The findings of the re-licensure survey conducted 07/05/22 through 07/07/22 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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

MCCMemory 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 07/07/22, conducted 12/27/22 through 12/28/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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

MCCMemory 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 re-visit to the re-licensure survey of 07/07/22, conducted 06/21/23, 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 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors, and available for inspection. Findings include, but are not limited to:

A tour of the facility conducted on 07/05/22 identified the facility lacked the following postings:

* The name of administrator or designee in charge;

* The facility staffing plan; and

* A copy of the most recent survey.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Administrator) on 07/07/22. She acknowledged the findings.

1. 2. All required postings are completed including the following: Name of the Administrator, name of administrator designee when Administrator is out of the building on evenings, nights and weekend. The facility staffing plan is posted and copy of the most recent (current) survey is posted. If accepted, this POC will also be posted along with the return visit survey. All postings are visible and located in public area near the entrance to MC.

3. Daily evening and night shift changes to the posting will be noted.

4. Nurse Manager.

Based on interview and record review, it was determined the facility failed to thoroughly investigate an incident to rule out suspected abuse or neglect for 1 of  1 sampled resident (# 1) who experienced an injury of unknown cause. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.

Progress notes dated 04/05/22 through 07/05/22, incident reports and the 02/2022 service plan were reviewed and revealed the resident was found on the floor and experienced a cut to the right arm on 05/18/22.

The facility lacked documented evidence of a thorough investigation to rule out abuse and neglect as a cause of the resident's injury.

The need to thoroughly investigate Resident 1's injury of unknown cause to rule out abuse and neglect or to report to the local SPD office was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings. The facility was asked to report the injury to APS prior to the end of the survey. Conformation was received on 07/07/22.

1. Res #1 incident reviewed and since the cause of resident's injury could not be determined, an APS report was filed as requested during the time of this state survey.

1.All injuries of unknown origin will be thoroughly investigated and called to APS within 24 hours of discovery of injury. A tracking document will log all injuries, investigations completed and calls to APS with dates and times.

2.Daily

Nurse Manager

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activity program based upon individual and group interests, physical, mental, and psychosocial needs for the residents. Findings include, but are not limited to:

Observation during the re-licensure survey, dated 07/05/22 through 07/07/22, revealed a lack of scheduled and unscheduled activities provided to residents.

Staff 1 (Administrator) stated the community had been without an activity person for some time on 07/05/22. An activity calendar was requested and she verified there was not one.

Failure to provide an activity program based on individual and group needs was reviewed with Staff 1 and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

Activities program (pg 9)

1.Each resident has been evaluated for individual interests and abilities for participation in social and recreational activities. Accommodations are provided as needed. These have been added to their SPs.

2.A weekly schedule of activities will be developed and posted for review by caregivers with each resident to attend with an escort. Activities are based on individual and group interests, physical, psychosocial and mental needs and limitations.

3.An attendance record will be kept of each resident participation in each activity daily. Updates to the SP will occur every 90 days or more often as needed.

Nurse Manager.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental and psychosocial needs for the residents. This is a repeat citation. Findings include, but are not limited to:

Observations during the re-visit survey, dated 12/27/22 through 12/28/22, revealed a lack of scheduled and unscheduled activities provided to residents.

Staff 1 (Administrator) stated the community had been without an activity person since 12/20/22. An activity calendar was posted but current staff were not following it regularly.

Failure to provide an activity program based on individual and group needs was reviewed with Staff 1 and Staff 15 (Contract RN) on 12/28/22. They acknowledged the findings.

1. The posted schedule for resident scheduled activities is in the process of revision. Each residents' choice and any accommodations needed will be identified in their service plan and re-evaluated every quarter. The revisions include activities of resident choices and abilities based on resident evaluations. All care staff are instructed to conduct activities (of residents' interests) on their shift with an exception for the night shift. All care staff will be trained in how to conduct various activities along with access to equipment and supplies.

2. Daily shift reports will include identification of activities to be conducted, by whom and when. A resident participant attendance record will be kept for each activity. This will help identify which residents prefer which activities. When residents prefer solo activities or other social activities not listed on the schedule, this will also be identified and provided and reflected in their services plan.

3. Weekly audits of staff documented activities including the name of the activity, the residents attending and staff leading the activity.

4. Administrator or designee will audit and revise as needed weekly.

2. Resident 3 was admitted to the facility in 02/2021 with diagnoses including Alzheimer's disease, dementia and falls.

The resident's most recent evaluation, dated 02/2022 was reviewed on 07/05/22. Per interview with caregiving staff, the 02/2022 evaluation was not reflective of the resident's current health status and needs.

An updated quarterly evaluation was requested from Staff 2 (Nurse Manager). No additional documentation was received.

The need to ensure residents were evaluated quarterly was discussed with Staff 1 (Administrator) and Staff 2 on 07/07/22. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 08/2019.

The resident's most recent quarterly evaluation, dated 02/20/22 was reviewed on 07/06/22.

The facility lacked documented evidence Resident 1's physical health status, needs and preferences were evaluated at least quarterly.

The need to ensure Resident 1's evaluation was preformed quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements, was completed, signed and dated prior to move-in for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed and quarterly evaluations were updated timely for 2 of 2 sampled residents (#s 1 and 3) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility on 05/10/2022. The move-in evaluation was reviewed and the following components had not been addressed:

* Customary routines for eating;

* List of medications and PRN use;

* Vital signs if indicated by diagnosis, health problems, or medications;

* Presence of depression, thought disorders or behavioral or mood problems and effective non-drug interventions;

* Confusion;

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

* Ability to understand and be understood;

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

* Nutrition habits;

* List of treatments, type, frequency, and level of assistance needed;

* Fall risk and history;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements;

* Smoking, ability to smoke safely; and

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

The "Pre-Move In Evaluation And Update As Needed Form" was dated for 05/10/22 with no signatures or dates. .

The need to ensure move-in evaluations addressed all required elements, were completed, signed and dated prior to move-in was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manger) on 07/07/22. They acknowledged the findings.

1.An updated move in evaluation has been completed for Res #1 and includes all required elements in a move in evaluation. The evaluation has been signed and dated. An updated quarterly resident evaluation has been completed for Resident #1.

2.Facility has revised and updated New Move-In Evaluation form with all required elements per OAR 411-054-0034.

3.Each new resident evaluation will be reviewed by both RN and Administrator prior to move in to ensure all elements have been evaluated and evaluators' signatures and dates documented.

Administrator

2. Resident 1 was admitted to the facility in 08/2019 with diagnoses including Alzheimer's disease.

The resident's most recent quarterly evaluation, dated 02/20/22, was reviewed on 12/28/22.

An updated quarterly evaluation was requested from Staff 1 (Administrator). No additional documentation was received.

The need to ensure residents were evaluated quarterly was discussed with Staff 1 on 12/28/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4) whose evaluation was reviewed and quarterly evaluations were updated timely for 1 of 1 sampled resident (#1) whose quarterly evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2022 with diagnoses including dementia and chronic pain.

The move-in evaluation lacked the following elements:

* Customary routines, including eating and bathing;

* Mental health issues, including history of treatment and effective non-drug interventions;

* Cognition, including orientation and confusion;

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

* ADLs, including dental status;

* Nutrition habits and fluid preferences;

* List of treatments;

* Indicators of nursing needs;

* Complex medication regimen;

* Recent losses;

* Unsuccessful prior placements; and

* Smoking, including the ability to smoke safely.

The need to ensure new move-in evaluations contained all required elements was discussed with Staff 1 (Administrator) on 12/28/22. She acknowledged the findings.

1. An evaluation has been completed for Resident #4 that includes all required elements. An updated quarterly evaluation has also been completed with an update to Service Plan.

2. As Maryville Memory Care is currently transitioning to Point Click Care ( PCC= electronic health record system), all 39 elements listed in OAR 411-054-0034 (Resident Move-In Evaluation; Resident Evaluation General and 30 day review are included and will be completed for all residents.

3. PCC will be programed with 30 day alert status to review, revise and sign off on Initial Evaluation.

4. Administrator or designee.

2. Resident 3 was admitted to the facility in 02/2021 with diagnoses including Alzheimer's disease, dementia and falls.

The resident's service plan, dated 02/2022, and Temporary Service Plans (TSPs) were reviewed, care staff were interviewed and observations of the resident were made. The service plan was not reflective of the resident's current status and lacked clear caregiving instruction in the following areas:

* Interventions for refusing to shower and get up in the mornings;

* ADL assistance relating to oral care, dressing, needing two staff members to assist to stand at times and toileting assistance;

* Striking out at caregiving staff;

* Food and beverage preferences;

* Independent with choosing items off of the menu each week;

* How often staff should be checking on the resident;

* Fall interventions;

* Behavior interventions;

* Activities, both group and independent; and

* Preference to sleep late Monday through Saturday.

An updated service plan was requested from Staff 2 (Nurse Manager) on 07/06/22. The service plan received was dated 03/2022 and there were no changes from the 02/2022 service plan.

There were observations of the facility using agency staff on 07/06/22 and 07/07/22. It was confirmed that without knowing the residents, the agency staff relied on the service plan to provide care.

The need to ensure service plans were updated at least quarterly, reflective of residents' current care needs and provided clear caregiving instruction was discussed with Staff 1 (Administrator) and Staff 2 on 07/07/22. They acknowledged the findings.  

3. Resident 1 was admitted to the facility in 08/2019 with diagnoses including dementia.

The resident's 02/2022 service plan and temporary service plans were reviewed and were not reflective of the resident's needs and preferences and did not give clear instruction to the staff regarding the resident's sleep and meal routines. The service plan was not updated quarterly to reflect any changes to the resident's health status, needs, or preferences.

During the survey, Resident 1 was observed to sleep throughout the majority of the morning and afternoon. In a 07/07/22 interview with Staff 2 (Nursing Manager), she relayed this pattern was common for the resident. When asked how the facility ensured the resident's nutritional needs were met, Staff 2 stated staff offer him/her a nutritional shake when a meal is missed.

Staff 2 acknowledged the 02/20/22 service plan was not reflective of the resident's sleeping pattern, nutritional shake as a meal supplement and had not been updated quarterly as required.                                                                                                                              

The need to ensure Resident 1's service plan was updated quarterly, reflective of their                                                                                                            needs and preferences and gave clear instruction to staff was discussed with Staff 1 (Administrator) and Staff 2 on 07/07/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of current care needs, provided clear direction to staff regarding the delivery of services and were updated quarterly for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including late onset Alzheimer's disease.

Observations from 07/05/22 through 07/07/22 were made, interviews with staff were conducted and records were reviewed. The following components were either not reflective of the resident's current care needs or did not provide clear direction to caregiving staff:

* Bathing;

* Grooming;

* Personal hygiene;

* Dressing;

* Eating and nutrition;

* Continence and toileting needs;

* Elopement risk;

* Mental status and behavior;

* Skin;

* Sensory needs including glasses;

* Evacuation assistance; and

* Social and emotional needs.

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

1. Res #2 SP has been updated and includes specific caregiver instructions for bathing, grooming, personal hygiene, dressing, eating and nutrition; toileting needs, elopement risk, skin, mental status and behavior, sensory needs including glasses, evacuation assistance and social, emotional needs including but not limited to the following: care refusals; when 2 person assistance may be needed; how to prevent and respond to striking out at caregivers; food, beverage preferences with menu and snack selection; preferences to sleep late into the mornings; social and physical activities and emotional needs.

All agency staff are required to review each assigned resident's SP. Res #1 SP has been updated to provide specific caregiver instructions related to resident's sleep pattern and nutritional needs.

3. SP's will be updated by AOC. Every resident will have an evaluation at least every 90 days, and with significant change, with an updated SP to reflect their care needs based on their routines and preferences. Residents who do not eat meals regularly are offered nutritional supplements and will be monitored for weight loss at least monthly.

4.Nurse Manager

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1 and 3's most recent service plans lacked documentation 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 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

1.Service Plan Teams have been organized and include administrator or designee, nurse manager and med tech or caregiver if administrator is not available. Residents and their representatives are invited to attend either in person or by phone conference call to review the SP proposed. All attendees will sign and date the SP. Copies are offered to resident representatives. A calendar schedule of all 90-day recurring SPs will be constructed in advance and a letter will be mailed to each Res rep inviting to proposed time and date. This schedule will be 2 weeks in advance of the 90-day due date.

2.A tracking document will be used to ensure on time SP Teams are meeting to comply and Team meeting schedules.

3. Audits will be conducted twice a month for 4 months.

4.Administrator

2. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Grover's disease and late onset Alzheimer's disease.

The resident's facility records were reviewed and identified the following skin issues:

* 05/12/22 - left buttock;

* 05/12/22 - right shoulder with a scab;

* 05/12/22 - left upper arm with a scab;

* 05/12/22 - left mid back; and

* 05/20/22 (signed as a late entry on 06/10/22) - a lesion on the resident's scalp.

Observations of Resident 2 throughout the survey showed a red mark on his/her scalp.

Evidence of monitoring at least weekly through resolution was requested on 07/07/22 from Staff 2 (Nurse Manager). No additional documentation was received.

3. Resident 3 was admitted to the facility in 02/2021 with diagnoses including Alzheimer's disease, dementia and falls.

The resident's facility records were reviewed and identified the following issues:

a. Resident 3 had resident to resident altercations on 03/13/22, 04/01/22, 06/20/22 and 06/24/22. There was no documented evidence the facility determined and documented what action or intervention was needed for the resident, or if the determined action or intervention was communicated to staff on each shift.

b. A progress note dated 05/12/22 reported Resident 3 "woke up [that] morning and began vomiting." Staff 2 (Nurse Manager) evaluated the resident that same day and documented, "will continue to monitor." There was no documented evidence Resident 3's short term change of condition was monitored through resolution.

c. On 06/16/22, Resident 3 had a witnessed fall. Per facility investigation report, the intervention of having on a gait belt and non-skid socks was implemented. An interview with care staff revealed the only known intervention was the resident was to wear a gait belt. There was no documented evidence the facility's determined action or intervention was communicated to staff on each shift or the intervention was monitored for effectiveness.

d. Resident 3 had an on-going rash located on various parts of his/her body. Per interview with Staff 6 (MT/CG) on 07/07/22, she gave the treatments to the caregivers, and they administered the treatment. This was confirmed by Staff 8 (CG). Staff 8 also reported, "some days it looks better, but most days it doesn't." There was no documented evidence staff had reported the status of the resident's rash to the MT or Staff 2. Staff 2 and Staff 6 confirmed they had not looked at the rash.    

The need to monitor short changes of condition weekly through resolution as well as determine and document what action or intervention was needed for the resident, and communicate the action or intervention to staff on each shift was discussed with Staff 1 (Administrator) and Staff 2 on 07/07/22. No additional information was received.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were monitored with progress noted at least weekly through resolution and interventions were evaluated for effectiveness for 3 of  3 sampled residents (#1, 2 and 3), who experienced a change of condition. Findings include, but are not limited to:

Resident 1 was admitted to the MCC in 08/2019 with diagnoses including dementia.

The resident's 04/05/22 through 07/07/22 progress notes, incident reports and temporary service plans (TSP's) were reviewed and revealed the following:

* 05/18/22 - Resident found on floor with a cut on the right arm;

* 06/03/22 - Fall; and

* 06/28/22 - Resident found on floor.

The facility lacked documented evidence of new interventions determined, documented and communicated to staff on each shift to help prevent Resident 1's incidents.   

The need to ensure interventions were determined, documented and communicated to staff on all shifts was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

1.Res # 1 has an updated evaluation for falls with intervention and staff instructions provided for monitoring effectiveness of interventions and documenting on ALERT Charting.

Nurse has reviewed and included additional interventions. Res #2 has an updated evaluation and assessment for multiple areas of chronic skin condition including skin eruptions, scabs, lesions and reddened areas. Weekly skin assessments are conducted and documented for resolution or additional interventions as needed. Res # 3 fall risk and interventions have been evaluated and SP updated. Re-occurring chronic skin condition has been re-evaluated with update to SP. Skin will be assessed weekly and documented in progress notes.

2. Training all caregiver and new staff will include change of condition with nursing assessment, ALERT charting, Temporary SP and weekly evaluation for effectiveness of interventions.

3. Weekly progress note by nurse will include date of a focused nursing assessment for resolution.

Staff will be trained on CoC and reporting requirements with tools, STOP AND WATCH and SBAR. Nurse Manager will notify RN of significant change of condition without delay. RN will complete Nursing Assessment for CoC and generate a new SP.

4.Nurse Manager

Based on observation and interview, it was determined the facility failed to ensure medications administered by the facility were set-up or poured and documented by the same person who administers the medications for 1 of 2 (# 3) sampled residents who received physician ordered topical skin treatments. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 02/2021 with diagnoses including Alzheimer's disease and dementia.

The resident's facility records were reviewed. The service plan, dated 03/2022, instructed caregivers to "apply prescribed creams to [affected parts of the body, twice] a day." MARs dated 06/01/22 through 07/05/22 were reviewed. The initials of the staff member on the MARs reflected the MT's initials who was on duty at the time.

It was confirmed in an interview on 07/07/22 at 9:46 am with Staff 6 (MT/CG) that the MT gives the CGs the topical treatments and the CGs apply it to Resident 3. Staff 6 also confirmed she was not present when the treatment was being administered. During an interview with Staff 8 (CG) on 07/07/22 at 9:57 am, she stated the MT gives her the creams and she applies them to the resident's affected areas.   

The need to ensure staff who set up the medications was the same person who documents the medications were applied was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

1. Res # 3 has topical cream applied. Caregiver notifies Med Tech to administer.

2. All medications including prescribed creams and topical skin treatments will be administered by Med Techs.

3. A review and training for medication administration policy and procedure is scheduled for all Med Techs. This will be included in all new hires for Med Tech training and updated in P&Ps for training and competency evaluations.

4. Nurse Manager

Based on interview and record review, it was determined the facility failed to ensure all medication orders were carried out as prescribed and signed physician orders were available onsite for 2 of 3 sampled residents (#s 1 and 3) whose MARs and orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 02/2021 with diagnoses including Alzheimer's disease and dementia.

The resident's facility record was reviewed.

a. On 06/28/22 the order for Nystatin cream (for rash) was discontinued by the prescribing physician. Staff continued to document that the cream was being applied to Resident 3's rash from 06/29/22 through 07/05/22.

b. The following physician's orders were not available onsite:

* Scheduled and PRN acetaminophen (for pain);

* Levothyroxine (for thyroid);

* Prevident (tooth decay prevention);

* Spironolact - HCTZ (for edema);

* Triamcinolone cream (for rash);

* PRN ondansetron (for nausea and/or vomiting); and

* PRN ployethylene (for constipation).   

The need to ensure prescriber orders were being followed and were available onsite was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 2019 with diagnoses including dementia.

The resident's record was reviewed during the survey and revealed there were no signed physician's orders for the following medications and treatments which were administered to Resident 1:

* Chlorhexidine gluc 12% solution (dental health);

* Vitamin D-3 (supplement); and

* Aspercream with Lidocaine 4% cream (pain).

In a 07/07/22 interview with Staff 2 (Nurse Manager) she acknowledge the facility lacked written, signed orders in the resident's record for the medications.

The need to ensure written, signed orders in the resident's record for all medications and treatments administered by the facility was discussed with Staff 1 (Administrator) and Staff 2 on 07/07/22. They acknowledged the findings.

1.Res #3 MARs and Medical orders have been reviewed and updated. Res #1 has signed medical orders on site.

2.All new medical orders will be reviewed twice weekly by nurse manager. Nurse manger will obtain an updated list for each resident's medications from the electronic medication reporting system every 90 days. The list will be reviewed for accuracy, allergies and medical diagnosis. RN to review and sign off including PRN parameters based on individual assessments. These orders will be reviewed and sent to the PCP for signature with a cover letter to return with signature and any corrections needed.

3.Twice weekly review of new medical orders. Every 90 days for review of all medications for all residents with authorized signature obtained.

4.Nurse Manager     

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and had resident specific parameters for PRN medications for 2 of 3 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including late onset Alzheimer's disease.

The resident's 06/01/22 through 07/05/22 MARs were reviewed.

Resident 2 had an order for Milk of Magnesia to be administered "every day as needed for constipation."

There was no documented evidence of resident specific parameters on when to administer the medications.

2. Resident 3 was admitted to the facility in 02/2021 with diagnoses including Alzheimer's disease and dementia.

The resident's 06/01/22 through 07/05/22 MARs were reviewed.

Resident 3 had an order for polyethylene glycol powder to be administered "in 4 - 6 ounces of fluids and take by mouth every day as needed for constipation."

There was no documented evidence of resident specific parameters on when to administer the medications.

Staff 6 (MT/CG) stated she would administer a PRN bowel medication every "two to three days" during an interview on 07/07/22 at 9:46 am.  

The need to ensure resident specific parameters for PRN medications was included in the MAR was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

Med administration

1.Res #1 has received an updated evaluation and SP with changes added to the MAR. PRN bowel protocol is discontinued. Scheduled routine medication is ordered.

2.All PRN bowel medications have been discontinued for all residents. All residents have been reassessed for bowel function routine and patterns to determine if routine scheduled meds may be needed in addition to daily non-pharmacological interventions such as increasing fluid and fiber intake. This has been updated on each SP. All PRN medications will include parameters and documentation for effectiveness.

3.Weekly reviews of all PRNs administered with correct documentation and administration procedures followed.

4.Nurse Manager

Based on interview and record review, it was determined the facility failed to employ a full-time Administrator scheduled to be on-site at least 40 hours per week. Findings include, but are not limited to:

Staff 1 (Administrator) reported on 07/06/22 that she was also the Assistant Administrator in the attached Skilled Nursing Facility license.  

When asked how much time she spent in the MCC, Staff 1 stated she spent about "75%" of the time working on the memory care unit and "25%" of the time working in the skilled unit. Staff 1's office was located in the Skilled Nursing Facility.

The need to ensure the Administrator had 40 hours of committed time in the MCC was discussed with Staff 1 on 07/07/22. She acknowledged the findings.   

1.Administrator has moved her office to the MC.

2.Administrator will be in the MC full time.

3.Annually

President of Maryville.     

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:

On 07/05/22, the ABST was requested from Staff 1 (Administrator). She reported the facility was still collecting the data needed to input into the "system."

There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.

The need to implement an ABST was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

1.Nurse Manager and Administrator are collecting information from staff to determine each resident's care services and time.

Updates are provided to DHS every 2 weeks on the progress of these efforts.

2.Each new resident will be added to the ABST.

3.The acuity and census will be updated regularly to reflect each resident for any changes including increases in care time.

3. Monthly or sooner if indicated by CoC.

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly hired, direct care staff (#s 5, 7 and 9) completed abdominal thrust and First Aid training within the required 30 days of hire. Findings include, but are not limited to:

Training records were reviewed with Staff 1 (Administrator) on 07/06/22 and revealed the following:

Training records for Staff 5 (MT) hired 05/11/22, Staff 7 (CG) hired 03/21/22, and Staff 9 (CG) hired 02/10/22, lacked documented evidence of First Aid and abdominal thrust training.

The need to ensure newly-hired direct care staff completed abdominal thrust and First aid training within 30 days of hire was reviewed with Staff 1 and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

1.Staff # 5 and # 7 are completing training for First Aid and Abdominal Thrust.

An audit has been completed to identify staff training needs and dates of completion.

2.A list of all training topics with required times will be tracked and completed including DOH, within 30 days and annual training. Staff who do not complete required training on time, will be taken off the work schedule until completed.

3.All new hires will receive comprehensive list of all required training.

Administrator

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 10 and 12) completed abdominal thrust and First Aid training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed with Staff 1 (Administrator) on 12/27/22 and revealed the following:

Training records for Staff 10 (CG), hired 11/19/22, and Staff 12 (MT/CG), hired 09/13/22, lacked documented evidence of current First Aid and abdominal thrust training.

The need to ensure newly-hired direct care staff completed abdominal thrust and First aid training within 30 days of hire was reviewed with Staff 1 and Staff 15 (Contract RN) on 12/28/22. They acknowledged the findings.

1. A formal letter will be sent to both staff members directing them to complete required training as soon as possible. The letter will require the date of expected completion and their signature indicating agreement to the requirements. Resources for completing the required training will also be included.

Steps to disciplinary actions for failure to complete this continued employment requirement will be stipulated in the letter.

2. A revision will be made to include the notice as stated above in every new employee packet with deadline and resources for completing the requirements.

3. Monthly audits for all staff training will be conducted to ensure compliance.

4. Administrator or designee.

Based on interview and record review, it was determined the facility failed to document all required components of fire drills and failed to provide fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to:

1. Fire drill records from 12/2021 through 06/2022 were reviewed on 07/07/22. The facility lacked documented evidence fire drills included the following required components:

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* Number of occupants evacuated.

2. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.

On 07/07/22, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Manager). They acknowledged the findings.

1.Fire drill records have been updated to include collection of information required for each drill such as: escape routes used; identification of any problems with or any resident refusal; number of occupants evacuated and time period for evacuation. Unannounced fire drills will be conducted every other month activating the fire alarm on different shifts. Fire and life safety instructions will be provided to all MC staff on alternating months.

2.Monthly training will include review of Fire and Life Safety.

3.Monthly

4.Administrator

Based on interview and record review, it was determined the facility failed to document all required components of fire drills and failed to provide fire and life safety instruction to staff on alternate months of fire drills. This is a repeat citation. Findings include, but are not limited to:

1. Fire drill records from 09/2022 through 12/27/22 were reviewed on 12/27/22. The facility lacked documented evidence fire drills included the following required components:

* Escape route used; and

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills.

2. The facility lacked documented evidence fire and life safety instruction was consistently provided to staff on alternate months.

On 12/28/22, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (Administrator). She acknowledged the findings.

1.  Documentation for December 2022 Fire drill has been completed with all required components.

2. All future fired drills will include required documented components including variation of the escape routes and any problems encountered; residents who resisted or failed to participate in a fire drill.  

Fire and life safety instructions will be provided and documented for all staff on alternate fire-drill months along with list of attendance.

3. A monthly audit will be conducted for documentation requirements on both fire drills and life safety trainings.

4. Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

Facility fire and life safety training records were reviewed on 07/07/22. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods and responsibilities within 24 hours of admission and annually.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Manager) on 07/07/22. They acknowledged the findings.

Training for Residents on Fire and Life Safety Procedures.

1.While each resident has advanced dementia, it is not prudent to review the emergency evacuation procedures with them on move-in. However, each resident will be included in routine evacuation and emergency drills. Each resident will also be evaluated on move in for what type of assistance may be needed to evacuate the building.

2.Every other month during fire drill procedures, staff will follow SP to assist each resident as needed.

3.SP will be reviewed every 90 days for assistance needed during fire drill to determine if there any changes.

Administrator     

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This is a repeat citation. Findings include, but are not limited to:

Facility fire and life safety training records were reviewed on 12/27/22. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods and responsibilities within 24 hours of admission and annually.

The need to have documented evidence of all fire and life safety training components for residents was discussed with Staff 1 (Administrator) on 12/28/22. She acknowledged the findings.

1. Written instructions on fire drill and emergency evacuations will be developed and reviewed with all residents' POAs. A signature and date will be obtained and kept in residents' charts.  Residents with cognitive abilities will be included in this procedure with documentation indicating their ability and if unable, an explanation will be documented. The emergency procedures and fire drill information will be reviewed annually with each resident and or their representative.

2.  This document will also be included with new move-in packets for all new residents indicating that it will be reviewed and signature required annually.

3. Quarterly audits will be completed to ensure compliance.

4. Administrator 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 C242, C252, C372, C420, C422, Z163 and Z164.

Refer C242, C252, C372, C420, C422, Z 163 and Z 164.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common use areas were maintained in good repair. Findings include, but are not limited to:

The courtyard of the MCC was observed during survey.

The pathways within the interior courtyard had multiple drop-offs ranging from 1-3 inches from the sidewalk to the planting beds. The drop-offs created a potential fall hazard for residents who used the courtyard.

The drop-offs were shown to and discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Manager) on 07/06/22. They acknowledged the findings.

1.Courtyard flower beds have been filled and there is no longer a drop off from the sidewalks. All light weight furniture has been removed.

2.Routine inspection of any potentially hazardous areas in the courtyard.

3.Monthly.

4. Administrator

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

Observation of the facility on 07/06/22 revealed:

* Activity room had paint chipping and pealing off of the walls;

* Multiple resident unit doors had scrapes along the bottoms and around the lever type door handle;

* Exit doors, the doors of the bathing suite, laundry and fire sprinkler were in need of painting; and

* Door jambs leading into the courtyard and dining room were scuffed, gauged and were in need of paint.

The areas in need of repair were shown to Staff 1 (Administrator) and Staff 4 (Maintenance Manager) on 07/06/22. They acknowledged the findings.  

1.Activity room, exit doors, resident doors and door jams have all been repaired and painted.

2.Kick plates are ordered and will be installed for each resident's door to prevent scrapes and gouges.

3.Every two months.

4. Administrator

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building and the security devices intended to alert staff of a potential elopement were in working order. Findings include, but are not limited to:

Observations on 07/05/22 through 07/07/22 revealed the following:

a. All exit doors in the MCC were lacking an alarm or other acceptable system to alert staff when residents exited the building.

b. The facility utilized "wander guard" bracelets to notify staff of a potential elopement. During an interview with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22, they verified the bracelets didn't work on the unit and that they only worked in the Skilled Nursing Facility section of the building.

Residents were observed wearing the bracelets on the MCC unit.  

The failure to ensure exit doors were equipped with an alarming device or other acceptable system and devices to alert staff of a potential elopement were in working order was discussed with Staff 1 and Staff 2 on 07/07/22. They acknowledged the findings.

1.Alarms have been installed and tested on all exits. All staff have been instructed on how and when to respond to door alarms. All wander guards have been removed and each resident has been evaluated for risk of elopement, wandering and exit seeking.

Policy and procedure for wandering, exist seeking and elopement have also been updated. Staff will be trained on this. Each resident evaluation will be reviewed every 90 days during SP.

2.No resident will leave MC without a responsible person to escort and be in attendance. Prior

to resident leaving the building a log will be kept including the following: Responsible person, where is destination, how long and when expected back again. A sign out sheet will be kept at the desk outside of Med Room. For residents who have this arrangement, it will be on their SP and reviewed every 90 days. Staff on duty will ensure accurate and timely documentation to ensure the whereabouts and safety of each resident at all times.

3. Daily.

4. Nurse Manager.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to: C 152, C 231, C 242, C 350, C 361, C 372, C 420, C 422, C 510, C 513 and C 555.

See POC for C 152, C 231, C242, C 350, C 361, C372, C420, C 422, C510, C513, and C555.     

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C242, C372, C420 and C422.

Refer C242, C372, C420, and C422.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct care staff (#s 5, 7 and 9) had completed all required orientation, pre-service and competency training within required timelines. Findings include, but are not limited to:

Review of the facility's training records on 07/06/22 revealed the following:

a. The facility lacked documented evidence Staff 5, hired 05/11/22, completed pre-service training topic infectious disease prevention prior to starting job duties.

b. The facility lacked documented evidence Staff 7, hired 03/21/22, completed the pre-service training topics related to resident rights and the values of CBC care prior to starting job duties.

c. The facility lacked documented evidence for Staff 5, 7 and 9 who were hired on 02/10/22, for pre-service training fire safety and emergency procedures prior to starting job duties.

e. The facility lacked documented evidence Staff 5 and 7 completed pre-service dementia training prior to beginning job duties.

f. The facility lacked documented evidence Staff 5, 7 and 9 completed all required elements of the pre-service training prior to beginning job duties including:

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

g. The facility lacked documented evidence Staff 5, 7 and 9 demonstrated competency within 30 days of hire related to the following required training topics:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

The need to ensure newly hired staff completed pre-service training with all required elements including memory care specific training and demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager). They acknowledged the findings.

See POC for C372.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to: C 252, C 260, C 262, C 270, C 301, C 303 and C 310.

See POC for C 252, C260, C270, C301, C 303, and C310.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C252.

Refer C252

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in residents' service plans for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 3's service plans were reviewed during the survey. Each service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to ensure residents nutrition and hydration plan were developed and included in residents service plan was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

Nutrition and Hydration

1.Each resident will be evaluated for nutrition and hydration needs and will be added to their SP including preferences, including snacks. Full glass of preferred liquid will be offered during each medication pass and meal time. Staff will also offer liquid refreshments in between meals to each resident.

2.New Move-in Evaluation will be completed with food and fluid preferences and added to the SP.

3.SP's will be updated by AOC and will be reviewed every 90 days, and with significant change, for any changes in nutritional preferences or needs.

Weights are obtained on move-in and monthly for changes and will be included in the SP.

4. Nurse Manager     

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in residents' service plans for 1 of 2 sampled residents (# 4) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 4's service plan, dated 11/08/22, was reviewed during the survey. The service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to ensure individualized nutrition and hydration plans were developed and included in residents' service plans was discussed with Staff 1 (Administrator) and Staff 15 (Contract RN) on 12/28/22. They acknowledged the findings.

1. Resident #4 evaluation and service plan has been updated related to individualized choices and preference for nutrition and hydration.

2. All residents' evaluations will be reviewed and updated for specific food and fluid preferences. When residents are cognitively able to assist with making menu choices, staff will assist them to complete daily menu choices. When history of dehydration has been documented, the evaluation and service plan will reflect this with specific interventions to lower the risk for reoccurrence.

3. Annual staff training topic on risks for dehydration in vulnerable elderly will be conducted.  Quarterly audits will be conducted to ensure all Service Plans reflect current information related to nutrition and fluid preferences and approximately daily amount to be provided.

4. Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed and updated for each resident based on their activity evaluation, for 3 of 3 sampled residents (#1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Though Resident 1, 2 and 3's service plans offered some information about the resident's interests, the facility lacked documented evidence the residents had been evaluated relating to the following required elements:

* Current and Past interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist Resident with individualized activities.

The need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

Activity Evaluations and Program.

1.Each resident's family member has completed a survey for past and current resident interests. Each resident is evaluated for current abilities, skills, emotional and social needs, physical limitations and accommodations needed to participate. Activities include resident specific redirections and calming behaviors such as music and tactile objects. Daily structured and non-structured activities will be offered by caregivers. Specific interests will be included in each resident's SP and reviewed every 90 days or more often if a change of condition occurs.

2.Activates schedule based on resident's ability and interest will be posted for all to view.

3.Care staff will review with each resident daily and escort them to activity of choice. An attendance log will be kept by caregiver or person conducting the activity. Until an Activity Coordinator can be hired, Nurse Manager, Administrator and care staff will be scheduled to conduct activities daily.

Administrator.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on his/her activity evaluation, for 1 of 2 sampled residents (#4) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Though Resident 4's service plan offered some information about the resident's interests, the facility had not fully evaluated him/her in the following areas:

* Current skills and abilities;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no documented evidence of a specific activity plan that detailed what, when, how, and how often staff should offer and assist Resident 4 with individualized activities.  

The need to ensure activity evaluations addressed all required elements and included an individualized activity plan was discussed with Staff 1 (Administrator) on 12/28/22. She acknowledged the findings.

1.  Resident #4 has received a focused evaluation for life enhancement activities according to her current interests and ability. This is reflected in her updated service plan.

2. As mentioned previously in C242, each residents' evaluation will be revised to include current skills, abilities including physical abilities, limitations along with any adaptations necessary for participation. When a resident has been identified that needs behavioral interventions, specific activities targeting the behavior will be evaluated and documented in the service plan.   

3. Evaluations and service plans will be audited quarterly or more often as needed to ensure updated, current information is included for daily and as needed activities and socialization.

4. Administrator or designee.

2. Resident 3 was admitted to the facility in 02/2021 with diagnoses including Alzheimer's disease and dementia.

The resident's record and incident reports were reviewed. The following behaviors were identified:

* 03/13/22 - threw coffee at another resident;

* 04/01/22 - hit another resident with a box of tissues;

* 06/20/22 - threw a spoon at another resident; and

* 06/24/22 - threw coffee at another resident.

Resident 3's 03/2022 service plan revealed the following behaviors:

* Opposed to showering;

* Resistant to oral hygiene;

* Refusing to get up in the morning; and

* Wander guard placed on left wrist and listed in the elopement book.

Staff 8 (CG) stated on 07/07/22 at 9:57 am the resident would sometimes "hit me" and pointed to her bottom. When Staff 8 asked the resident why s/he was doing that, she said the resident replied, "Because I like to." Staff 8 talked about some interventions she uses with Resident 3 when care is being refused. The interventions were not documented in the resident's service plan.

There was no documented evidence the facility evaluated the resident's behaviors or included the behaviors on the service plan. There was no documented evidence of resident specific interventions to assist staff with these behavioral symptoms which negatively impacted the resident and others in the community.   

The need to ensure the facility developed individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator) and Staff 2 (Nurse Manager) on 07/07/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:

1. Resident 2 was admitted to facility 05/2022 with diagnoses including late onset Alzheimer's disease.

The resident's record indicated that between 05/10/22 and 07/04/22, Resident 2 had 20 documented incidents of inappropriate comments or behaviors and wandering. The behaviors often included physically grabbing or making inappropriate sexual comments towards female staff.

The resident's service plan dated 06/20/22 revealed the following behaviors:

* The resident "addressed some female caregivers with statements of a sexual nature" and has "attempted to touch female caregivers inappropriately."

* "Elopement risk: [Resident 2] will not keep a wander guard on," and "has taken off each wander guard" that was "placed on [his/her] wrist. We will reach out to family to determine if there is someone who can escort [the resident] to and from Mass on Sundays."

An interview with Staff 8 (CG) on 07/06/22 confirmed that when female caregivers get too close when providing care, the resident will grab them. To reduce the behavior Staff 8 talked about some interventions she uses, which were not documented on the resident's service plan.

An interview with Staff 2 (Nurse Manager) on 07/06/22 revealed there was no individualized behavior plan implemented as Celexa was started to treat his/her behaviors.

There was no documented evidence the facility evaluated the resident's behaviors or included the behaviors on the service plan. There was no documented evidence of resident specific interventions to assist staff with these behavioral symptoms which negatively impacted the resident and others in the community.

On 07/07/22, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

Behavioral Plans

1.Resident # 2 and #3 have updated SP to include behavioral interventions for staff to follow.

Staff approaches have been changed and documented to reduce resident altercations. Resident challenging behaviors have decreased in frequency.

2.Staff have been trained to anticipate unintentional triggers for residents' expressions of distress, including environmental stressors, (such as temperature, lighting and noise); caregiver approaches to care and identifying the want or need expressed in the behavior and responding immediately with evaluation of the situation such as Pain? Potty? Snack? Boredom? New Move in residents will be monitored for behavioral expressions of distress for 30 days due to the change of environment. All residents who present challenging behaviors will have an evaluation /assessment and TSP completed by Nurse Manager in consultation with RN and or Administrator with interventions and monitoring for effectiveness by nurse manager. Antipsychotic medication will not be requested or administered without RN assessment.

3.Nurse Manager report weekly to RN and Administrator.

4. Nurse Manager.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury and the doors to the secured outdoor area remained unlocked during the day time. Findings include, but are not limited to:

The facility was toured on 07/06/22 and 07/07/22.

The secured courtyard area had multiple chairs, tables and a bench that were easily moveable and not of sufficient weight or design to prevent resident injury.

On 07/06/22 at 10:30 am, Staff 2 (Nurse Manager) was requested to unlock the courtyard doors. She stated it was usually locked during the rain as to prevent an unsampled resident from slipping outside. It was not raining at that time. The courtyard doors were checked again on 07/07/22 at approximately 8:40 am. The doors across from the dining room were locked and it was not raining.

The need to ensure furniture in the outdoor recreation area was of sufficient weight and design as to prevent resident injury and the doors to the secured courtyard were unlocked during the day time and when inclement weather was not an issue was discussed with Staff 1 (Administrator) and Staff 2 on 07/07/22. They acknowledged the findings.

1.All unsafe furniture has been removed from the courtyard. Courtyard door remains unlocked and a sign is posted to keep unlocked during daylight hours.

2.Doors to courtyard will be checked each shift.

3.Twice daily.

Nurse Manager.

Based on observation and interview, it was determined the facility failed to post directions for the keypad code and its operation on the outside of the door to allow access to the unit. Findings include, but are not limited to:

The MCC had an entrance door with a keypad lock that was accessible from the Skilled Nursing Facility portion of the building. Although a code was posted outside the door, it was not the correct one.

During an interview with Staff 1 (Administrator) on 07/05/22, she reported the previous Administrator disabled the keypad lock prior to her being hired on 08/24/20.

The requirement that the keypad code be posted was discussed with Staff 1 on 07/06/22. She acknowledged the finding.

Correct Code to enter unit from both nursing home and street has been posted.

2.Anytime the codes are changed, the postings will change with the updated codes.

3.Quarterly.

Administrator.