility in 06/2023 with diagnoses including anemia and cervicalgia (neck pain).

Resident 4's MARs, dated 09/01/23 through 10/16/23, corresponding progress notes and physician's orders were reviewed and revealed there was no documented evidence the facility had physician's orders to administer the following medications:

* Ascorbic acid tablet (for supplement), 250 mg, one tablet, once daily;

* Ferrous sulfate tablet (for supplement), 325 mg, one tablet, once daily; and

* Hydrocodone (for pain), 5-325 mg, one tablet, four times daily.

The need to ensure signed physician or other legally recognized practitioner orders for all medications were in the resident's facility record was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings, and no additional documentation was provided.

1. For Resident #6 medications listed in SOD were ordered or purchased. For Resident #3 order was clarified from provider to hold Midodrine for blood pressure greater than 135/60 each time the medication is given. For Resident #4 signed orders were obtained for medications listed in SOD. For Resident #5, MTs were provided with training regarding nursing notifications and oxygen order was update in the MARs.  

2. Health and Wellness Director (HWD) or designee will review missed medications during clinical meeting and assist in reordering medications as needed. Medication carts will be audited monthly to review supplies on hand. Medications for individual residents will be reviewed quarterly during service planning again to reconcile supplies with physician orders. MTs received training regarding medication ordering, when to notify the HWD, and order entry. All resident's were reviewed too ensure signed orders and all medications were on hand

3. Daily during clinical meeting, monthly during cart audits, and quarterly during service planning.

4. Health and Wellness Director and Executive Director or designee

Based on observation, interview, and record review, it was determined the facility failed to carry out medication and treatment orders as prescribed for 2 of 3 sampled residents (#s 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition.

Review of Resident 8's physician orders dated 01/12/24 and MARs from 12/18/23 through 01/29/24 revealed the following:

Resident 8's physician's order dated 06/21/23 which directed staff to provide a nutritional supplement drink, such as Boost or similar product, three times a day with every meal.

Observations of the resident during the morning and noon meals on 01/29/24 through 01/31/24 revealed Resident 8 did not receive the physician ordered nutritional supplement drink despite staff signed as provided on the resident's MARs.

Interviews conducted with staff on 01/29/24 through 01/30/24 between 10:20 am - 4:10 pm revealed the following: Staff 13 (MT), Staff 24 (Dining Services Manager), Staff 23, 25 and 27 (CGs), stated they were unaware Resident 8 had an order to receive a nutritional supplement drink with each meal.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

2. Resident 9 moved into the facility in 03/2017 with diagnoses including Type 2 diabetes mellitus.

Resident 9's MARs, dated 12/18/23 through 01/29/24 and prescriber orders were reviewed and identified the following:

a. The resident had an order for Lantus SoloStar insulin (for diabetes) to inject 33 units in the morning. Hold for CBG under 150.

* On 12/18/23 the residents CBG was 120;  

* On 12/25/23 the residents CBG was 131; and

* On 01/01/24 the residents CBG was 200.

There was no documented evidence the insulin was held on 12/18/23 or 12/25/23 and on 01/01/24 the MAR indicated the insulin was held when it should have been administered.

b. The resident had an order for sliding scale Insulin Lispro (for diabetes), CBG's 141-180 administer 2 units.  

On 12/17/23 the residents CBG was recorded as 144. The MAR noted the MT held the insulin when they should have administered 2 units.

The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. Re-education was provided on 2/1/24 for unlicensed staff and on 2/8/24 for Medication Technicians regarding Resident 8's Nutritional Shake. Re-education for Medication Technicians regarding parameters for holding medications, and notification to the resident's physician has been scheduled for 3/6/24. Resident 9's insulin was discontinued so no further invention needed for that medication. Full review of Medication Administration Records for parameters, notifications, and clarification for unlicensed staff will be completed for the other residents by 3/17/24.

2. Medications held for outside parameters will be reviewed as part of clinical meeting daily to verify the parameters were followed and notifications made as needed.

3. Daily at clinical meeting.

4. Health and Wellness Director, Executive Director, or Designee

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 1 of 1 sampled resident (# 1), who had documented medication and treatment refusals. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 06/2023 with diagnoses including cervicalgia (neck pain), constipation, and heart failure.

The resident's MARs, dated 09/01/23 through 10/16/23, were reviewed and revealed facility staff documented Resident 4 refused the following orders:

* Acetaminophen (for pain) on three occasions;

* Metamucil (for constipation) on 15 occasions; and

* Daily weights on six occasions.

On 10/18/23, Staff 2 (Health and Wellness Director) confirmed there was no documented evidence the practitioner was notified of the multiple medication and treatment refusals.

On 10/19/23, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC).  They acknowledged the findings, and no additional documentation was provided.

1. Resident #4's provider was notified of medication refusals.

2. Daily at clinical meeting all medication refusals and notifications will be reviewed for completion.  Any missed notifications will be completed at this time. Medication refusals  and notifications were reviewed for October 2023 for all residents to ensure physican was notified.

3. Daily at clinical meeting.

4. Health and Wellness Director and Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 3 of 5 sampled residents (#s 3, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including depression and high blood pressure.

Physician's orders, MARs dated 09/01/23 through 10/16/23 and progress notes dated 07/17/23 through 10/14/23 were reviewed. The following inaccuracies were found:

a. The parameters for administering lisinopril (for high blood pressure) were to notify the RN if "systolic [blood pressure] is above 160 or less than 90; if diastolic [blood pressure] is above 100 or less than 50; pulse is above 100 or less than 60." There were 31 times from 09/01/23 through 10/16/23 that the blood pressures or pulse rate was outside of the parameters. There was no documented evidence the RN was notified.

b. Staff were directed to monitor for "significant side effects" related to an anti-depressant and lists the side effects of dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, and decreased appetite. The RN directed staff on each shift to "Document (+) if present and notify MD; (-) if not present." Staff documented "(+)" on 09/12/23, 10/08/23, and 10/14/23. There was no documented evidence the facility contacted the physician on the three dates.

Additionally, staff were documenting "NA", "X", "0", "n", "N", and "y" instead of "(+)" or "(-)" as directed, 58 times between 09/01/23 through 10/16/23.

d. Staff were directed to monitor the resident for depression on each shift, they were directed to "Document number of times behavior occurs", and "if present attempt non-pharmacological interventions: A - calm approach, B - therapeutic communication, C - decrease stimulation, D - see behavior note." Lastly, staff were to document "E-effective, I-ineffective". There were 42 instances between 09/01/23 and 10/16/23 when staff entered information that was not accurate based on the MAR instruction.

The need to ensure residents' MARs were accurate was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

3. Resident 5 was admitted to the facility 01/2021 with diagnoses including Type 2 diabetes and heart disease.

The resident's MAR, dated 09/01/23 through 10/16/23, and physician's orders were reviewed. The following inaccuracies were identified:

* Resident 5's physician order for hyoscyamine (for secretions) 0.125 mg tablet directed staff to give every four hours;

* Resident 5's MARs for hyoscyamine 0.125 mg tablet directed staff to give one tablet every four hours PRN;

* Resident 5's physician order for haloperidol lactate (for agitation) 2 mg directed staff to give every six hours PRN; and

* Resident 5's MARs did not reflect the order for haloperidol lactate 2 mg PRN.

In an interview with Staff 2 (Health and Wellness Director) on 10/18/23, she acknowledged the order for haloperidol lactate was discontinued by the physician and the MARs were not updated.  

The need to ensure the MARs were accurate was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including constipation.

The resident's 09/01/23 through 10/16/23 MARs and physician's orders were reviewed. The following PRN bowel medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order:  

* Fleet enema;

* Milk of magnesia; and

* MiraLax powder.

During an interview on 10/18/23, Staff 9 (MT/Caregiver) confirmed the electronic MAR system did not have parameters on which medication should be administered and in what order listed for staff.

The need to ensure resident's MAR was accurate and included resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC).  They acknowledged the findings.

1. Training provided to all Med Techs in regards to Resident #6 hold parameters and notifications to the RN. RN clarified parameters for bowel care meds for Resident #3. Resident #5's MAR updated to reflect current physician orders.

2. Daily at clinical meeting, MAR documentation as well as new physican orders will be reviewed to ensure MAR accuracy. During quarterly service planning, medication lists will be reviewed for medication parameters and then sent to physician for review. When resident's receives new or updated medication orders they will be monitored for potential adverse side effects and any ongoing interventions related to medications will be added to the care plan.

3. Daily at clinical meeting.

4. Health and Wellness Director and Executive Director or designee

3. Resident 10 was admitted in 10/2023 with diagnoses which included hypertension and diabetes.

Residents 10's MARs and physician orders were reviewed from 01/01/24 through 01/29/24 and the following was noted:

* The physician discontinued an order for Benadryl 25mg one tablet every six hours as needed for rash on 11/21/23. However, the discontinued medication was still listed on the current MAR; and

* Resident 10's MAR instructed staff to administer Milk of Magnesia 30 ml as needed for bowel care "if Miralax is ineffective". However, neither the MAR nor record had an order for Miralax.

In an interview on 01/31/24 at 3:15 pm, Staff 1 (ED) reviewed the resident's MAR and acknowledged it was inaccurate. She stated the MAR would be updated to reflect current, accurate orders.

On 02/01/24 at 2:40 pm, the need to ensure MARs were accurate was discussed with Staff 1 (ED) and Staff 6 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 3 of 3 sampled residents (#s 8, 9, and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition.

a. Resident 8's MARs and physician orders were reviewed from 01/01/24 through 01/31/24 and found to be lacking resident-specific parameters and instructions for the following medications:

* The MAR included multiple PRN pain medications that lacked clear parameters related to what sequence they should be administered and the MAR did not contain resident specific instructions for staff describing how the resident expressed pain.

* The MAR included multiple PRN psychotropic medications for anxiety, agitation, and delirium. The MAR did not contain resident specific instructions for staff describing how the resident expressed anxiety, agitation, and delirium.

b. From 01/01/24 through 01/30/24 MT's initialed that they administered a nutritional supplement three times per day. However, interviews with Staff 9 (MT) and Staff 13 (MT) revealed staff had not consistently administered the supplement and the MAR was inaccurate.

On 02/01/24, the need for an accurate MAR including resident-specific parameters and clear instruction for unlicensed staff was discussed with Staff 1 (ED) and Staff 6 (RCC). They acknowledged the findings.

2. Resident 9 moved into the facility in 03/2017 with diagnoses including Type 2 diabetes mellitus.

The resident's MAR, dated 12/18/23 through 01/29/24, and physician's orders were reviewed.

a. The MAR documented the following inaccuracies related to the residents diabetic management:

* CBG checks four times per day lacked medication specific instructions for when to notify the provider;

* On 12/21/23 CBG value was marked out of parameter however, the CBG value wasn't recorded; and

* On 12/30/23 and 12/31/23 sliding scale insulin lispro (for diabetes) was given without documenting the number of units administered.

b. The MAR lacked the following related to PRN psychotropic medications:

An order for lorazepam every two hours, PRN for anxiety/agitation lacked clear medication instructions that directed unlicensed staff what anxiety/agitation looked like for the resident and when to notify the prescriber or nurse.

c. Parameters and clear instructions for the following PRN pain medications:

* Apply warm compress every 6 hours, PRN;

* Tylenol every 4 hours, PRN;

* Hydrocodone every 8 hours, PRN;

* Instructions for how long to wait before administering hydrocodone after morphine was already administered; and

* Monitor pain every two hours for three days. If asleep do not wake, mark as 02 code (defined on the MAR as med refused) if the resident was asleep.  

The need to ensure the MARs were accurate was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. Re-education was completed with Medication Technicians on 2/8/24 regarding administration of items on the electronic Medication Administration Record. Re-education for Medication Technicians has been scheduled for 3/6/24 on medication administration process and parameters. Resident #8's MAR was updated to reflect instruction for staff regarding the specific instructions describing how to identify pain, anxiety, agitation, and delirium as well instructions on which  of resident's pain medications to administer first. Re-education provided on 2/8/24 regarding administration of resident 8's nutritional shake. Re-Education provided has been scheduled for Medication Technicians regarding sliding scale insulin and accurate recording of administered doses. Resident 9's MAR was updated to reflect instructions for unlicensed staff regarding resident's pain medications and how to identify anxiety/agitation. Resident #9's CBGs has been discontinued, so no further intervention needed. Resident 10 had new signed orders on 1/31/24 and MAR was updated to reflecty these orders.

2. At the clinical meeting, select Medication Administration Records and new physican orders will be reviewed to confirm their accuracy. Medication orders with hold parameters will be periodically reviewed.  The vitals log for residents with monitored vitals will be sent to their health care provider as needed. Resident orders and medication records will be reviewed by 3/17/24 to verify parameters are present and that notifications are being made to appropriate health care providers.

3. Daily at clinical meeting and additionally as needed.

4. Health and Wellness Director and Executive Director or designee.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#5) who was prescribed psychotropic medications. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 01/2021 with diagnoses including depression and anxiety.

Review of Resident 5's MAR, dated 09/01/23 through 10/16/23, and physician orders revealed the following:

* Clonazepam 0.5 mg (anti-anxiety medication), one tablet every six hours, PRN for anxiety; and

* Lorazepam 0.5 mg (anti-anxiety medication), one tablet every six hours PRN for severe agitation.

The above PRN psychotropic medications were administered to the resident five times from 10/01/23 through 10/16/23. There was no documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications.    

In an interview on 10/19/23, Staff 12 (MT) confirmed she was unaware of the non-pharmacological interventions to attempt for Resident 5.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                               On 10/19/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

1. Non-pharmacological interventions were developed and communicated to the staff related to Resident #5's as needed psychotropic.

2. Non-pharmacological interventions for new psychotropic medications will be developed when new orders are received. Exisiting interventions will be assessed for ongoing effectiveness during service planning. All residents with antipsychotic and benzodiazipine medications were reviewed and non-pharmacological interventions were put in place.

3. Will be evaluated daily during clinical meeting as needed with new psychotropic medication orders received. Interventions to be reviewed quarterly during service planning.

4.  Health and Wellness Director and ED  

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (ED) on 10/18/23 at 11:30 am. Staff 1 reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident. Three of six sampled resident service plans were not reflective of the resident status which would impact the ABST.

There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. Additionally, the staffing hours recommended by the current tool were reviewed and failed to correspond with the number of staff listed on the staffing plan.

The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 on 10/19/23. She acknowledged the findings. No further information was provided.

1. Community is in process of working with Corrective Action on reviewing Brookdale's Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified.

2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale's tool.

3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly.

4. Executive Director or designee.

Based on interview and record review it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:

The facility previously had a condition placed on the facility's license because the ABST the facility was using didn't meet regulation.

During an interview on 01/30/24, Staff 1 (ED) stated the facility was using the "Brookdale ABST".

A review of the facility's Acuity Based Staffing Tool (ABST) identified the following:

1. The ABST tool failed to include all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide each task.

2. The ABST had multiple ADLs grouped together in subcategories. For example, dressing was grouped together with grooming.

3. The tool failed to address the following ADL's, individually:

* Personal hygiene;

* Transfer in and out of bed or a chair;

* Repositioning in bed or chair;

* Assisting with leisure activities;

* Assisting with communication, assistive devices for hearing, vision, speech;

* Responding to call lights; and

* Safety checks, fall preventions.

The ABST tool was reviewed and discussed with Staff 1 on 01/30/24. She acknowledged the findings.

1. Community is in process of working with Corrective Action Team on reviewing Brookdale's Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified.

2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale's tool.

3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly.

4. Executive Director or designee.

Based on interview and record review it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:

The facility previously had a condition placed on the facility's license because the ABST the facility was using didn't meet regulation.

During an interview on 05/29/24, Staff 1 (ED) stated the facility was using the "Brookdale ABST".

A review of the facility's Acuity Based Staffing Tool (ABST) identified the following:

1. The ABST tool failed to include all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide each task.

2. The ABST had multiple ADLs grouped together in subcategories. For example, dressing was grouped together with grooming.

3. The tool failed to address the following ADL's, individually:

* Personal hygiene;

* Transfer in and out of bed or a chair;

* Repositioning in bed or chair;

* Assisting with leisure activities;

* Assisting with communication, assistive devices for hearing, vision, speech;

* Responding to call lights; and

* Safety checks, fall preventions.

The ABST tool was reviewed and discussed with Staff 1 on 05/29/24. She acknowledged the findings.

1. Community is in process of working with Corrective Action Team on reviewing Brookdale's Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified.

2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale's tool.

3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly.

4. Executive Director or designee

Based on interview and record review, it was determined the facility failed to ensure  unannounced fire drills included all required components. Findings include, but are not limited to:

Facility fire drill records dated 04/2023 through 10/2023 were reviewed with Staff 4 (Maintenance Director) on 10/16/23. The facility lacked documented evidence unannounced fire drills included the following component:

Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills.

The requirement to ensure unannounced fire drills included all required components was discussed with Staff 1 (ED) and Staff 4 on 10/19/23. They acknowledged the findings.

1. Drill was completed on 10/27/23 to include information on resident participation and concerns.

2. Monthly fire drills will include any problems encountered with or comments relating to residents who resisted or failed to participate in the fire drills.

3. Reviewed monthly during fire drills

4. Maintenance Manager and Executive Director or designee.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed in fire and life safety procedures at least annually. Findings include, but are not limited to:

On 10/16/23 fire and life safety records were reviewed with Staff 4 (Maintenance Director) and the following was identified:

There was no documented evidence residents were re-educated annually in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire.

On 10/19/23, the need to ensure fire and life safety instruction was provided to each resident at least annually as required by the Oregon Fire Code was discussed with Staff 1 (ED) and Staff 4. They acknowledged the findings.

1. All residents provided with fire and evacuation safety training with siganature obtaind to confirm training was completed.

2. Residents will be provided with fire and evacuation safety training annually by the Maintenance Manager or as part of a care conference.

3. At least once annually.

4. Maintenance Manager and Executive Director or designee.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training at least annually. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed during the revisit survey. The following was lacking from the records:

* Documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training at least annually was reviewed with Staff 1 (ED) on 01/31/24 at 10:20 am. The findings were acknowledged. No further information was provided.

1. Re-education was completed with current residents on site on 2/2/24.

2. Fire Safety Training will be scheduled for residents on an annual basis. New residents will receive fire safety training upon move in and annually with other residents. Training records will be stored in a binder in the Executive Director's office.

3. Re-education on fire safety training for residents will be completed annually, with education on fire safety for new residents completed as needed.

4. Executive Director, Maintenance Technician, or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C252, C260, C270, C280, C290, C303, C310, C361, C422, C510, and C513.

1. The community team will create and implement a revised plan of correction for C252, C260, C270, C280, C290, C303, C310, C361, C422, C510 and C513.

2.The District Director of Operations, District Director of Clinical Services and Brookdale clinical specialists will connect with the community team a minimum of twice weekly via in person visits, training/support calls, and/or remote documentation review. This additional monitoring will continue for the next 30 days, then move to weekly for the following 30 days, and then monthly for the next 30 days.

3. Will be reviewed with District team as described above.

4.The community has entered into an agreement with a department-approved Registered Nurse Consultant.  The District Director of Operations, District Director of Clinical Services and their designees will be responsible for verifying that the corrections are completed.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to: C 260, C 361, and C 455.

1. The community team will create and implement a revised plan of correction for C260 and C361.

2. The community team will continue to coordinate with the District Management team to ensure compliance with corrections on a regular and as needed basis. Executive Director will work with community team to review compliance during daily stand-up and clinical meeting as well as regular monthly review of systems.

3. District Team will complete site revists on a scheduled basis as well as Executive Director review at least weekly to ensure compliance with both plan of correction and ongoing overall compliance.

4. District Management and Executive Director.

Based on observation and interview, it was determined the facility failed to ensure all exterior Residential Care Facility's (RCF) grounds were kept orderly, free of litter and refuse. Findings include, but are not limited to:

Observations of the facility grounds on 10/16/23 revealed the following:

A large rusted generator with numerous exposed wires along with several pieces of polyvinyl chloride (PVC) pipe and an opened bag of potting soil lying next to the generator.

The facility's exterior grounds were toured with Staff 1 (ED) on 10/18/23. She acknowledged the findings.

1. Pieces of PVC pipe and potting soil were removed. Maintenance Manager contact Regional Maintenace Tech for further guidance regarding removal of the generator.

2. Exterior areas of the building will be regularly inspected at least once monthly and cleaned as needed.

3. Inspection of the community grounds will be completed monthly.

4.Maintenance Manager and Executive Director or designee.

Based on observation and interview, it was determined the facility failed to ensure all exterior Residential Care Facility's (RCF) grounds were kept orderly, free of litter and refuse. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility grounds on 01/29/24 through 02/01/24 revealed the following:

The courtyard was observed with drop-offs up to approximately two inches from the sidewalk to the rock landscape near the west courtyard door and a raised portion of sidewalk on the walking path which created tripping hazards. Debris of multiple disposable coffee cups, empty cigarette packages and dog excrement was also observed in the courtyard area.

The facility's exterior grounds were toured with Staff 6 (RCC) and discussed with Staff 1 (ED) on 02/01/24. They acknowledged the findings.

1. River rock was raked into the south corner of the courtyard to eliminate the drop off beside the sidewalk. The courtyard and gazeebo areas were cleaned. Apartment doors were repainted.

2. Regular inspection of the courtyard will be completed by front desk staff. Staff will clean the gazebo and empty any trash. Staff will document this daily task on a task sheet to be reviewed by Business Office Coordinator weekly. Staff will create work orders for any items in need of repair.  Weekly walkthroughs of the courtyard and exterior grounds will be completed by Maintenance Technician to verify items are in good repair. Inspections will be documented on weekly building inspection form. Work orders will be created as needed and repairs will be made in a timely manner.

3. Daily cleaning for the courtyard, weekly inspection of courtyard and building exterior and repairs will be made as needed.

4. Executive Director or designee

Based on observation and interview, it was determined the facility failed to ensure the interior surfaces were kept clean and in good repair and free of unpleasant odors. Findings include, but are not limited to:

The interior of the building was toured on 10/16/23 through 10/18/23. The following areas were observed to need cleaning and/or repair:

* Multiple resident doors on the first, second and third floors had scuffs and dings;

* All doors leading to the interior courtyard had scuffs and dings;

* Both elevator doors and frames had scuffs and dings;

* The carpet was stained in front of the elevator near the electrical north room, and the inside of the elevator had stained and scuffed flooring and scuffed walls;

* The washers and dryers in the laundry room on the second floor had dirt and debris. The shelf above the washers and dryers was stained with soap residue; and

* Pervasive urine odors were noted on the third floor near room 310.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 10/18/23. She acknowledged the findings.

1. All apartment and courtyard doors have been inspected, cleaned and painted/repaired as needed. Laundry room and carpets were also cleaned. Elevator walls and floor were cleaned.

2. Common area surfaces and carpets have been placed on a cleaning schedule and will be cleaned monthly, spot cleaning will be completed as needed. Apartment door exterior cleaning will be added to weekly housekeeping assignments. Immediate repairs will be completed as needed. Maintenance and Executive Director will conduct a weekly walkthrough of all community common areas to note any areas in need of cleaning/repair.

3. Scheduled cleaning/painting will occur monthly.  Weekly walkthrough will note areas of immediate need.

4. Maintenance Manager and Executive Director, or designee.

Based on observation and interview, it was determined the facility failed to ensure interior surfaces were kept clean and in good repair and free of unpleasant odors. This is a repeat citation. Findings include, but are not limited to:

The interior of the building was toured on 01/29/24 through 02/01/24. The following areas were observed to need cleaning and/or repair:

* Multiple resident doors on the first, second and third floors had scuffs and dings;

* All doors leading to the interior courtyard had scuffs and dings;

* The courtyard door near the electrical north room loudly banged when closed;

* Both elevator doors and frames had scuffs and dings;

* The inside of the elevator near the electrical north room, had scuffed flooring and scuffed walls;

* The stairwells had stained carpets and debris;

* The washers and dryers in the laundry room on the second floor had dirt and debris;

* The first pillar in the dining room had a hole in the upper portion of the drywall;

* The kitchen alcove near the kitchen entrance had scuffs, dings, chipped and worn away paint leaving exposed wood on the dividing wall, and a gap between the floor and wall near the kitchen entrance had collected dirt and debris; and

* Pervasive urine odors were noted on the third floor near room 310.

The areas in need of cleaning and/or repair and unpleasant odors were shown to Staff 6 (RCC) and discussed with Staff 1 (ED) on 02/01/24. They acknowledged the findings.

1. Apartment doors were repainted to address scuffs on 2/19/24. Courtyard and other doors will be repainted by 3/17/24. Carpet cleaning in the hallways was completed on 2/17/24 and was scheduled for routine cleaning. The pillar in the dining area was repaired. Additional repairs in the dining area and kitchen alcove will be completed by 3/17/24. Soiled carpet in 3rd floor apartment identified in Statement of Deficiency will be removed and replaced with vinyl flooring by 3/17/24. East elevator cleaned and request to have interior cab modernized is in process with elevator company. Stairwells will be vaccummed and spot shampooed by 3/17/24.

2. Weekly interior inspection will be completed by Maintenace Technician and documented on the weekly building inspection sheet. Work orders will be created for any repairs as needed and then completed in a timely manner.

3. Weekly interior inspections will be completed and repairs made as needed.

4. Executive Director or designee.