The findings of the re-licensure survey, conducted 09/11/23 through 09/21/23, 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 for Home and Community Based Services Regulations.
Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities 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
A situation was identified during the survey where failure of the facility to comply with the Department's rules was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:
OAR 411-054-0025 (4) Reasonable Precautions
The facility put an immediate plan of correction in place during the survey and the situation was abated.
The findings of the re-visit survey to the 09/21/23 re-licensure survey, conducted 12/11/23 through 12/12/23, 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 for Home and Community Based Services Regulations.
Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:
During the re-licensure survey, conducted 09/11/23 through 09/18/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the severity and number of citations.
1. A situation was identified which constituted an immediate threat to the health, safety and welfare of residents and required an immediate plan of correction in the following area:
OAR 411-054-0025 (4) Reasonable Precautions.
The facility put an immediate plan of correction in place during the survey and the situation was abated.
2. Refer to deficiencies in the report.
The licensee has brought all resources to the implementation
of actions based on the findings in this survey. This includes
resources related to staff education, diet modifications, residents rights, abuse reporting, infection control practices, PCC training, environmental needs and any additional resources that may be needed to ensure all deficiencies are corrected and a sustainable plan is implemented. Please refer to this plan of correction for further information.
There are no detail notes for this visit.
During the acuity interview, two sampled and five unsampled residents were identified as requiring modified texture meals and/or modified liquid consistencies.
Resident 1 and 2's clinical records were reviewed. Resident 1 was evaluated on 03/20/23 to need mechanical soft diet textures, and Resident 2 had a signed physician order, dated 08/28/23, indicating s/he required pureed textures and honey thick liquids.
During the survey, on 09/12/23 through 09/13/23, residents were observed to receive inaccurate diet textures and consistencies as follows:
* During an observation on 09/12/23 at 12:45 pm, caregivers provided all residents with gelatin dessert with whipped topping. The surveyor (Speech Pathologist) questioned a member of the kitchen staff about the preparation of the gelatin and was informed it was prepared traditionally. This gelatin was considered a thin liquid and not suitable for residents who required thickened liquids. The surveyor requested all gelatin be removed from the residents requiring thickened liquids.
* On 09/12/23 at 12:47 pm, the residents who required mechanical soft textures were served cubes of cut meat which appeared to be ham. Staff 7 (CG) reported it was turkey and was instructed by the surveyor (Speech Pathologist) to press down against the meat using a fork. She was unable to crush the meat prior to her thumbnail blanching white, which indicated the meat was not mechanical soft.
* On 09/12/23 at 5:08 pm, Staff 13 (CG) was observed preparing thickened liquids for Resident 2 using Simply Thick. To prepare thickened liquids correctly, the caregivers had to know how many ounces of fluid needed to be thickened and the target consistency. Staff 12 (CG) and Staff 13 were unable to identify the sizes of the glasses used by the facility. Staff 12 reported Resident 2 required pudding thick liquids and s/he was served pudding thick liquids. Resident 2 had a physician's order for honey thick liquids dated 08/28/23.
* On 09/12/23 at approximately 5:15 pm, Resident 1 was served a dinner of a cut tuna salad sandwich with crusted bread, a cut hashbrown patty with ketchup, and a mixed fruit cup with grapes and a fruit pit. Upon inspection from the surveyor (Speech Pathologist), it was determined the crusted bread, crusty hashbrown skin, grapes, and fruit pit were not considered mechanical soft.
* On 09/12/23 at 5:20 pm, the surveyor (Speech Pathologist) requested a mechanical soft test tray meal from the facility's kitchen. Dinner consisted of a cut tuna salad sandwich, a cut hashbrown patty with ketchup, and a mixed fruit cup. When pressed firmly with a fork, the hashbrown crusts and grapes from the fruit cup remained whole, which indicated those items were not mechanical soft.
* On 09/12/23 at 5:40 pm, Staff 16 (CG) provided vanilla ice cream to Resident 2 and an unsampled resident who required nectar thick liquids. Staff 2 (Business Office Manager) was instructed to remove the ice cream immediately for the residents' safety because it was considered a thin liquid.
* On 09/12/23 at 5:52 pm, Staff 13 was observed by the surveyor (Speech Pathologist) to spoon feed liquids to an unsampled resident. The unsampled resident was identified to require nectar thick liquids. Upon inspection of the liquids, the consistency was between honey and pudding thick.
Following the request for an immediate plan of correction, additional observations were made on 09/13/23:
* At 4:10 pm Staff 29 (CG) pushed a rolling cart down the hallway with pitchers of unknown fluids and a container of Simply Thick. Staff 29 was asked how many pumps she needed to give to Resident 2, who required a honey thick texture for fluids. Staff 29 replied, "I have no idea. This is my fifth day working here. I don't even know all the resident's faces. I was told to do two pumps and then I stir it around until it looks thick enough. Sometimes I add more." Staff 29 was not sure on the size of the cups being used and was asked to stop any further service of fluids to residents requiring a modified consistency until she received further training.
Following the observation, the surveyor had a discussion with Staff 1 (ED) on 09/13/23 and shared the above observation. Staff 1 stated, "It [thickener] shouldn't be on the cart," and immediately left and headed in the direction of the kitchen.
The IJ plan of correction was presented to the surveyors and approved on 09/13/23 at 4:12 pm. The situation was abated.
Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 2 of 2 sampled residents (#s 1 and 2) and multiple unsampled residents. Residents received inaccurate diet textures and consistencies, placing them at risk for aspiration, choking and/or death. Findings include, but are not limited to:
Additional meal observations were made on 09/13/23:
* At 8:15 am residents requiring mechanical soft diets were served cut up quiche, peach pieces, and bacon pieces. During the meal, this surveyor observed Staff 16 (CG) putting multiple chunks of bacon and pieces of quiche on a fork and feeding it all to an unsampled resident, who was on a mechanical soft diet, in the same bite.
The facility failed to ensure residents who required modified diet textures and consistencies were served the appropriate diet as evaluated or prescribed. This placed the residents at risk for choking, aspiration, and/or death.
The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED) and Staff 3 (Regional Director of Operations) on 09/13/23 at 11:30 am.
An immediate plan of correction was requested by the survey team on 09/13/23 at 11:30 am, and the situation was abated.
1.
RN provided hands on training for appropriate diet textures at noon meal on 9/13/23.
RN provided hands on training for appropriate diet textures at dinner meal on 9/13/23.
Simple directions for mixing thickened liquids was posted for care staff with glass size to ensure correct thickness on 9/13/23.
Executive Director and BOM will monitor for appropriate diets and feeding techniques until all staff have received training and competency verified.
Kitchen staff were trained on 9/19/23 by Janelle Lasai on diet textures and modified diet preparatation.
Pre thickened liquids are in use.
Care staff will not prepare thickened liquids. Any liquids requiring thickening that cannot be purchased pre thickend will be mixed by trained dietary staff.
Staff will received training on Friday 9/22/23 in an all staff meeting on modified diets, feeding assistance and feeding residents safely. Those not in attendance will not assist in dining room until training is documented.
2.
Kitchen staff will be trained at time of hire by qualified staff member and competency verified. Kitchen Staff Will be monitored prior to completing their training by a qualified staff member.
All new staff who assist in the dining room will receive training on modified diets and thickened liquids prior to assisting residents in the dining room.
All new staff will receive training on how to feed residents safely before assisting with meals.
Cherrywood will schedule dietary consultant visit quarterly to review diets and provide oversite and training for kitchen staff.
After initial training, training on proper feeding and diets will be conducted quarterly via all staff meetings.
Staff serving meals will verify the food served matches the diet order for that resident according to their diet card.
Diet orders will be reviewed quarterly and with Change of Condition.
3.
LN will evaluate foods prepared for all diet textures weekly to ensure they are correct for 6 weeks.
LNwill watch a meal service and assisted feeding weekly to monitor for safety or staff training needs for 6 weeks and twice monthly after that.
The Executive Director will assign someone from the leadership team to monitor quality control during all meal times.
4.
The Executive Director and Dietary Manager will be responsible.
There are no detail notes for this visit.
8. During an interview on 09/15/23 at 12:55 pm with Staff 15 (MT), observations were made of a text message exchange between Staff 15 and Resident 2's hospice RN. The correspondence included Resident 2's name and current medical treatments. Staff 15 confirmed the cell phone observed was her own personal phone and she used it to clarify a medication held.
The facility failed to have medical and other records kept confidential.
The failure to ensure resident medical records were kept confidential and to ensure residents were treated with dignity and respect was discussed with Staff 1 (ED), Staff 2 (Business Office Manager), and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings, and confirmed the staff were not to be using their personal cell phones for work matters.
Based on observation, interview, and record review, it was determined the facility failed to ensure multiple sampled and unsampled residents were treated with dignity and respect related to ADL needs, freedom from verbal and physical abuse, receiving services in a manner which protected their privacy and dignity, and ensuring medical and other records were kept confidential. Two unsampled residents experienced verbal abuse by a caregiver. Findings include, but are not limited to:
1. During an interview on 09/13/23, Staff 7 (CG) reported seeing and hearing Staff 9 (CG) say, "Don't ****ing do that to me," "You are not going to heaven," and "[Unsampled resident name] is taking the ****ing plates off my cart" to unsampled residents within the past week. Staff 7 reported s/he informed the facility management of the incidents.
During an interview on 09/13/23, Staff 1 (Executive Director), Staff 2 (Business Office Manager), and Staff 3 (Regional Director of Operations) reported not being informed of Staff 9's comments to residents. Staff 3 indicated an immediate investigation of Staff 9's comments would be initiated.
The facility failed to ensure staff members were aware of being mandatory reporters and failed to set expectations for staff conduct while providing care to the residents. Staff 7 failed to immediately report the verbal abuse allegations of Staff 9 to the facility management, and Staff 9 continued to provide care to residents.
On 09/14/23, a copy of the facility's self-report to the local Seniors and People with Disabilities (SPD) office of Staff 9's actions was provided. On 09/15/23, a copy of the facility investigation indicated Staff 9 had engaged in conduct that did rise to the level of resident abuse and would be terminated immediately.
On 09/15/23, the need to ensure residents were free from verbal abuse and neglect was discussed with Staff 1. She acknowledged the findings.
2. On 09/11/23 through 09/13/23 multiple caregivers were observed standing over residents while assisting with meals not providing a dignified dining experience.
3. On 09/11/23 at the beginning of lunch service, an unsampled resident asked a surveyor, "Why are there no chairs where I sit?" and pointed to the table in the corner with no chairs. At 12:00 pm, it was observed that there were 15 chairs on the perimeter of the dining room and four tables without any chairs. At 12:03 pm on 09/11/23, Staff 29 (CG) reported, "All residents should have a chair, no resident should have to move dining room chairs. The chairs on the back wall are because of high acuity residents using wheelchairs or other devices." Between 12:09 pm and 12:23 pm, the surveyor observed six residents move chairs to their dining room tables. No staff were observed to assist the residents in moving chairs.
4. On 09/13/23 a caregiver had been assisting Resident 1 with lunch. With food still left on the plate, the caregiver left Resident 1 unattended for greater than 30 minutes until a different caregiver intervened as Resident 1 began to eat a straw wrapper.
5. On 09/13/23 at 1:21 pm, Resident 5 was eating lunch in his/her room in a reclined position of approximately 120 degrees, with lower extremities elevated. Resident was in a semi-side-lying position eating from the plate of food placed on the left side of his/her body. Food was found on his/her chair, clothes and floor.
6. On 09/14/23 at 10:14 am, an unsampled resident participated in activities with about 12 other residents. Observed the resident slumped down in his/her wheelchair wearing clothing which exposed more than half of his/her upper thighs. Staff 2 (Business Office Manager) was alerted to assist the resident in a position change and offer a lap blanket or a change in clothing.
7. The following was observed during breakfast on 09/13/23:
* Staff 16 (CG) gave an unsampled resident a bite and spilled some on his/her lap, which was covered in an apron. Staff 16 did not clean up the spilled food.
* An unsampled resident picked up pieces of quiche with his/her fingers and ate them. Staff 16 came to the table, gave the resident two more bites, then moved his/her plate just out of his/her reach.
* Multiple sampled and unsampled residents ate with their fingers when no staff member was assisting them to eat.
1.
Staff member reported for possible verbal abuse was terminated after internal investigation.
Every staff member interview were coached by the interviewer regarding what constitutes abuse and their role as a mandatory report including how to make a report.
Staff members received training on how to properly feed residents on 9/22/23. This training included sitting and completing the meal before move away.
During dining room observation, staff received coaching on assisting residents with chairs at meal times.
Staff were trained on how to set up residents for meals when delivering a room tray.
Service plan was updated for resident slumping in chair to reflect her preferred way to sit. Staff will order loose leg coverings to protect her dignity when up in chair.
Staff member using her cell phone to communicate with Hospice RN was provided written counseling as she was aware this is against policy.
2. Diningroom is being monitored by management staff at meal times to provide coaching and ensure residents are being fed properly and are not eating with their fingers. The dietician is observing meals and dining and will assist with teaching staff feeding techniques. Dietician will assess residents for nutritional and meal time assistance needs.
MD was contacted to request OT again for resident in wheelchair to assess any needed adjustments to equipment to ensure her comfort when up in wheelchair.
All Medication Adminsitration staff will receive updated training on protecting resident health information including the prohibited use of cell phones.
3.
Dining room will be monitored daily for two months and at least weekly after to ensure staff are following all dining procedures.
Dietician will provide initial training and oversite of kitchen and dining room twice weekly until community is in compliance.
Dietician will visit the community quarterly thereafter to assist with maintaining compliance.
4.
Executive Director, Food Service Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including Alzheimer's disease and hyperlipidemia.
The resident's current service plan, dated 07/17/23, progress notes, dated 06/17/23 through 09/11/23, and incident reports and investigations were reviewed, and staff were interviewed. Multiple incidents were identified:
* 06/25/23 - unwitnessed, non-injury fall;
* 08/12/23 - unwitnessed, non-injury falls;
* 08/18/23 - two unwitnessed, non-injury fall;
* 08/30/23 - unwitnessed, non-injury fall;
* 09/09/23 - unwitnessed, non-injury fall; and
* 09/10/23 - unwitnessed, non-injury fall.
There were no documented evidence the falls were investigated to rule out abuse and/or neglect.
The resident experienced fifteen additional unwitnessed, non-injury falls which were not investigated in a timely manner to rule out abuse and/or neglect and included:
* 07/22/23 - unwitnessed, non-injury fall;
* 07/24/23 - three unwitnessed, non-injury falls;
* 07/29/23 - unwitnessed, non-injury fall;
* 08/02/23 - unwitnessed, non-injury fall;
* 08/08/23 - unwitnessed, non-injury fall;
* 08/10/23 - unwitnessed, non-injury fall;
* 08/12/23 - unwitnessed, non-injury fall;
* 08/15/23 - unwitnessed, non-injury fall;
* 08/16/23 - three unwitnessed, non-injury falls;
* 08/17/23 - unwitnessed, non-injury fall; and
* 09/11/23 - unwitnessed, non-injury fall.
The surveyor requested the incidents be reported to the local SPD office. Verification the facility reported the unwitnessed falls was received on 09/21/23.
The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to promptly investigate incidents to rule out abuse and/or neglect and report suspected abuse and/or neglect to the local Seniors and People with Disabilities (SPD) office when needed and failed to have documented evidence of an administrator review of investigations, for 2 of 6 sampled residents (#s 5 and 7). Findings include, but are not limited to:
2. Resident 7 was admitted to the facility in 08/2017 with diagnoses including Alzheimer's disease and congestive heart failure.
The resident's current service plan, dated 06/06/23, progress notes, dated 06/11/23 through 09/11/23, and incident reports and investigations were reviewed, and staff were interviewed. Multiple incidents were identified:
* 06/20/23 - resident-to-resident altercation;
* 06/25/23 - unwitnessed, non-injury fall;
* 07/12/23 - unwitnessed, non-injury fall;
* 07/25/23 - unwitnessed, non-injury fall;
* 07/28/23 - unwitnessed, non-injury fall; and
* 08/30/23 - unwitnessed, non-injury fall.
There were no documented evidence those incidents were investigated to rule out abuse and/or neglect.
The resident experienced two additional unwitnessed, non-injury falls, on 08/02/93 and 09/03/23, which were not investigated in a timely manner to rule out abuse and/or neglect.
The surveyor requested the incidents be reported to the local SPD office. Verification the facility reported the resident-to-resident altercation and the unwitnessed falls was received on 09/21/23.
The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
1.
All incidents noted during survey have been reported to APS and have had internal investigations by the Executive Director and nurse to the extend they were working for the community at the time of the incident.
2.
All incidents will be reviewed and investigated as required. All review and investigation will be document. Any incident where abuse can not be ruled out or abuse has not been ruled out timely per regulation will be reported to APS.
3.
Incident reporting and compliance will be audited weekly.
4.
The Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
2. Resident 2 was admitted to the MCC in 04/2018 with diagnoses including Alzheimer's disease.
A review of the resident's clinical record revealed the resident's most recent quarterly evaluation was completed on 09/11/23, which was during the re-licensure survey. On 09/12/23 at 1:07 pm the prior quarterly evaluation was requested. Staff 2 (Business Office Manager) confirmed the previous evaluation was dated 03/20/23 and there was no quarterly evaluation completed in 06/2023.
The need to ensure residents were evaluated quarterly was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 01/2023 with diagnoses including Alzheimer's disease and hyperlipidemia.
A review of Resident 5's clinical record revealed a quarterly evaluation had been completed, but was not dated or signed. On 09/15/23 further information, including when the quarterly evaluation was completed and by whom, was requested from Staff 1 (ED). She acknowledged the information could not be provided.
The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
4. Resident 1 was admitted to the facility in 12/2018 with diagnoses including dementia.
The resident's most recent quarterly evaluation was completed on 03/20/23. The next quarterly evaluation was due on 06/20/23 and had not been completed.
On 09/14/23, the need to ensure resident evaluations were completed at least quarterly was discussed with Staff 1 (ED). She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements and/or quarterly evaluations were completed for 4 of 7 sampled residents (#s 1, 2, 4, and 5). Findings include, but are not limited to:
1. Resident 4 was admitted to the facility in 09/2023 with diagnoses including cognitive functioning deficits and major depressive disorder.
A review of the resident's initial evaluation revealed the following required elements were not addressed:
* Customary routines: sleeping, eating, bathing;
* Interests, hobbies, social, leisure activities;
* Spiritual, cultural preferences and traditions;
* List of current diagnoses;
* Mental health issues, including presence of depression, thought disorders, or behavioral or mood problems history of treatment, and effective non-drug interventions; and
* Environmental factors impacting the resident's behavior, including noise, lighting, and temperature.
The need to address all required elements in the initial evaluation was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
1.
All evaluations for residents 1, 5, 2, 4, identified in the survey have been updated to reflect all required information.
We are in the process of completing new evaluations, service plans and service plan team meetings for all our residents.
2.
Roles and responsibilities for evaluation completions, updates and service plans including team meetings have been established.
3.
Audit of evaluation due dates and completion will be performed weekly using our electronic medical record system.
4.
Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
2. Resident 3 was admitted to the facility in 06/2023 with diagnoses including dementia.
Review of Resident 3's service plan, dated 06/30/23, and progress notes, dated 06/30/23 through 09/11/23, determined the service plan was not reflective and/or did not provide clear instructions to staff in the following areas:
* Showering/bathing;
* Nutrition and hydration;
* Challenging behaviors;
* Activities; and
* Elopement/wandering risks.
On 09/15/23 the need to ensure service plans were reflective of residents' current status and provided clear instructions to staff was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager). They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences and provided clear direction to staff regarding the delivery of services for 4 of 7 sampled residents (#s 1, 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the MCC in 04/2018 with diagnoses including Alzheimer's disease.
Resident 2's current service plan, dated 09/11/23, was reviewed, observations were made, and interviews were conducted between 09/11/23 and 09/15/23. Resident 2's service plan was not reflective and did not provide clear instruction to staff in the following areas:
* How the resident expressed pain;
* Frequency of positional changes when in bed;
* Frequency of safety checks;
* How the resident expressed anxiety and non-pharmacological interventions for his/her anxiety;
* Use of pillows for positioning while in bed to decrease risk of skin breakdown;
* Hospice services provided;
* Use of an air pressure mattress, including the recommended settings;
* Shaving preferences;
* Puréed diet and honey thick liquids provided by teaspoon; and
* Use of a Broda chair.
The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Business Office Manager) and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 01/2023 with diagnoses including Alzheimer's disease and hyperlipidemia.
The current service plan, dated 07/17/23, was reviewed. The service plan was not reflective of the resident's current status and/or did not provide clear direction to staff in the following areas:
* Dressing;
* Personal hygiene including washing face, shaving, and oral, hair, nail and foot care;
* Bowel and bladder management;
* Interventions for behaviors with bowel incontinence;
* Bathing, including preferences for time of day and gender of caregiver;
* Toileting, including two-person assist and type of incontinent products used;
* Transfer assist, including two-person assist and gait belt;
* Evacuation assistance;
* Skin, including management of lower extremity edema per HHRN instructions;
* Vitals to be taken and frequency;
* HHRN and PT services;
* Frequency of safety checks;
* Fall interventions including when to use fall mats;
* Elopement risk;
* Cognitive status;
* Medication management;
* Communication ability;
* Location preference for eating meals and proper setup;
* Hearing ability; and
* Mobility including level of assistance needed and assistive devices used.
The need to ensure service plans were completed quarterly, were reflective of residents' current needs, and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
4. Resident 1 was admitted to the facility in 12/2018 with diagnoses including dementia.
Observations, interviews and review of the current service plan, dated 06/29/23, revealed the service plan was not reflective of the resident's current status and/or lacked clear instructions to staff, in the following areas:
*Transfer assistance needed; and
*Eating assistance needed.
On 09/14/23, the need to ensure service plans were reflective of resident care needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (ED). She acknowledged the findings.
1.
Resident 2 - Evaluation and service plan have been updated to include information related to pain expression, position changes, frequency of safety checks, positioning of pillows for skin breakdown prevention, hopsice services, air mattress, shaving, diet and Broda chair.
Resident 3 - Evaluation and service plan have been updated to include information related to showering/bathing, nutrition/hydration, challenging behaviors, activities, and elopment/wandering risk.
Resident 5 - Evaluation and service plan have been Evaluation and service plan have been updated to include information related to dressing, hygiene, bowel/bladder, behavioral interventions related to bowel in continence, bathing, toileting, transfer assistance, evacuation, skin, safety checks, and fall interventions.
Resident 1- Evaluation and service plan have been updated to include information on transfer and eating assistance.
2.
We are in the process of completing new evaluations, service plans and service plan team meetings for all our residents.
3.
Audit of service plan completion will be performed weekly using our electronic medical record system. Resident services coordinator will review service plans for accuracy and ensure they reflect the current needs and preferences of the resident prior to providing to the staff.
4.
Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose service plans were reviewed. Findings include, but are not limited to:
Resident 1, 2, 3, 4, 5, 6 and 7's most recent service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans.
On 09/14/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED). She acknowledged the findings.
1.
Resident 1, 2, 3,4 and 5 - New evaluations and service plans have been completed; service plan meetings are being scheduled and will be conducted prior to compliance date.
2.
Community has identified staff for the service planning team and will have documented team participation.
Community will coordinate a service plan meeting schedule and document resident/responble party attendance/envolvement.
3.
Schedule of service plans teams and meetings will be audited monthly to ensure all compliance.
4.
The Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
2. Resident 3 was admitted to the memory care community in 06/2023 with diagnoses including dementia.
In the acuity interview on 09/11/23, Staff 18 (MT) identified Resident 3 as having behavior issues and having been in a resident-to-resident altercation.
The resident's service plan, dated 06/30/23, progress notes, dated 06/30/23 through 09/11/23, and incident reports were reviewed. The records revealed the following:
* 09/05/23 - Resident 3 was put on "alert charting" for behaviors following an incident where s/he began "yelling and swearing at staff and other residents" and "flipping off everyone"; and
* 09/09/23 - Resident 3 was involved in a resident-to-resident altercation in which s/he threw a pillow at another resident, while loudly calling him/her crude names and using profanity.
There was no documented evidence resident-specific interventions were developed to address those behaviors.
In an interview on 09/13/23, Staff 1 (ED) acknowledged the lack of behavioral interventions in Resident 3's service plan.
On 09/15/23, the need to implement and document resident-specific interventions for challenging behaviors was discussed with Staff 1 and Staff 2 (Business Office Manager). They acknowledged the findings.
3. Resident 2 was admitted to the MCC in 04/2018 with diagnoses including Alzheimer's disease.
Observations of the resident and interviews with staff were completed. The resident's service plan, dated 09/11/23, and progress notes, dated 06/12/23 through 09/08/23, were reviewed. The following was revealed:
a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and documentation of resolution:
* 07/07/23 - Coccyx/buttocks wound;
* 07/19/23 - Boil and rash to bilateral armpits;
* 08/06/23 - Change to a mechanical soft diet; and
* 08/19/23 - Start of lactulose (for constipation).
b. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and the communication of the determined actions or interventions to staff on all shifts:
* 08/01/23 - Start of clindamycin (for rash);
* 08/03/23 - Increased yelling and uncontrolled physical jerking;
* 08/19/23 - Admit to hospice;
* 08/19/23 - Start of morphine (for pain) and Ativan (for anxiety);
* 08/27/23 - Start of ipratropium bromide (for shortness of breath); and
* 08/28/23 - Change to a puréed diet and honey thick liquids.
The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift and the changes of condition were monitored weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Business Office Manager) and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were monitored and progress was documented at least weekly until resolved, and actions or resident-specific instructions or interventions identified, implemented and communicated to staff for 5 of 6 sampled residents (#s 1, 2, 3, 5 and 7) reviewed for changes of condition. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including Alzheimer's disease and hyperlipidemia.
The resident's current service plan, dated 07/17/23, progress notes, dated 06/17/23 through 09/11/23, and incident reports and investigations were reviewed, and staff were interviewed. The following changes of condition were identified:
* Twenty-eight unwitnessed, non-injury falls between 06/25/23 and 09/11/23;
* Multiple medication changes;
* Three ER/hospital visits and returns;
* Multiple skin issues; and
* Admit to home health services.
There was no documented evidence interventions were determined, documented, implemented, and/or monitored for effectiveness for the resident's 28 falls noted above.
There was no documented evidence the facility evaluated the resident's medication changes and skin issues, implemented interventions, and/or monitored the changes until resolution.
The need to evaluate changes of condition, implement interventions for changes, and monitor interventions for effectiveness, was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
4. Resident 1 was admitted to the facility in 12/2018 with diagnoses including dementia.
Resident 1's record was reviewed for changes of condition and revealed the following:
* On 06/14/23, 06/27/23, 07/18/23, and 08/17/23 Resident 1 experienced witnessed and unwitnessed non-injury falls.
There was no documented evidence the facility evaluated the resident after each fall to determine what actions or interventions were needed to minimize the further occurrence of falls.
On 09/14/23, the need to determine and document what actions or interventions were needed when a resident experienced a short-term change of condition was discussed with Staff 1 (ED). She acknowledged the findings.
5. Resident 7 was admitted to the facility in 08/2017 with diagnoses including Alzheimer's disease and congestive heart failure.
The resident's current service plan, dated 06/06/23, progress notes, dated 06/11/23 through 09/11/23, and incident reports and investigations were reviewed, and staff were interviewed. The following changes of condition were identified:
* 06/20/23 - resident-to-resident altercation;
* 06/25/23 - unwitnessed, non-injury fall;
* 07/12/23 - unwitnessed, non-injury fall;
* 07/24/23 - decrease in appetite and interaction;
* 07/25/23 - unwitnessed, non-injury fall;
* 07/28/23 - unwitnessed, non-injury fall;
* 08/30/23 - unwitnessed, non-injury fall; and
* 09/05/23 - change of condition related to needing increased assistance with toileting and transfers.
There was no documented evidence interventions were determined, documented, implemented, and/or monitored for effectiveness for the resident's five falls noted above.
There was no documented evidence Resident 7's significant change of condition related to requiring increased assistance with toileting and transfers was referred to the RN for assessment.
The need to evaluate changes of condition, implement interventions for all falls and other incidents, and monitor interventions for effectiveness was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
1.
Resident 5 - We have re-evaluated this resident, updated the service plan and conducted a RN assessment in collaboration with our consultant staff; new fall prevention interventions have been added.
Resident 3 - This resident has been evaluated for behaviors. The Service plan identifies triggers and interventions for behaviors.
Resident 2 - This resident's has been re-evaluated and the service plan has been updated. An RN assessment was completed for this resident by the RN at the time of survey and will be reviewed in collaboration with our consult staff.
Resident 1 - This resident has been evalutated for falls and the service plan has been reviewed and update for fall interventions.
Resident 7- Has been evaluated by RN for falls and service plan has been updated for fall prevention and interventions.
2.
Alert charting will be completed by Med Techs on each shift for all short term changes of condition.
3.
Alert charting for short term changes will be monitored weekly by the Resident Services Coordinator for accuracy and completion.
4.
The Executive Director, Resident Services Coordinator and RN are responsible.
There are no detail notes for this visit.
2. Resident 2 was admitted to the MCC in 04/2018 with diagnoses including Alzheimer's disease.
Review of the clinical record and interviews with staff revealed Resident 2 had a stage two wound on his/her right buttock/coccyx area which was first identified by the facility's staff on 06/14/23.
The stage two wound constituted a significant change in condition for which an assessment by the facility RN was required.
There was no documented evidence the facility RN conducted an assessment which included documentation of the resident's status.
During an interview on 09/14/23 at 3:13 pm, Staff 6 (RN) confirmed the assessment did not have the resident's status documented.
The need to ensure significant changes of condition were assessed by an RN and included findings, resident status and interventions was discussed with Staff 1 (ED), Staff 2 (Business Office Manager) and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition and documented findings, resident status, and interventions made as a result of the assessment for 2 of 5 sampled residents (#s 2 and 7) who experienced significant changes. Findings include, but are not limited to:
1. Resident 7 was admitted to the facility in 08/2017 with diagnoses including Alzheimer's disease and congestive heart failure.
The resident's clinical record was reviewed, and staff were interviewed. The resident experienced the following:
* 09/05/23 - change of condition related to needing increased assistance with toileting and transfers.
On 09/05/23 Staff 15 (MT) documented in a progress note the resident had experienced a change of condition, needing " ... more assistance on transferring and in the restroom." There was no documented evidence the facility RN had assessed the resident's change of condition.
The RN was not available for an interview.
The need for the RN to assess significant changes of condition and document findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
1.
Resident 2 - RN completed an assessment for skin issued identified by staff. The skin is currently intact.
2.
We have returned to a paper skin monitoring system that allows for signed documentation from the RN as well as other licensed staff.In addition, we have implemented a new documentation form for the RN to follow relating to significant changes of condition and service plan updates.
3.
The skin documentation will be reviewed weekly to assure it is being completed by the RN as required.
4.
The Executive Director, RN and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure new interventions from outside providers were implemented for 1 of 2 sampled residents (#5) who received services from outside providers. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 01/2023 with diagnoses including Alzheimer's disease and hyperlipidemia.
Resident 5's current service plan dated, 07/17/23, progress notes, dated 06/17/23 through 09/11/23, and outside provider notes, dated 08/24/23 through 09/07/23, were reviewed and noted the following:
* 09/07/23 - "L [left] w/c [wheelchair] brake needs to be adjusted."
On 09/11/23 through 09/13/23, Resident 5 was observed to transfer in and out of his/her wheelchair with caregiver assist multiple times. Caregivers attempted to lock the left brake unsuccessfully and the chair would move about 1" to 2" during a transfer. Staff 9 (CG) stated, "I think home health is supposed to fix that."
On 09/12/23 Staff 1 (ED) was asked how new interventions from outside providers were addressed. She clarified the lead MT reviewed the provider note and "if it's something important it gets noted in the progress note." Staff 18 (MT) initialed the 09/08/23 HHPT provider note with "Noted," but no information about the brake was documented in the progress notes reviewed. Staff 1 stated, "I think we have to find out who supplied the chair and have them fix it. I don't think we can fix it here."
On 09/14/23 Staff 18 and Staff 4 (Environmental Services Director) were interviewed about the new intervention to fix the wheelchair brake. Staff 18 stated, "I was going to try and find another wheelchair and the HHPT was working on getting a new wheelchair also" for Resident 5. Staff 4 agreed to fix the brake and was observed taking Resident 5's wheelchair following the interview. \
There was no documented evidence the intervention was followed up and initiated.
On 09/15/23, the need to ensure the facility implemented outside provider interventions was discussed with Staff 1 and Staff 2 (Business Office Manager). They acknowledged the findings.
1.
Resident 5 - Wheelchair brake has been fixed as per Outside provider recommendation.
2.
Outside providers will continue to use the communication sheet with each visit. These sheets will be reviewed by the Resident Services Coodinator who will address any recommendations and service plan updates as indicated prior to the note being placed in the resident chart.
3.
We will evaluate this new process weekly for the next quarter, further evaluation schedule will be determined by compliance.
4.
The Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols for 2 of 7 sampled residents (#s 2 and 5) during ADL care and meal service. Findings include, but are not limited to:
1. Resident 2 was admitted to the MCC in 04/2018 with diagnoses including Alzheimer's disease.
Observations of Resident 2 during the survey revealed s/he was dependent on two staff for all incontinent care, and s/he needed assistance with incontinent care while in bed.
On 09/11/23, from 1:01 pm to 1:11 pm, the surveyor obtained permission and observed two caregivers provide incontinence care for Resident 2. Both caregivers failed to change gloves after removing soiled clothing, a soiled incontinence brief and then wiping Resident 2's perineum. The caregivers proceeded to touch the resident's clean incontinence brief, the resident's lower legs and both sides of the resident's body, the clean incontinence brief, barrier cream, bed linens, the resident's fall mat, and the bed control. Both caregivers doffed their gloves, and one removed the incontinence garbage from the resident's room. That caregiver touched the resident's door handle, keys and the door where the trash was disposed. Both caregivers performed hand hygiene following the disposal of the resident's garbage.
The need to ensure the facility established and maintained infection prevention and control protocols to provide a safe, sanitary and comfortable environment was discussed with Staff 1 (ED), Staff 2 (Business Office Manager), and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings.
2. Observations were made during the survey to determine adherence to universal precautions for infection control.
Resident 5 was admitted to the facility in 01/2023 with diagnoses including Alzheimer's disease and hyperlipidemia.
The following observations of incontinence care were observed and identified the following:
* On 09/12/23, at 9:25 am, the surveyor observed Staff 7 (CG) and Staff 10 (CG) provide incontinence care to Resident 5. Staff 10 failed to change gloves after wiping urine and fecal matter from Resident 5's bottom area. Staff 10 touched the resident's brief, pants, shirt, gait belt and the resident's wheelchair while wearing the same soiled gloves.
* On 09/13/23, at 1:50 pm, the surveyor observed Staff 9 (CG) and Staff (16) provide incontinence care to Resident 5. Staff 9 and Staff 16 donned gloves without first performing hand hygiene. Staff 9 and Staff 16 assisted in doffing resident's brief and pants prior to sitting on the toilet. Staff 9 identified the resident's brief was soiled and both staff assisted in removing. Staff 9 then doffed her gloves to leave the bathroom and returned with a new brief. No handwashing was observed after doffing and prior to donning new gloves. Staff 16 donned the new brief and touched the resident's socks and pants while wearing the same soiled gloves. Staff 9 assisted Resident 5 to stand up while both staff provided perineal care with wipes. Staff 9 and Staff 16 touched the resident's brief, pants, shirt, gait belt and wheelchair with the same soiled gloves while they assisted him with a transfer back to his/her wheelchair.
3. On 09/11/23, observations during lunch service identified the following:
* At 12:15 pm a caregiver was observed providing meal assistance to Resident 2 and an unsampled resident. The caregiver placed her left hand on the wheelchair armrest of Resident 2 while using her right hand to provide meal assistance. The caregiver turned around and provided meal assistance to another resident with her left hand as she placed her right hand on the wheelchair armrest. Also the caregiver was observed to crouch down and rest both hands on the resident's lap trying to wake the resident up and then went back to providing meal assistance to both residents with the same process. The caregiver did not change her gloves or perform hand hygiene.
* At 12:35 pm a caregiver was asked to assist a resident who was falling asleep. She donned gloves, rubbed the resident's back, inserted a straw in the cup and brought the cup to his/her mouth to drink, and moved the wheelchair closer to the table. Afterwards, the caregiver turned around and provided meal assistance to Resident 2. The staff member was not observed to change her gloves or perform hand hygiene prior to assisting Resident 2.
* At 12:45 pm a Jello dessert was sitting at the table for a resident. A caregiver returned the dessert to the rolling cart that was headed back to the kitchen with approximately eight remaining leftover Jello desserts. At 12:58 pm the surveyor spoke with Staff 28 (Cook) to determine what was done with the Jello desserts that came into the kitchen. He reported, "We cover and date them and they are good for three days." The surveyor asked Staff 28 to throw out the leftover Jello desserts due to a staff member placing one back on the cart that had been already served to a resident. He agreed and complied.
4. On 09/13/23 at 8:40 am a rolling cart was observed leaving the kitchen with uncovered oatmeal to be delivered to resident rooms. On 09/18/23 the surveyor spoke to Staff 27 regarding the need for all food items leaving the dining room to be covered. She acknowledged the findings.
The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) on 09/18/23. She acknowledged the findings.
1.
Staff will be trained by Licensed Nursing regarding infection control during resident care and hygiene, including appropriate use of gloves, when gloves need to be changed and hand hygeine.
Staff will be trained by the dietician on infection control during meal times and meal service, including hand hygiene before and after assisting residents and surfaces.
Kitchen staff will be trained by the dietician on safe handling and storing of food. Any food sent out of the kitchen will not be stored for use later but will be thrown out.
2.
We have a hand hygiene observation tool that will be put into use to monitor staff understanding and obersevance of infection control procedures.
All staff will be trained on infection control including but not limited to hand hygiene, surface comtaination, spread of infection and need for good infection control practices.
3.
Resident personal care, tray service, meal time service and feeding will be monitored twice weekly to monitor infeciton control practices are being followed by staff.
4.
The Executive Director, Food Services Director and Resident Services Director will be responsible.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 5 sampled residents (#s 2, 5, and 7) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the MCC in 04/2018 with diagnoses including Alzheimer's disease.
The resident's MARs and TARs, dated 08/01/23 through 09/10/23, corresponding progress notes, and prescriber orders were reviewed. The resident had the following prescriber orders dated 08/19/23 unless otherwise noted:
* Artificial Tears - two drops in each eye two times a day (for eye dryness);
* Clindamycin topical 1% gel - one application applied topically two times a day. Apply to bilateral axillae BID (for rash);
* Ipratropium bromide 500 mcg/2.5 mL solution - two puffs inhaled four times a day PRN for shortness of breath. Order date was 08/26/23;
* Lactulose 10 g/15 mL syrup - 30 mL orally two times a day for constipation;
* Lorazepam 0.5 mg - take one tablet by mouth three times daily for anxiety;
* Milk of Magnesia 400 mg/5 mL - take 30 mL orally once a day PRN at bedtime;
* Morphine 20 mg / mL - take 0.5 mL by mouth three times daily for pain;
* Nystatin powder - apply topically to bilateral armpits twice daily until redness/rash are resolved. Order date was 02/27/23;
* Remedy Skin Cream - apply topically to both buttocks every shift for skin breakdown prevention. Order date was originally 02/27/23, and it was modified to one application applied topically three times a day on 08/19/23; and
* Resident to be last up and first down and turned on side after being up (for skin protection). Order date was 02/27/23.
a. The facility held the nystatin powder 41 times in 08/2023 and one time in 09/2023 because the resident was receiving another treatment to the armpits. An order to hold the medication was requested on 09/14/23 at 10:07 am. The facility provided a discontinuation order dated 09/01/23 and no additional documentation indicating the medication was to be held.
b. According to the MAR and an interview with Staff 15 (MT) on 09/13/23 at 1:03 pm, Resident 2 received the ipratropium bromide solution by nebulizer. The order for the nebulizer treatment was requested on 09/14/23 at 10:07 am. The physician order provided by the facility was dated 09/15/23, or during the re-licensure survey.
c. The facility held the resident's lactulose order on 08/23/23 because s/he received PRN Milk of Magnesia on the same date. On 09/15/23 at 12:45 pm, Staff 15 reported she made the decision to hold the medication and had no documented order from the resident's prescriber.
d. On 09/01/23, Resident 2's order for clindamycin was modified to continue two times a day for five more days and then discontinue. The resident continued to receive the medication from 09/07/23 - 09/11/23.
e. Resident 2 received the Milk of Magnesia on 08/16/23 at 10:42 am and 08/23/23 at 5:38 am. The resident's order indicated the medication be administered at bedtime.
f. Resident 2's MARs and TARs had the following blanks:
* Artificial tears on three occasions;
* Lactulose on one occasion;
* Lorazepam on two occasions;
* Morphine on two occasions;
* Remedy Skin Cream on five occasions; and
* Resident to be last up and first down on seven occasions.
On 09/13/23 at 1:03 pm, Staff 15 and the surveyor reviewed the resident's medication supply, MAR and TAR. Staff 15 was unable to confirm whether the orders had been administered as prescribed.
The need to ensure all medications were administered as prescribed and written, signed physician orders were documented in the resident's facility record for all medications the facility was responsible to administer was reviewed with Staff 1 (ED), Staff 2 (Business Office Manager), and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 01/2023 with diagnoses including Alzheimer's disease and hyperlipidemia.
The resident's progress notes, dated 06/17/23 through 09/11/23, MARs, dated 08/01/23 through 09/11/23, and physician orders were reviewed and revealed the following:
a. It was unclear if the following medications were administered, as the MARs had blanks on the entries for 09/02/23:
* Atorvastatin (for hyperlipidemia); and
* Docusate/senna (for constipation).
On 09/14/23 at 3:10 pm the surveyor and Staff 18 (MT) reviewed the medication supply and the MAR. She was unable to confirm whether the orders had been administered as prescribed due to the previous single dose packaging having been disposed of already.
The need to ensure the facility administered all medications per physician's order and initialed the MARs for administration of all medications and/or treatments was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
3. Resident 7 was admitted to the facility in 08/2017 with diagnoses including Alzheimer's disease and congestive heart failure.
The resident's 08/01/23 through 09/11/23 MARs and TARs, along with current physician orders, were reviewed. The following scheduled medications and/or treatments had no initials indicating they were administered for several administration times between 08/07/23 and 08/09/23:
* Artificial Tears (for dry eyes);
* Lidocaine/prilocaine 2.5% cream (for pain and muscle spasms);
* Pulmicort (inhaler); and
* Compression socks (for water retention in legs).
The need for staff to follow physician orders and initial the MARs and TARs for administration of all medications and/or treatments was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager) on 09/15/23. They acknowledged the findings.
1.
Resident 2 - Medication and Treatment orders have been reviewed and updated for accuracy.
Resident 7 - Medication and Treatment orders have been reviewed and updated for accuracy.
2.
Resident Services Coordinator will review all current medication and treatment orders and provide updated directions as appropriate. Resident Services Coordinator will review all new medication and treatment orders upon receipt to ensure clear direction for staff and accuracy.
3.
Weekly audit of Medication records.
4.
The Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused to consent to an order for 2 of 2 residents (#2 and 3) who had medication refusals. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 03/2023 with diagnoses including hypertension and osteoarthritis.
The resident's 10/01/23 to 10/30/23 MAR and progress notes dated 08/01/23 to 10/30/23 were reviewed, and interviews with staff were conducted. The following was identified:
On 10/14/23 staff documented on the MAR the resident refused to consent to the following orders:
* Potassium chloride (for low potassium);
* Furosemide (for edema);
* Acetaminophen (for pain);
* Calcium carbonate (for osteoporosis);
* Curcumin (for osteoarthritis);
* Fexofenadine (allergies);
* Lostartan (for hypertension);
* Metoprolol succinate (for hypertension);
* Multivitamin (for nutritional supplement);
* Sertraline (for depression/anxiety);
* Vitamin D3 (for nutritional supplement); and
* Omeprazole (GERD).
Resident 3 had returned from the hospital on 10/13/23 and had new orders to increase her furosemide 20 mg to two tablets for two days (10/14/23 and 10/15/23) and on 10/16/23 return to one tablet once daily. The MAR revealed that Resident 3 received only one 40 mg dose of furosemide and on 10/16/23 resumed taking 20 mg daily.
During an interview at 1:50 pm on 10/31/23, Staff 7 (RCC) confirmed that the physician was not notified when the resident refused the medications.
The need to notify the physician when a resident refused consent to orders was discussed with Staff 1 (ED) and Staff 6 (Wellness Services Director, LPN) on 11/02/23. They acknowledged the findings.
There are no detail notes for this visit.
2. Resident 2 was admitted to the facility in 04/2018 with diagnoses including Alzheimer's disease.
Resident 2's signed physician orders and 08/01/23 through 09/10/23 MARs were reviewed during the survey.
The following medications lacked medication-specific instructions for administration or resident-specific parameters for PRN dosing:
* Acetaminophen 650 mg suppository (for pain);
* Ipratropium bromide 0.02% (for shortness of breath or wheezing);
* Morphine 20 mg/mL (for pain or shortness of breath); and
* Ondansetron HCL 4 mg (for nausea or vomiting).
In an interview with Staff 15 (MT) on 09/13/23 at 1:03 pm, she confirmed resident-specific parameters for PRN dosing and medication-specific instructions for administration of PRN medications were not available in the electronic MAR.
The need to ensure the facility's MAR included medication-specific instructions and resident-specific parameters for PRN dosing was discussed with Staff 1 (ED), Staff 2 (Business Office Manager), and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and provided clear instruction and parameters for administration of PRN medications for 2 of 5 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 12/2018 with diagnoses including dementia.
Resident 1's signed physician orders and 08/01/23 through 09/11/23 MARs were reviewed during the survey.
Resident 1 was prescribed the following PRN medications for constipation:
* Milk of Magnesia 400mg/5ml; and
* Bisacodyl 10mg suppository.
The MAR failed to include clear parameters and instructions to unlicensed staff for when each medication should be administered.
On 09/14/23, the need to ensure MARs included parameters for PRN medications was discussed with Staff 1 (ED). She acknowledged the findings.
1.
Resident 1 - Medicaton record has been reviewed and parameter were put into place for bowel care medication.
Resident 2 - Medication record has been reviewed and parameters were added for comfort care medications.
We are currently reviewing all medication records for appropriate parameters and direction for staff.
2.
Resident Services Coordinator will review all new medication and treatment orders upon receipt to ensure clear direction for staff and accuracy.
3.
Weekly audit of Medication records.
4.
The Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation for 3 of 5 sampled residents (#s 1, 2 and 5). Findings include, but are not limited to:
Review of Residents 1, 2, and 5's records, interviews with staff, and observations of the residents revealed ABST entries were not reflective of the residents' current care needs. The ABST data showed multiple ADL elements which reflected zero minutes when the residents required more than zero minutes of assistance.
On 09/14/23, inaccuracies on resident entries for the ABST tool were discussed with Staff 1 (ED). She acknowledged the findings.
1.
The ABST has been updated for residents 1, 2 and 5 to reflect current care needs.
2.
We are in the process of updating all resident service plans. The ABST will be updated in correlation with these updates to ensure resident current needs are reflected.
3.
The ABST will be reviewed weekly to verify appropriate updates occurred.
4.
Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents within 24 hours of admission and re-instruction at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:
Review of facility records on 09/13/23 identified the following deficiencies:
* There was no documented evidence residents had received fire safety instruction within 24 hours of admission to the facility; and
* There was no documented evidence annual training on fire safety was provided to residents.
In an interview on 09/14/23, Staff 4 (Environmental Services Director) acknowledged there had been no fire safety instruction provided to residents.
On 09/15/23 the need to provide fire safety instruction to residents within 24 hours of admission and at least annually thereafter, in accordance with the OFC, was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager). They acknowledged the findings.
1.
All residents will be instructed in Fire and Life Safety procedures as their cognition allows.
2.
We have implemented a form to document instruction date and fire/life safety needs. Documentation of instruction and residents abilty/needs for evacuation will be maintained in their medical record.
3.
Will be evaluated monthly for compliance.
4.
Executive Director and Environmental Services Director will be responsible.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were clean and in good repair. Findings include, but are not limited to:
During a tour of the facility on 09/11/23, the following was observed:
* The wood flooring in the dining room had many dark marks, scrapes and gouges.
In an interview on 09/11/23, Staff 4 (Environmental Services Director) acknowledged the damage to the floor.
On 09/14/23, the need to maintain surfaces in good repair was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager). They acknowledged the findings.
1.
We have engaged an outside vendor to assess and provide recommendations for the dining room floor.
2.
Floor care will be maintained by the Enviromental Services Director.
3.
Monthly environmental audit will be preformed.
4.
The Executive Director and Environmental Services Direcor will be responsible.
There are no detail notes for this visit.
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:
Refer to C 150, C 160, C 200, C 231, C 361, C 422, and C 513.
Please refer to plan of correction for C150, C160, C200, C231, C361, C422, and C513.
There are no detail notes for this visit.
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:
Refer to C 252, C 260, C 262, C 270, C 280, C 290, C 295, C 303, and C 310.
Please refer to the plan of correction for C252, C260, C 262, C270, C280, C290, C295, C303, and C 310.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose records were reviewed. Findings include, but are not limited to:
Resident 1, 2, 3, 4, 5, 6 and 7's service plans lacked documented evidence of individualized nutrition and hydration needs, preferences and abilities, as required for memory care residents.
On 09/15/23 the need to develop an individualized nutrition and hydration plan for each resident in the MCC was discussed with Staff 1 (ED), Staff 2 (Business Office Manager), and Staff 3 (Regional Director of Operations). They acknowledged the findings.
1.
All residents cited in survey have bene evaluated and service plans were updated to include personalize nutrition and hydryation plans.
2.
We are currently reviewing all resident service plans to ensure personalized nutrition and hydration plans are included. The Consult Dietician will assess each residents nutrition and hydration needs and will provide recommentations to community.
3.
Hydration and Nutrition plans will be evaluated quarterly with service plan team meetings or with any significant COC.
4.
The Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.
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 their activity evaluation, for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose records were reviewed. Findings include, but are not limited to:
Resident 1, 2, 3, 4, 5, 6 and 7's service plans, assessments, and evaluations were reviewed. The records lacked documented evidence the facility had evaluated the residents':
* Past and current interests;
* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Activities that could be used as behavioral interventions, if necessary.
There was no documented evidence of specific activity plans which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities.
On 09/15/23, the need to ensure all residents had individualized activity plans developed and implemented, based on their activity evaluations, was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager). They acknowledged the findings.
1.
All residents cited on the survey have been evaluated for activities and service plans have been updated.
2.
We have implemented an Activity Evaluation document in addition to the life story questionaire to create a resident specific activity plan. We are currently completing an activity evaluation for all residents.
3.
Activity evaluations will be reviewed quarterly with service plan team meetings or with a significant change of condition.
4.
The Executive Director and Life Enrichment Director will be responsible.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to evaluate residents' behaviors which negatively impacted the resident or others in the community and update the service plan for 3 of 3 sampled residents (#s 3, 8 and 9). Findings include, but are not limited to:
1. Resident 3 was admitted to the memory care community in 06/2023 with diagnoses including dementia.
In an acuity interview on 09/11/23, Staff 18 (MT) identified Resident 3 as having exhibited negative behaviors and having been involved in a resident-to-resident altercation.
Review of Resident 3's records, interviews with staff, and observations of the resident between 09/11/23 and 09/15/23 were conducted. The resident's progress notes, incident reports reviewed from 06/30/23 through 09/11/23 revealed the resident had behaviors including anxiety, throwing items at others, yelling insults and profanities, and refusing to follow staff direction.
Resident 3's behavioral symptoms were not evaluated nor included on the service plan.
On 09/15/23, the need to evaluate residents' behaviors and include them on the service plan was discussed with Staff 1 (ED) and Staff 2 (Business Office Manager). They acknowledged the findings.
2. Resident 8 and Resident 9 were admitted to the MCC in 03/2022 and 07/2022, respectively, with diagnoses including Alzheimer's disease.
At approximately 9:29 am on 09/12/23, Resident 8 and Resident 9 were observed standing in the hallway embracing and kissing. No information regarding the relationship had been provided to the surveyors during the acuity interview.
On 09/12/23 at 10:22 am, Staff 1 (ED) reported the residents were not married to each other, but rather had spouses or long-term partners outside the facility. Staff 1 also reported the two residents had engaged in sexual activities prior to her tenure as ED.
Resident 8's current service plan, dated 03/16/23, and most recent evaluations, dated 03/10/22 and 03/16/23, and progress notes from 06/07/22 through 06/18/23, were reviewed. Resident 9's service plan, most recently updated 06/16/23 and 09/11/23, most recent evaluation, dated 09/11/23, and progress notes from 07/22/22 through 09/12/23, were also reviewed. Incident reports related to Resident 8 and 9's relationship were requested. Staff 1 confirmed the facility did not have any pertinent incident reports for either resident on 09/12/23 at 11:09 am.
There was no documented evidence the facility evaluated the relationship between Resident 8 and Resident 9 or their cognitive ability to consent to a romantic or sexual relationship, and no documentation of previous communication about the relationship to the residents' families was provided.
The current service plans for both residents lacked information regarding the relationship between Resident 8 and 9.
The need to evaluate residents' behaviors which negatively impacted the resident and others within the community, and update the service plan was discussed with Staff 1, Staff 2 (Business Office Manager), and Staff 3 (Regional Director of Operations) on 09/15/23. They acknowledged the findings. Prior to exit, the facility initiated the evaluation of both residents, contacted the residents' families regarding the relationship, and educated caregivers regarding the relationship.
1.
Resident 3 was evaluated related to behaviors, triggers and effective interventions. The service plan has been updated to reflect behavioral needs.
Resident 8 and 9 - we have requested an evaluation by MD for abiltiy to consent to a relationship. Both service plans have been updated to reflect the relationship and current interventions to prevent intimate relations. Service plans will be updated after consent can be determined.
2.
We are in the process of updating all resident service plans including needs for behavioral supports.
3.
Will be evaluated quarterly and more often as needed for behavioral changes.
4.
The Executive Director and Resident Services Coordinator will be responsible.
There are no detail notes for this visit.