The findings of the re-licensure survey, conducted 05/15/23 through 05/18/23, 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, 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

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 re-visit of the re-licensure survey of 05/18/23, conducted 11/06/23 through 11/08/23, 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, 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

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 re-visit to the re-licensure survey of 05/18/23, conducted on 12/28/23, 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, OARs 411 Division 57 for Memory Care Communities, 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 an activity program based on individual and group interests. Findings include, but are not limited to:

At the time of the survey, the facility was home to 47 residents, who resided in the Memory Care Community.

The 05/2023 Activity Calendar was reviewed. The following activities between 05/15/23 and 05/17/23 were not observed:  

* Musical Monday, scheduled for 05/15/23 at 10:45 am;

* Seated workout video, scheduled for 05/15/23 and 05/16/23 at 1:30 pm;

* Snacks and hydration, scheduled for 05/15/23 at 2:30 pm;

* Fiddle and Fidget, scheduled for 05/15/23 at 3:30 pm;

* Fiddle and Fidget, scheduled for 05/16/23 at 9:30 am; and

* Reading hour, scheduled for 05/17/23 at 9:30 am.

Residents were observed sitting in common areas for long periods of time, sleeping while a television played continuously, wandering the halls, or remaining in their rooms. Staff were only observed coloring with Resident 6 on the 200 unit.

Resident 1's 03/29/23 service plan stated the resident was not able to attend activities due to the resident's condition. The service plan had a list of activities including listening to music or sitting outside when weather permits. During the survey, the resident was observed to either stay in the bed or the recliner in their room, sleeping or rocking most of the time without TV or music on. A review of 05/2023 activity calendar which was posted on the unit, did not include a music activity nor was the resident observed sitting outside 05/15/23 through 05/18/23 as weather permitted.

Resident 4's activity plan stated his/her favorite activities were "baking and exercise". A review of the monthly calendar for 05/2023 which was posted on the unit, did not include any baking activities and the exercise program was not provided on 05/15/23 through 05/18/23 as scheduled.

In an interview on 05/18/23, Staff 1 (ED) stated some of the scheduled activities on each unit were "caregiver lead" and the facility had one "life enrichment" staff who provided activities between the four neighborhoods. Staff 1 acknowledged that some of the caregiver lead activities had not occurred and the activity program was "still a work in progress".

On 05/16/23 and 05/18/23, failure to provide an activity program based on individual needs and group interests was reviewed with Staff 1, Staff 2 (RN) and Staff 3 (LPN) on 05/18/23. They acknowledged the findings.

1. Retraining with care staff on the importance of caregiver lead activities will be given.

2. The activity calendar will be changed to reflect slightly different times for activities to ensure the activities director can give time to each side without missing the activity or running late.

3. Meetings with the executive director and activities director will be held weekly to ensure compliance. Daily hudles with care staff and managers will be held to ensure their compliance as well.

4. Executive director, activities director or designee will follow up.

2. Resident 1 was admitted to the MCC in 03/2019 with diagnoses which included dementia.

Interview with care staff and observations of Resident 1 during the survey showed the resident did not have lower extremity edema.

Resident 1's POLST (Physicians Orders for Life-Sustaining Treatment), dated 06/15/20, indicated the resident's wishes of "do not resuscitate."

Resident 1's evaluation, dated 06/15/23, was not reflective of his/her needs in the following areas:

* Resuscitate when needed; and

* Edema on lower extremities status.

The need to ensure the evaluation was reflective of Resident 1's current care needs was discussed with Staff 1 (ED) on 05/16/23. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2), and failed to ensure subsequent evaluations were updated to reflect residents' preferences and used as the foundation to develop residents' service plans for 2 of 2 sampled residents (#s 1 and 2) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 03/2023 with diagnoses including vascular dementia with agitation, chronic pain, insomnia and Hepatitis C.

a. The following elements were not addressed in the move in evaluation:

* Ability to use the call system;

* Fluid preferences; and

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

b. Resident 2's 30 day evaluation was dated 04/20/23. Due to the resident's diagnoses and not having family, some elements in the initial evaluation were addressed by the facility documenting that the resident didn't know or was not being able to answer the question. Staff had time from the initial evaluation through the 30 day evaluation to get to know Resident 2. The following elements were not updated on the 30 day evaluation:    

* Customary routines relating to sleeping, eating and bathing;

* Interests, hobbies, social and leisure activities;

* Dental issues;

* Nutrition habits and fluid preferences;

* How the resident exhibits nicotine cravings;

* Who the medical provider was at the time; and

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

The need to ensure all elements of the move-in evaluation were addressed and updated in subsequent evaluations to be used as the foundation of the resident's service plan was discussed with Staff 1 (ED) and Staff 3 (LPN) on 05/18/23. No additional information was received.

1. Resident 1's evaluation was updated to ensure the missing items were corrected. Resident 2's evaluation was corrected with the missing items. The move in evaluation was also corrected to include all elements.

2. During our quarterly service plans, clinical team will throughouly review each section to ensure accuracy. During a move in, 30 day, quarterly and change of conditions evaluation, they will also be reviewed for accuracy.

3. Every time an evaluation is needed.

4. Executive director or desigee if ED unavailable will ensure compliance before completion.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and implemented services for 3 of 5 sampled residents (#s 1, 2 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2019 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 05/15/23 thru 05/17/23, revealed Resident 1's service plan was not reflective of the resident's status and not implemented in the following areas:

* Grooming;

* Brushing teeth;

* Elevating legs while on recliner;

* Lay in bed on left side one hour after all meals;

* Use of soft knee pad;

* Washing face;

* Apply barrier cream after each incontinent care; and

* Activities.

On 05/16/23 and 05/18/23, the service plan was discussed with Staff 1 (ED). She acknowledged the service plan was not reflective of the resident's status and not being implemented.

2. Resident 2 was admitted to the facility in 03/2023 with diagnoses including vascular dementia with agitation and Hepatitis C.

The resident's record was reviewed, the resident was observed, and staff were interviewed.

Resident 2's service plan lacked clear direction regarding the delivery of services including a written description of who shall provide the services and what, when, how, and how often the services shall be provided in the following areas:

* Interventions related to anxiety;

* How to redirect the resident when s/he was wandering into other resident's rooms;

* Grooming including oral care, dental status and shaving;

* Behaviors associated with toileting habits;

* How the resident exhibited nicotine withdrawal;

* PRN nicotine tablet availability;

* Most current food and beverage preferences;

* Activity assistance needed;

* Universal precautions relating to bodily fluids, laundry and personal housekeeping needs; and

* The resident's medical provider.

The need to ensure service plans provided clear caregiving direction which included a written description of who shall provide services and what, when, how and how often the services shall be provided was discussed with Staff 1 (ED) and Staff 3 (LPN) on 05/18/23. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 05/2022 with diagnoses including dementia, agitation and generalized pain.

Resident 6's service plan, dated 03/29/23, and Interim Service Plans were reviewed. The resident was observed, and staff were interviewed.

Resident 6's service plan lacked clear direction regarding the delivery of services including a written description of who shall provide the services and what, when, how, and how often the services shall be provided in the following areas:

* How the resident communicated pain;

* Non-pharmaceutical pain interventions when the resident was sitting for long periods of time;

* Clear instruction relating to the resident's interventions related to behaviors;

* What precipitated the resident's behaviors;

* Food and beverage preferences;

* If the resident had a roommate;

* The use of a bed side commode; and

* Current activity interests.

The need to ensure service plans provided clear caregiving direction which included a written description of who shall provide services and what, when, how and how often the services shall be provided was discussed with Staff 1 (ED) and Staff 3 (LPN) on 05/18/23. They acknowledged the findings.   

1. Resident 1, 2, and 6 service plans have been corrected to fix the missing information.

2. The facility is currently auditing all service plans, and during the quarterly service plan updates, clinical team will throughouly review each section to ensure accuracy.

3. Every time a service plan is being completed for a quarterly review and a change of condition.

4. Executive director or desigee if ED unavailable will ensure compliance before completion.

5. On 05/17/23 at 9:45 am a staff member was observed exiting a resident's room holding unbagged linens which she set on the floor in the hallway. She was observed speaking with another staff member and describing that the linens were soiled. A few minutes later, the soiled linens were picked up off the floor and set inside the hall closet in an open container with no lid.

The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary and a comfortable environment, which included the prevention of transmission of communicable diseases was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 05/17/23 at 1:30 pm. They acknowledged the findings.

3. Observations were made during the survey to determine adherence to universal precautions for infection control.

On 05/16/23, approximately 9:00 am, the surveyor observed Staff 16 (CG) and Staff 17 (Life Enrichment) provide incontinence care to Resident 1.

During the observation, Staff 16 failed to change gloves after removing a soiled incontinent product and wiping urine from Resident 1's bottom area. Staff 16 touched the resident's hair, clean incontinent product and the resident's blanket while wearing the same soiled gloves.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) on 05/16/23. She acknowledged the findings.

4. During the survey on 05/15/23 and 05/16/23, the surveyor observed 100 hall's residents for lunch. Multiple residents were using their hands to grab food or/and dinner rolls from their plates. The residents were not observed to wash their hands prior to lunch.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) on 05/16/23. She acknowledged the findings.

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

1. Resident 2 was admitted to the facility in 03/2023 with diagnoses including vascular dementia with agitation and Hepatitis C.

Per the resident's service plan, the resident had defecated in his/her shower while a bathing task was being completed. The service plan also directed staff to assist the resident with hand hygiene after toileting.

An interview on 05/16/23 at 12:15 pm, Staff 8 (CG) revealed Resident 2 defecated in his/her shower independently without being assisted with bathing. Staff 8 would know the resident used the shower for elimination when she walked down the hall and smelled the odor.

Resident 2 was observed being cued to the lunch meal on 05/15/23 and 05/16/23. The resident had not been cued to wash his/her hands prior to the meal.

The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary and a comfortable environment, which included the prevention of transmission of communicable diseases was discussed with Staff 1 (ED) and Staff 3 (LPN) on 05/18/23. They acknowledged the findings.  

2. Resident 6 was admitted to the facility in 05/2022 with diagnoses including dementia and agitation.

An Interim Service Plan, dated 05/16/23, identified the resident with the behavior of touching his/her own feces. The information was confirmed in an interview with Staff 10 (MT) on 05/17/23 at 11:15 am. The resident wasn't in the common area and Staff 10 reported she liked to keep her eye on the resident as s/he would independently use the restroom and sometimes touch his/her fecal matter.

Resident 6 was observed in the dining room prior and during the lunch meal on 05/15/23. The resident had not been cued to wash his/her hands prior to eating the meal. The resident was not observed in the dining room on 05/16/23 as s/he ate lunch in his/her room. Staff verified the resident did not get his/her hands washed prior to eating the meal.

The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary and a comfortable environment, which included the prevention of transmission of communicable diseases was discussed with Staff 1 (ED) and Staff 3 (LPN) on 05/18/23. They acknowledged the findings.

1. Reeducation was given to staff about infection control relating to properly bagging soiled linens, resident care and assisting residents with their hand hyiene.

2. Hand towels with crockpots were provided to each hall to promote resident hand hygiene before and after meals. All staff have access to bags for soiled linens and re-education will be provided.

3. Rounding with managers will be done during meal times to ensure residents are being provided the hand towels. Random rounding will be done to ensure changing of gloves are being done during pericare with residents and staff are bagging up soiled linens.

4. ED will be responsible to aid managers in rounding with staff.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 4 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 03/2019 with diagnoses including dementia.

Review of the 04/28/23 physician's order and the 05/01/23 through 05/15/23 MAR revealed the following:

* Suspension (liquid form) Keflex 500 mg, three times daily for five days for skin infection.

* The MAR indicated five extra doses of the medication were administered.  

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) on 05/16/23. She acknowledged the findings.

1. Med Tech meeting was help to review the errors found and how we can avoid it in the future. Med tech meetings will continue to be held.

2. System put in place to have a separate place for antibiotics. Staff will not add the antibiotic to the mar until it is received in house. Med techs will keep the order on their carts in a folder to ensure it is checked on. Once received, Med techs will enter the medication into the MAR and place in the triple check system for further review.

3. Each time an antibiotic is prescribed.

4. ED, LPN, and med room manager.

4. Resident 9 moved into the facility in 08/2023 with diagnoses including dementia.

The resident's MAR dated 10/01/23 to 11/06/23 and current physician's orders were reviewed. There was no documented evidence of signed physician orders in the resident's facility record for the following medications:

* Cephalexin 500 mg - Take 1 capsule by mouth every six hours for 10 days for infection;

* Naproxen 250 mg - take 1 tablet by mouth two times daily for pain; and

* Rifaximin 550 mg - take one tablet by mouth two times daily for hepatic encephalopathy.

In an interview on 11/07/23, Staff 3 (LPN) was unable to locate the physician's orders for the three medications. Staff 3 contacted the prescriber on 11/07/23 and a copy of the orders were obtained and provided for review.

The need to ensure written, signed physician orders were in the residents' facility record was discussed with Staff 21 (Regional Operations Support) on 11/08/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's record for all medications the facility was responsible to administer and medication and treatment orders were carried out as prescribed for 4 of 4 sampled residents (#s 1, 8, 9, and 10) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including dementia and chronic pain.

Review of the 09/18/23 physician's orders and the 10/01/23 through 11/06/23 MAR revealed the following:

* A physician ordered Morphine 20 mg/ml concentrated liquid, 0.5 mLs four times daily for moderate to severe acute pain.

* The MAR indicated the resident was not administered a scheduled dose of the Morphine on 10/19/23 at 6:00 AM.

The need to ensure medication orders were carried out as prescribed was reviewed with

Staff 21 (Regional Operations Support), and Staff 3 (LPN) on 11/08/23. They acknowledged the findings.

3. Resident 8 moved into the MCC in 06/2019 with diagnoses including dementia.

The resident's quarterly service plan dated 10/26/23 and current physician orders were reviewed. Resident 8 had a physician's order dated 10/19/23 for mechanical soft diet textures, and the service plan indicated s/he was to receive regular textures.

On 11/06/23, Resident 8 was observed eating a regular textured snack of tortilla chips and nacho cheese. Another observation was made at lunch on 11/07/23 where the resident received regular textured chicken pieces and a buttered roll.

On 11/07/23, Staff 21 (Regional Operations Support) confirmed there was no clarifying physician order dated after 10/19/23 that indicated the resident was to receive regular textures. Instruction regarding Resident 8's diet change was provided to the caregivers through an Interim Service Plan on 11/07/23 at 1:08 pm.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 21 and Staff 3 (LPN) on 11/08/23. They acknowledged the findings.

2. Resident 10 moved into the memory care facility in 12/2022 with diagnoses including dementia and a history of stroke.

A review of the resident's 10/01/23 through 11/06/23 MAR, chart and physician's orders revealed the following:

* The facility filed physician's orders in resident binders. Resident 10's binder did not have orders for a nutritional supplement, "Boost", and the most current orders, dated 08/04/23 and 09/18/23 for Risperdal (for behavioral disorder and aggression).

In an interview on 11/07/23, Staff 3 (LPN) was unable to locate the physician's orders for the nutritional supplement and the most recent orders for Risperdal. Staff 3 contacted the prescriber on 11/07/23 and a copy of the orders were obtained and provided for review.

* The MAR did not include the physician's order for Risperdal 1 mg by mouth every evening routinely, for physical aggression. Staff 3 confirmed resident 10 had not been receiving the medication as ordered.

The need to ensure medication orders were documented in the resident's facility record and carried out as prescribed was reviewed with Staff 21 (Regional Operations Support) and Staff 3 on 11/08/23. They acknowledged the findings.

1.) 2nd checks will be reviewed by the medroom manager for the orders that have been received and then the 3rd check process will be conducted by the LPN following the 2nd check by the medroom manager and orders will be placed in filing system for staff to file. LPN will review filing to ensure it was completed. Missed Medication report will be reviewed during stand up and any omissions will be followed up on and corrected.

2.) Executive Director will conduct a stand down meeting to ensure all orders have gone through the 3rd check system and placed in filing.

3.) All systems will be reviewed with Medroom Manager and LPN each week during quality assurance meeting. All current medication orders will be reviewed every 90 days at the time of service plan review to make sure a copy of all orders are in the resident record and that orders are correct and filed appropriately.

4.) Executive Director will be responsible for making sure that all corrections have been completed.

2. Resident 1's service plan, dated 03/29/23, stated s/he required:

* Two-person assist with dressing and toileting;

* Skin treatment on coccyx area two times daily; and

* Housekeeping and laundry tasks both daily and weekly.

A record review of Resident 1's ABST, dated 05/16/23, did not have any minutes assigned to treatment, housekeeping and laundry task and did not have enough minutes assigned to the two-person assist with dressing and toileting tasks.

In an interview with Staff 1 (ED), she acknowledged that the ABST did not match with the resident's service planned needs.

The need for the facility to use the ABST to determine the time needed for all care needs was reviewed with Staff 1 on 05/16/23. She acknowledged the findings.

3. Resident 2's service plan, dated 05/04/23, was reviewed, the resident was observed and staff were interviewed.

The resident's service plan provided direction to staff in the following areas:

* Grooming, including oral hygiene and shaving;

* Stand by toileting assistance; and

* No staff assistance needed in leisure activities.

An interview with Staff 8 (CG) on 05/16/23 at 12:15 pm revealed she did not provide oral hygiene and Resident 2 had behaviors associated with toileting habits which required her to provide personal care and housekeeping for the resident. Staff 8 also reported the resident was not independent in leisure activities.

During observations of Resident 2 on 05/15/23 and 05/16/23, there was no evidence the resident was being shaved or being taken to the restroom. The resident was not able to self initiate leisure activities and paced for most of the observed time. Resident 2 was observed to go to his/her room but the call light was not observed to be used nor were staff observed going into his/her room.  

A review of Resident 2's ABST, dated 05/09/23, revealed an inaccuracy of minutes assigned in the following areas:

* Personal hygiene such as shaving and mouth care;

* Bowel and bladder management;

* Assisting with leisure activities;

* Responding to call lights; and

* Completing resident specific housekeeping services relating to toileting habits.

The need for the facility to use the ABST to determine the time needed for all care needs was reviewed with Staff 1 (ED) on 05/18/23. She acknowledged the findings.

Based on observation, interview and record review, the facility failed to determine time needed for all care needs relating to the Acuity Based Staffing Tool (ABST) and the residents' service plans for 3 of 4 residents reviewed (#s 1, 2, and 3). Findings include, but are not limited to:

1. Resident 3's service plan, dated 05/04/23, stated s/he required:

* Cueing and reminders to use walker when ambulating;

* Cueing and redirecting for behaviors;

* Breathing exercises to be conducted by Med Aides seven times a day; and

* Housekeeping and laundry tasks both daily and weekly.

A record review of Resident 3's ABST, dated 03/16/23, did not have any minutes assigned to the first three areas identified in the service plan, and did not have enough minutes assigned to the housekeeping and laundry tasks.

In an interview with Staff 1 (ED), she acknowledged the ABST did not match the resident's service planned needs.

The need for the facility to use the ABST to determine the time needed for all care needs was reviewed with Staff 1 on 05/17/23. She acknowledged the findings.

1. ABST was updated for the listed residents that were out of compliance.

2. Everytime there is an update to the service plan, the ABST tool will be updated with the accurate information.

3. Every Wednesday with IDT meeting and when a COC is entered.

4. ED or desigee will update the ABST when an update is made.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented in accordance with Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill and fire and life safety records from 11/2022 through 05/2023 were reviewed.

There was no documented evidence the facility addressed the following areas during the fire drills:

* Problems encountered; and

* Comments relating to residents who resisted or failed to participate in the drills.

Staff were interviewed on 05/16/23 and 05/17/23. They were not able to identify where the designated point of safety was located.

The need to ensure the facility conducted fire drills per the OFC and staff knew the designated point of safety was reviewed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 05/17/23. They acknowledged the findings.

1. Retraining on fire and life safety will be done to ensure staff are aware of the designated point of safety. Maintenance director will update the fire drills to address any missing information found in survey.

2. Fire drills will be reviewed by the ED and maintenance director after they are ran to ensure proper documentation is done.

3. Monthly with monthly drills

4. ED will be the one to review the documentation.

Based on 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 C303 and C513.

1.)The current Plan of Correction will be reviewed with all managers during stand up meeting to ensure the plan of correction is being followed

2.) The plan of correction was being reviewed weekly and it will be reviewed as needed going forward

3.) at daily stand up meeting

4.) Executive Director

Based on observation and interview, it was determined the facility failed to ensure there was locked storage for all chemicals and toxic materials. Findings include, but are not limited to:

Facility grounds were toured from 05/15/23 through 05/17/23 and revealed multiple areas inside the building had unlocked storage of chemicals and toxic materials.

The facility was toured with Staff 1 (ED) and Staff 5 (Maintenance Director) on 05/17/23. They acknowledged the above findings.

1. Retraining with staff on proper locking of chemicals and toxic materials.

2. Managers will do rounding daily to ensure closets are locked and chemicals are secured away.

3. Daily rounding

4. Maintenance director and ED will ensure staff stay in compliance.

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

Observations of the facility 05/15/23 through 05/17/23 revealed the following:

* Room 306 had pervasive odors and the bathroom flooring had an approximately 8" x 8" stain present;

* Room 306 was missing a memory box and nameplate for resident to identify their room;

* The kitchenette in neighborhood 100 was missing baseboards;

* A doorframe in neighborhood 100 was in disrepair;

* There was peeling and/or missing felt on multiple tabletops; and

* The outdoor tables in both courtyards were covered in brown debris.

The facility was toured with Staff 1 (ED) and Staff 5 (Maintenance Director) on 05/17/23 at 1:30 pm. They acknowledged the findings.

1. 306 is scheduled for flooring, shadow box outside of 306 is on order, basboards have already been replaced in 100, table tops are scheduled to be refelted, tables are being cleaned in outside courtyard.

2. Maintenance director will update the ED on the status of the repairs and orders.

3. Weekly checks in to be held until compliance is met

4. ED and Maintenance director will see it is corrected.

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

Multiple observations of the interior of the MCC were completed between 11/06/23 and 11/08/23.

These observations revealed a pervasive odor which was first noted at the entrance to the 300 neighborhood, and then the odor intensified through the resident apartment hallway up to apartment 306.

The need to ensure the facility was free from unpleasant odors was discussed with Staff 21 (Regional Operations Support) on 11/08/23. She acknowledged the findings and a plan to mitigate the odor was started on 11/08/23.

1.)

A) rounding of community by each manager to identify odors and resolve the issue causing the odor

B)Interventions will be put in place to reduce the issue causing the odor. Different interventions will be tried and documented until one is found that is effective

C) Weekly carpet cleaning will be done in 300 hall at minimum to help reduce odor.

2.) Managers rounding will be done on paper to ensure that this is occurring by all managers

3.) Each day it will be evaluated during rounding done by the managers and Executive Director

4.) Executive Director will ensure that the plan of correction is being followed

Based on observation and interview, it was determined the facility failed to ensure a separate area with closed containers was available which allowed for the storage and handling of soiled linens and clothing and provide a one way flow of soiled items from the soiled area to the clean area. The facility also failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens. Findings include, but are not limited to:

Observation of the laundry room on 05/15/23 revealed the following:

* Multiple open containers which held soiled linens; and

* A container of dirty linens on the clean side of the laundry room which included a shoe located at the top of the container with brown matter observed on the sole.  

Interviews with staff members on 05/15/23 through 05/17/23 indicated the flow of soiled linens was to enter the laundry room where the washing machine was located, go past the dryer and through the clean clothes area to the hopper, where the soiled linens would be rinsed. The rinsed items would cross back over the clean clothing area and the dryer to be placed in the washing machine.

Staff members stated they used the "builder detergent" to wash soiled linens that could not be bleached. There was no information regarding the presence of a chemical disinfectant in the detergent.  

The need to ensure a separate area with closed containers was available which allowed for the storage and handling of soiled linens and clothing, the need for a one way flow of soiled linens and clothing, and the need for a chemical disinfectant when washing soiled linens and clothing was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 05/17/23. They acknowledged the findings.

1. There is a hopper and washing machine now located in the 100 hall. We will have two well marked linen closed containers, one labeled soiled and the other labeled clean. Each hall will have a soiled container available. Sanitizing detergent will be available to staff on the 100 hall and the laundry room.

2. Staff are being continually trained on the process of taking soiled laundry to the hopper to rinse off the soil and wash it in the washing machine in the neighborhood before bringing it to the dryer in the laundry room.

3. Daily reminders during shift huddle for the first month, then as needed.

4. ED, maintenance or designee

Based on observation and interview, it was determined the facility failed to ensure the glass and area surrounding the fireplace did not exceed 120 degrees Fahrenheit. Findings include, but are not limited to:

On 05/15/23, fireplaces were observed in each of the neighborhood living rooms. The living room in neighborhood 200 had the only fire place that was able to be turned on.  The surface of the fireplace, when the temperature was taken, measured at 150 degrees Fahrenheit.

The need to ensure the glass and area surrounding the fireplace did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 05/17/23. They acknowledged the findings.

1. Maintenance Director has been working on getting gates made to block the fireplace from being touched when turned on. Fireplaces have been disengaged for now until the gates are made.

2. When manager rounds are completed, managers will ensure the gate it still around the fireplace and not moved.

3. Daily rounding with managers to ensure the gate is in place and not tampered with.

4. Executive Director

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exited the MCC. Findings include, but are not limited to:

The facility was toured 05/15/23 through 05/17/23. The doors leading from each of the four neighborhoods to the exterior courtyards did not have working door alarms or other acceptable system that alerted staff when a resident exited the neighborhood.  

The need to provide an alarm or other system on the exit doors for each neighborhood was reviewed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 05/17/23. They acknowledged the findings.

1 Door chimes were placed on all outside doors leading to the courtyards

2. Daily rounding by managers to ensure the doors leading to the courtyard are still turned on and in working order

3. Daily rounding

4. All managers.

Based on observation, 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:

C 242, C 361, C 420, C 510, C 513, C 530, C 540 and C 555.

Refers to tags C242, C361, C420, C510, C513, C530, C540, 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 C513.

Refer to plan of correction for C513

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#18) completed all required orientation training before performing any job duties and pre-service training prior to providing services independently, and failed to ensure 3 of 3 long term, direct care staff (#s 16, 19 and 20) completed a total of 16 hours of in-service training annually. Findings include, but are not limited to:

Staff training records and the facility's staff training program were reviewed on 05/17/23 and 05/18/23. The following deficiencies were identified:

1. Staff 18 (Housekeeper) was hired on 01/03/23.

The facility could not provide documented evidence that Staff 18 completed the required orientation training prior to performing any job duties and pre-service dementia training prior to providing services independently in one or more of the following topics:

* Abuse reporting requirement training was completed on 03/15/23;

* Infectious Disease Prevention training was completed on 04/12/23; and  

* Pre-service Dementia training was completed 03/16/23.

2. Staff 16 (CG), Staff 19 (CG) and Staff 20 (CG) were hired on 02/01/21. Training records were reviewed from 02/01/22 through 02/01/23.

The annual staff training provided lacked documented evidence of how much time was spent training on the provision of care in CBC and in dementia training.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (ED) on 5/17/23 and 5/18/23. She acknowledged the findings.

1. Staff will have completed classes done before working on the floor. New documentation of trainings are being recorded and placed in the training binders to document all the all staff trainings for continuing documentation. The facility is going through the training binders and each topic will have a space to track the time. After the time is recorded, the training binder will have a time associated with each topic.

2. BOM will ensure new hires have all documents completed before working on the floor. BOM will update the forms after each all staff to ensure the staff have documentation of continuing education.

3. ED will ensure to follow up with the BOM to double check the required documents are completed.

4. ED will monitor BOMs compliance.

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:

C 252, C 260, C 295 and C 303.

Refers to C252, C260, C295, C303

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 C303.

Refer to plan of correction for C303

2. Resident 2 was admitted to the facility in 03/2023 with diagnoses including vascular dementia with agitation.

Although the activity evaluation was completed the day prior to move-in, it was noted Resident 2 was not able to answer the questions due to his/her dementia diagnosis.

The resident had two subsequent activity evaluations; the 30 day dated 04/20/23 and a change of condition dated 05/04/23. Staff had time from the initial evaluation through the most recent evaluation to get to know Resident 2.

The following was not addressed on the 05/04/23 activity evaluation:

* Current interests;

* Current abilities and skills; and

* Identification of activities for behavioral interventions.

There was no individualized activity plan developed that reflected the resident's activity preferences and needs nor was there a selection of daily structured and non-structured activities provided that were included in the resident's service plan.

The resident was observed on 05/15/23 to sit for short periods of time while a movie was playing, get up, walk down the hall and back, then sit back down. This was repeated numerous times prior to the noon meal being served. As staff were getting the meal ready to serve, they put 70's music on in the dining room. Resident 2 was observed to stand up from the recliner s/he was in while the movie was on, stop, listen to the music and sit back down. The resident repeated this four times prior to being cued to the dining room.

On 05/16/23, the resident was observed walking back and forth on the unit, only sitting for a meal. The television was on and no music was playing.

The need to ensure each resident had an individualized activity plan and that activities based on those plans were provided was discussed with Staff 1 (ED) and Staff 3 (LPN) on 05/18/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Residents 1, 3 and 4's service plans offered some information relating to the resident's past and current interests, emotional and social needs, and physical abilities and limitations. However, there was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized or group activities based on the resident's evaluation.

Observations of the residents from 05/15/23 through 05/17/23 revealed a lack of activity programs that included the residents in one to one or group interaction.

The need to ensure each resident had an individualized activity plan and that activities based on those plans were provided was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 05/17/23. They acknowledged the findings.

Refer to C 242.

1. Care plans were updated to show more details relating to activities to include what, when, how and how often staff should offer assistance with activities. Training with staff to be watching for what residents enjoy to add to the service plan.

2. Service plans will be updated to include the missing information and the IDT will be retrained on the process of what needs to be included in the activities section.

3. This will be followed up on everytime a service plan in updated to ensure accuracy.

4. Executive Director or designee.

2. Resident 6 was admitted to the facility in 05/2022 with diagnoses including dementia, agitation and generalized pain.

On 05/16/23 at 11:54 am, Resident 6 attempted to jab another resident with silverware in the dining room. Staff escorted the resident out of the common area and into his/her room.

Resident 6's service plan, dated 03/29/23, and Interim Service Plans were reviewed. The resident was observed and staff were interviewed.

On 05/17/23 at 11:15 am, Staff 10 (MT) was asked about interventions used when Resident 6 displayed agitation. She identified interventions such as giving snacks, candy, asking the resident to help her with something, change of face for refusing care, and approaching the resident with a kind tone of voice. Staff 10 also reported she noticed an increase in agitation when the resident was in pain and would ask him/her to move around if she noticed the resident had been sitting for an extended amount of time.

Resident 6's service plan addressed the resident's behavior symptoms that negatively impacted him/herself and other residents. Some interventions were listed, however, the plan did not include instructions to staff on how to implement the interventions and none of the interventions Staff 10 reported were in the service plan. During observations, the only intervention observed was staff coloring with the resident on 05/15/23.

The need to ensure behaviors that negatively impacted the resident and others were evaluated, included in the service plan and interventions implemented by staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 05/18/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide a service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 5 sampled residents (#6 and 7) with documented behaviors.  Findings include, but are not limited to:

1. Resident 7 moved into the memory care facility in 12/2022 with diagnoses including dementia.

During observations on the unit on 05/18/23, Resident 7 was yelling at staff and on two occasions, directed his/her comments towards other residents. Several staff approached the resident to talk with him/her, however, the agitation and yelling continued. Other residents on the unit were observed to move away from the resident as s/he came near them. Resident 7 positioned him/herself in front of the television and continued to yell out at other residents and staff in the area.

In an interview on 05/18/23, Staff 12 (CG) and Staff 13 (CG) were asked about interventions used when Resident 7 displayed agitation and yelling. The caregiver's explained the resident had refused a shower earlier in the day and continued to refuse when offered a shower later. Staff reported the resident responded well to "chocolate and coca cola", however, none was currently available. Staff stated they "give [him/her] space".

The resident's current service plan, dated 03/18/23, was reviewed. The service plan addressed the resident's behavior symptoms that negatively impacted him/herself and other residents. Interventions were listed, however, the plan did not include instructions to staff on how to implement the interventions. During observations, staff did not implement the interventions stated in the service plan.

The need to ensure behaviors that negatively impacted the resident and others were evaluated, included in the service plan, and interventions implemented by staff was discussed with Staff 1 (ED) and Staff 3 (LPN) on 05/17/23. They acknowledged the findings.

1. Service plans updated with new information to fix missing information.

2. Training on behavior plans with staff. Training on how staff are to report new interventions they find useful with residents with behaviors. Also reporting to clinical team when interventions are unsucessful.  

3. Twice monthly and as needed trainings with staff to review behavior plans and interventions

4. Executive director or designee

Based on observation and interview, it was determined the facility failed to ensure access to a secured outdoor space which allowed residents to enter and return without staff assistance. Findings include, but are not limited to:

During the survey of the memory care unit between 05/15/23 and 05/17/23, the exterior courtyard doors in all four resident areas were locked.

Interviews with Staff 1 (ED) and Staff 4 (Caregiver Manager) on 05/15/23 revealed the current policy was for the courtyard doors to stay locked at all times unless a staff member was available to accompany the resident.

On 05/15/23 Staff 1 provided the facility's written policy which stated "Doors to the Courtyard will remain unlocked during the hours of 6:00 am up until 7:00 pm, unless inclement weather defined as freezing temperatures, snow and/or ice present, heavy rain or hail, high temperatures of 90 degrees or higher is present. The Executive Director, or Designee will require the doors to be locked until the weather passes. An "Inclement Weather" sign will be posted on doors leading to Courtyard, explaining that the doors will remain locked for safety until the weather/conditions have passed."

The temperature was measured on each day and did not rise above 86 degrees Fahrenheit during the times observations occurred.

The need for access to a secured outdoor space which allowed residents to enter and return without staff assistance was reviewed on 05/17/23 with Staff 1 and Staff 5 (Maintenance Director). They acknowledged the findings.

1. Door locks have been replaced allowing staff to have the courtyard doors unlocked from 6a-7p.

2. Manager rounding will have mangers checking the weather and the doors. Managers and staff will be trained to know what is considered inclement weather.

3. During daily rounding

4. Executive director or designee

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation areas were no less than six feet in height and failed to ensure outdoor furniture was of sufficient weight, stability and design to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The facility included one outdoor recreation area that connected resident neighborhoods 100 and 400, and one outdoor recreation area that connected resident neighborhoods 200 and 300. Both recreation areas were toured on 05/16/23 and the perimeter fence was measured at multiple areas to be 5' 10" in height.

On 05/16/23 the outdoor recreation area between neighborhoods 200 and 300 was toured and there was furniture present that was not of sufficient weight to prevent resident injury or aid in elopement.

The need for fences surrounding the perimeter of the outdoor recreation area being no less than six feet in height and outdoor furniture is of sufficient weight, stability and design to prevent resident injury or aid in elopement was reviewed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 05/17/23. They acknowledged the findings.

1. Mulch will be leveled out to ensure it is 6ft from the ground to the top of the fence.

2. Any time new mulch is placed or heavy rain that could cause areas to have extra mulch

3. Weekly and as needed

4. Executive director, maintenance director, or designee