The findings of the change of ownership survey, conducted 06/06/23 through 06/09/23, 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, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.  

Tag numbers beginning with 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

The findings of the first revisit to the re-licensure survey of 06/09/23, conducted 02/26/24 through 02/28/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 06/09/23, conducted 04/23/24 through 04/24/24, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the facility failed to provide effective oversight to ensure the quality of services rendered in the facility. Findings include, but are not limited to:

During the change of ownership survey, conducted 06/06/23 through 06/09/23, oversight to ensure the quality of services rendered in the facility was found to be ineffective, based on the number of citations.

Refer to deficiencies in the report.

C 150 Facility Administration: Operation

Please see POC below.

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

The MCC consisted of a long hallway with resident rooms on both sides with a multi-purpose room located at the end. This room served as the dining, activities and visiting area. A fully equipped kitchenette with a stove was located in the center of the room. There was a secured courtyard adjacent to the room.  

The memory care environment was toured on 06/07/23 and 6/08/23, the following safety issues were identified:

At 10:56 am on 06/07/23, the secure courtyard gate was observed to be unlocked and opened to the parking lot. The surveyor secured the gate and alerted Staff 1 (Memory Care Director) of the finding.

The cabinet below the kitchenette sink where cleaning chemicals and disinfectants were stored was not supplied with a lock;

Drawers in the kitchenette where sharp kitchen tools and knives were stored were unlocked;

Interviews with staff on 06/08/23 related to the stove indicated staff were unaware of the location for the shut off switch to the stove and there was no other safety device in place to ensure resident safety.

The above findings were shown to and discussed with Staff 1 and Staff 2 (ED). The shut off to the stove was located at the breaker box.

The need to ensure staff exercised reasonable precautions to maintain a secure and safe environment for residents was discussed with Staff 1 and Staff 2 on 06/09/23. They acknowledged the findings.  

1.Short term plan is to retrain all care staff about entry and exit to all areas from MC wing.

2. Long term plan is to install spring mechanism that will automatically close door and lock.  Maintenance will place lock on cabinet that stores chemicals in kitchenette area. Sharp kitchen tools and knives are now stored in a drawer that locks. All staff have been trained on how to locate and use oven shut off switch.

3. Frontier's routine Maintenance Schedule will be implemented.

4. MC Administrator and Executive Director are responsible for compliance.

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity in a homelike environment. Findings include, but are not limited to:

Observations made throughout the MCC on 06/06/23 through 06/09/23 identified the following:

Multiple window coverings throughout the MCC including resident bedrooms were inoperable and failed to provide privacy.

On 06/09/23, the need to ensure all window coverings were operable and protected residents' privacy and dignity was discussed with Staff 1 (Memory Care Director) and Staff 2 (ED) on 06/09/23. They acknowledged the findings.

1. Window coverings for all rooms have been addressed.

2. Maintenance staff will follow Frontier's 15 Min of Compliance and Monthly Maintenance checks to ensure window coverings are adequate.

3. Monthly by Memory Care Administrator

4. Memory Care Administrator and Environmental Services Director will be responsible.

Based on interview and record review, it was determined the facility failed to thoroughly investigate allegations of suspected abuse involving a resident-to-resident altercation and failed to report the incidents to the local Seniors and People with Disabilities (SPD) office for 1 of 1 sampled resident (#1) who experienced resident to resident altercations. Findings include, but are not limited to:

Resident 1 was admitted to the memory care facility in 07/2018 with diagnoses including dementia. Resident 1 required a walker for mobility.

Resident 1's clinical records were reviewed during the survey and showed the following:

* 12/21/22 : "resident had a resident-resident altercation ...";

* 12/30/22 : "Resident put their hands on another resident."; and

* 01/07/23 : "Resident had an altercation with another resident. [She/he] hit [her/him] in the stomach."

On 06/08/23 at 10:50 am, the documentation was reviewed with Staff 1 (Memory Care Director) and incident reports and APS notification was requested.

There was no documented evidence the incidents were reported to the local APS. Also, there was no documented evidence the incidents had been thoroughly investigated, interventions determined, and necessary measures were taken to protect other residents and to prevent the reoccurrence of the resident to resident altercations.

On 06/08/23, the surveyor requested Staff 1 report the incidents to SPD.  Subsequently, the surveyor received verification the incidents had been reported to SPD on 06/08/23.  

The requirement of investigating and reporting resident to resident altercations to SPD was discussed with Staff 1, Staff 2 (ED), Staff 3 (Health Service Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

1. MC Administrator reported to APD about resident to resident altercation.

2. MC Administrator was educated on abuse investigation and reporting requirements. MCA and RCC will read 24hr Communication Book and chart notes daily to ensure that IRs have been completed for events. ED will review all IRs promptly to ensure proper reporting of possible abuse/neglect and coach Memory Care Administrator on reporting.

3. Monthly audit of IRs by ED and MCA. ED will review any changes with OAR or other OHA guidance monthly.

4. MCA and Executive Director will monitor quarterly for compliance with all reporting requirements.

Based on interview and record review, it was determined the facility failed to ensure an evaluation was completed within eight hours of move-in for 1 of 1 sampled resident (#3) who had an urgent move-in, and quarterly evaluations were completed timely and were reflective of the resident's status for 1 of 2 sampled residents (#1) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2018 with diagnoses including dementia.

a. A review of Resident 1's clinical record revealed a quarterly evaluation had been completed on 04/30/22. The next quarterly evaluation would have been due three months later, on or about 07/30/22, 10/30/22, 01/30/23, and 04/30/23, respectively. There was no documented evidence of quarterly evaluation since 04/30/22.

b. The resident's most recent evaluation was dated 04/30/22. A review of the resident's progress notes, dated 03/08/23 - 06/06/23 showed the resident had experienced a general, overall decline and the evaluation was not updated in the following:

* Skin status;

* Fall risk;

* Bathing status;

* Multiple Emergency department visits; and

* Activity status.

In an interview on 06/08/23, Staff 1 (Memory Care Director) acknowledged the facility was behind in performing quarterly updates.

The need to perform evaluations, at least quarterly, with updates to health status, needs and preferences was discussed with Staff 1, Staff 2 (ED), Staff 3 (Health Service Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

2. Resident 3 was admitted to the assisted living facility in 01/2023 with a diagnosis of dementia.

A review of Resident 3's records showed the facility had completed an evaluation dated 01/06/23 prior to the resident move-in. Progress notes from 01/10/23 through 01/15/23 were reviewed and noted on 01/12/23 at 3:19 am the resident was found standing in the middle of the dining room with just his/her underwear on. On 01/12/23 Resident 3 was moved into the MCC. There was no documented evidence the facility had completed an evaluation for the resident moving into the MCC.

During an interview on 06/07/23 at 3:00 pm, Staff 3 (Health Services Director) confirmed, she had not completed an evaluation for Resident 3's move-in to the MCC.

On 06/09/23, the need to ensure evaluations were completed for when a resident moved from assisted living into the MCC was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3, and Staff 4 (Nurse Consultant). They acknowledged the findings.

1. Resident Corrections

#1 The Service Plan was updated 6.10.23 to reflect skin status, fall risk, bathing status, ER visits and activity status.

#3 Resident has been re-evaluated and a Service Plan created by a Service Planning Team including resident, POA, MCA and RN to address all the resident's needs, conditions, and prefereces.

2. Memory Care Administrator & Resident Care Coordinator will be retrained on completing Evaluations in SPA. Due dates will be reviewed prior to the upcoming month and a weekly schedule of completion dates will be shared with the Memory Care Administrator, Health Services Director, Executive Director, and Lifestyles Dir.  The Executive Director will review the Pre-Move-in evaluation of each resident prior to move in to ensure its complete and the eval date has been correctly recorded in SPA.  The Health Services Director or designee will review all completed Pre-Move-in  evaluations & Service Plans to ensure the Service Plan meets all the resident's needs and conditions.

3. The Executive Director and the Health Services Director will log their review of each PreMove In Evaluation for the next 60 days.

4. The Memory Care Administrator, Executive Director and the Health Services Director are responsible for compliance  

2. Resident 1 was admitted to the facility in 07/2018 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 06/06/23 thru 06/09/23, revealed Resident 1's service plan was not reflective of the resident's status and lacked clear instructions to staff in the following:

* Use of a floor matt;

* Oral health status;

* Personal hygiene status;

* Use of glasses;

* Cups with lids and straws used;

* Level of bathing assistance status; and

* Fall interventions.

b. The resident's service plan was last updated on 04/30/22, therefore not updated quarterly.

On 06/08/23 and 06/09/23, the service plan was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Service Director) and Staff 4 (Nurse Consultant). They acknowledged the service plan was not reflective of the resident's status and not updated quarterly as required.

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

1. Resident 2 was admitted to the MCC in 11/2019 with diagnoses including vascular dementia and osteoporosis.

Observations of the resident, interviews with staff, and review of the resident's record, including review of the service plan, dated 02/02/23, and temporary service plans showed the service plan was not updated quarterly, was not reflective of the resident's current care needs, had not been updated as needed when the resident experienced a significant change of condition and did not provide clear direction to staff in the following areas:

* Specific assistance needed with incontinence care provided in bed;

* Dental status and oral hygiene needs; and

* Significant weight loss.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 ( Health Services Director) and Staff 4 (Nurse Consultant) on 06/09/23. They acknowledged the findings.   

1. Resident Corrections

#2 care plan updated to reflect resident's status with clear instructions for staff, including, incontinence care while in bed, dental/hygiene needs, and weight loss.

#1 care plan updated to reflect resident's status with clear instructions for staff, including use of fall mat, oral/hygiene status, use of glasses, use of cups with lids, bathing status and fall interventions.

2. Resident Service Plans will be created based on the Multidisciplinary Evaluation, updated on or prior to the due date, and will address all current needs, conditions and preferences including the current physical and cognitive needs for assistance, including who, what, when, how and how often a service is to be performed with clear instructions as to how to perform the service according to the resident's wishes.  Service Plans will be created/updated by a Service Planning Team.  Service Plans will be in place before move-in, updated within the first 30d, and quarterly there after or as a Change in Condition arises and will be accessible to staff at all times.  

3. The Memory Care Administrator and Executive Director will log their review of 10% of all Service Plans monthly to ensure updates are made and instructions are clear.

4. The Memory Care Administrator, Executive Director, and Resident Care Coordinator are responsible for compliance.

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

Resident 1 and 2's most recent quarterly service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the resident and other required members of his/her Service Planning Team.

The need to ensure resident service plans were developed with a Service Planning Team was reviewed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Service Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

1. Resident Corrections

#1 & #2 the next Quarterly or COC Service Plan will be developed by a Service Team

2. The Executive Director, Resident Care Coordinator, Health Services Director, Lifestyles Director will be trained on requirement of a team to participate in Service Planning using OAR 411-054-0036 (5) Training will be logged. A Service Planning Team will be assembled applicable to resident need and choice, and may include the Executive Director or designee, the resident, the resident's legal representative, the Resident Care Coordinator, at least 1 care staff, and anyone the resident requests to actively participate in the process. The PCP, Case Manager(s), and family/friends of the resident's choosing will be invited in advance.  The Health Services Director will participate if the resident is receiving nursing services or has a current COC. The Service Planning Team will review evals/re-evals and plan for care that addresses all the resident's needs, conditions, and preferences with clear instructions including who, what, where, when, why, how, and how often a service is to be proviced.  All Service Planning Team members will sign the Service Plan and a copy will be placed in the Service Plan Binder where is is accessable to all care staff.

3.  See C 260

4. The Memory Care Administrator and Executive Director are responsible for compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes of condition had actions or interventions determined with weekly progress noted through resolution for 1 of 1 sampled resident (#1) who experienced short term changes in the area of skin and medication. Findings include, but are not limited to:

Resident 1 was admitted to the memory care facility in 07/2018 with diagnoses including dementia. Resident 1 required a walker for mobility.

On 06/09/23 at 9:40 am, the resident was observed to have an approximate dime sized area of redness on the back of his/her left thigh area.

Progress notes and Temporary Service Plan (TSP) dated 03/08/23 through 06/06/23 indicated the following:

* 03/17/23: started a new medication, lasix for edema;

* 03/30/23: open wound on left thigh; and

* 04/08/23: a bandage on left thigh (open wound).

There was no documented evidence the facility determined and documented what action or intervention was needed for the resident nor were the changes monitored through resolution.  

On 06/08/23 and 06/09/23, the above findings were reviewed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Service Director) and Staff 4 (Nurse Consultant). They acknowledged the findings.

Addendum written on 7.3.23

1. Resident Corrections

2. The MC Administrator and RCC will read Chart Notes, and review the 24hr Communication Binder containing Incident Reports and 24Hr Communication Sheets daily to identify COCs.  When a COC is identified, the resident will be evaluated by a trained person, usually the RCC, and Interim Service Plan(s) directing the care and observations to be made in Alert Charting will be initiated. The ISPs will be reviewed with staff and kept in the 24hr Communication Book till resolved. The RN will be notified and will determine whether the COC is significant or short term. In the case of a short term COC, the RN will review the ISP(s) and modify them if needed.  The resident will have a monitor note each shift (or as determined by the RN) in Chart Notes decribing the resident's response to the ISP/treatment plan until the condiditon is deemed resolved by the RN who will write a Chart Note describing the resolution which will end Alert Charting.  The Alert Charting log will indicate that AC has been discontinued.

3. The MC Administrator will audit the AC log to the ISPs in place to the Chart Notes weekly x 3 then monthly x 3.

4. The MC Administrator, the HSD, and the ED are responsible for compliance.   

2. Resident 1 was admitted to the memory care facility in 07/2018 with diagnoses including dementia and type II diabetes. Resident 1 required a walker for mobility.

On 06/09/23 at 9:40 am, the resident was observed to have an approximate dime sized area of on the back of his/her left thigh area.

Resident 1's 03/08/23 through 06/06/23 progress notes and TSPs were reviewed and the following was identified:

03/29/23: wound on left thigh (unopened wound);

03/30/23: the area, left thigh, became opened (open wound); and

04/08/23: a bandage on left thigh (open wound).

The new open wounds constituted a significant change in condition and an assessment by the facility RN was required.

In interviews on 06/08/23, Staff 3 (Health Service Director/RN) stated the resident was seen by the wound clinic and stated she had not assessed the resident's open wound status. The facility failed to ensure an RN assessment was completed for the open wounds.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN in accordance with their conditions, findings documented and interventions developed and implemented as a result of the assessment for 2 of 2 sampled residents (#s 1 and 2) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the MCC in 11/2019 with a diagnosis of vascular dementia.

During the entrance conference on 06/06/23, staff stated Resident 2 required full assistance with ADLs and meals, was on a pureed and thickened liquid diet and had recently been hospitalized and admitted to hospice.

A review of the resident's clinical record including charting notes dated 03/09/23 through 06/06/23 and resident weight history of 03/05/23 through 06/05/2023 showed Resident 2 experienced a significant change of condition on three separate occasions:  

a. Between 03/05/23 and 06/05/23, Resident 2 experienced a significant weight loss of 10.46% of his/her total body weight, or 9 lbs. over a three-month period.

Observations made during meal times on 06/7/23 and 06/08/23, identified the resident ate about 50% of his/her meals and drank a nutritional supplement three times a day.

b. On 05/19/23, Resident 2 returned from the hospital following a change in behavior and pocketing food which resulted in diagnoses of aspiration pneumonia and a urinary tract infection.

c. On 06/03/23, staff noted the resident was admitted to hospice.

There was no evidence the facility RN had completed a significant change of condition assessment for the weight loss, return from the hospital or admission to hospice, to include documented findings, resident status, and interventions made as a result of the assessment.

In an interview on 06/09/23, Staff 3 (Health Services Director) confirmed she had not completed assessments for the above significant changes of condition.

On 06/09/23, the need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 and Staff 4 (Nurse Consultant). They acknowledged the findings.   

1. Resident Corrective Actions

#1 3/17/23 - started new medication Lasix for edema. Currently still taking per MD order.

3/30/23 - Open wound to left thigh - resolved

4/8/23 - Bandage to left thigh - resolved

6/9/23 - Redness to back of left thigh - resolved

The Health Services Director was trained on resident Changes of Condition both Short Term and Significant, on 6.12.23 using the OAR Compliance Guidelines for COC. Follow up training on same is scheduled for 7.5.23.  The Health Services Director is registered for the July 11 - 13 2023 Role of the RN Class. The Memory Care Administrator and Resident Care Coordinator will be trained on COC reqiuirements on 7.5.23.  Memory Care Administrator and Resident Care Coordinator will retrain Resident Assistants and Med Techs to identify, document, and notifiy Health Services Director/Resident Care Coordinator/Executive Director re resident status changes. The Memory Care Administrator and Resident Care Coordinator will read the 24HR Communication notes and Chart Notes in QMar daily to identify and respond to resident changes. A clinical meeting will be held daily with the HSD, ED and MC Administrator reviewing MC resident changes so that the HSD/RN can designate a change as short term or Significant.  If Significant, the RN/HSD will determine whether a focused or comprehensive assessment is necessary and will perform the assessment including findings, resident condition, and interventions to be initiated, within 48hrs of discovery of the change.  The RN/HSD will monitor and document on the resident's changes weekly or as needed making changes as the resident's condition requires, thru resolution. Resolution or new baseline is described in a chart note stating the condition is resolved.  

The OAR Compliance Guidelines for COC will be at hand in the 24Hr Communication Binder for reference.  Each MC resident is discussed weekly in High Risk Mtg involving the Health Services Director, Executive Director, Resident Care Coordinator, and Memory Care Administrator.  The OAR Compliance Guidelines for COC will be at hand in the High Risk Binder for reference.

3. 10% of High Risk resident charts will be audited in July by Executive Director, Memory Care Administrator, & Resident Care Coordinator to see if COC's were properly identified, timelines followed, and condition documented correctly using ISPs (Interim Service Plans), QMar, Alert Charting, and SPA to update Service Plan and weekly monitoring is documented.  The Audit will be logged.

4. The Executive Director and Health Services Director are responsible.

Addendum written 7.3.23

2.  A clinical meeting will be held daily with the HSD, ED and MC Administrator reviewing MC resident changes of the past 24hrs so that the HSD/RN can designate a change as short term or Significant.  If significant, the RN/HSD will determine whether a focused or comprehensive assessment is necessary and will perform the assessment documenting findings, resident condition, and interventions to be initiated, within 48hrs of discovery of the change.  The RN/HSD will monitor and document on the resident's changes weekly or as needed making HSP changes as the resident's condition requires, thru resolution. Resolution or new baseline is described in a chart note stating the condition is resolved.  

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 4) who received an insulin via subcutaneous injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 06/06/23, Resident 4 was identified to be diabetic and was administered insulin injections by non-licensed staff.

Resident 4's insulin administration record and MARs, reviewed from 05/01/23 through 06/06/23, showed insulin had been administered by Staff 1 (Memory Care Director), Staff 7 (MT), Staff 8 (CG), Staff 9 (MT) and Staff 14 (MT) on multiple occasions.

Delegation records for Resident 4, reviewed on 06/08/23 and revealed the following:

a. Staff 1, Staff 7, Staff 8, Staff 9 and Staff 14's initial delegation to administer insulin to Resident 4, completed on 09/17/22, 10/25/22, 05/25/22, 02/03/23 and 02/02/23, lacked documentation in the following areas:

* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable;

* Rationale that the task could be safely delegated to the caregiver; and

* Frequency the client should be reassessed, including rationale.

b. The most recent periodic inspection, supervision and re-evaluation of the delegation of insulin for Staff 1, Staff 7 and Staff 8, completed 03/07/23, 03/04/23 and 02/26/23, lacked documentation in the following areas:

* Nursing assessment and condition of the resident, to include determination that the resident's condition remained stable and predictable; and

* The initial re-evaluation was not completed within 60 days of the initial delegation for Staff 1 and Staff 8.

c. Staff 8 administered Resident 4 insulin injection on multiple occasions without a current evaluation of skills by the current facility RN. The current evaluation of the insulin injection for Staff 8's skills and ability was completed on 02/26/23 and scheduled for re-evaluation in 90 days which approximately was 05/26/23. There was no documented evidence the facility RN re-evaluated Staff 8's skills and ability as of 06/08/23.

d. Staff 9 and Staff 14 administered Resident 4 insulin injections on multiple occasions without a current evaluation of skills by the current facility RN. The initial evaluation of the insulin injection for Staff 9 and 14's skills and ability was completed on 02/03/23 and 02/02/23 and scheduled for re-evaluation in 60 days which approximate was 04/03/23. There was no documented evidence the facility RN re-evaluated Staff 9 and 14's skills and ability as of 06/08/23.

The need to ensure staff who administered subcutaneous injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1, Staff 2 (ED), Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

C 282 Delegation  

1. Resident Corrections

#2 Diabetic assessment was performed & documented on 6.8.23 by the RN and resident found to be stable and predictable for insulin delegation. 3 FT MTs received training, and were skill checked by Health Services Director observing administration of the injectable medication. The delegatee Documentation was completed and the next evlauation dates are logged.  

2.  The Health Services Director will be trained on Delegations by the Regional Nurse using OSBN Division 47 Administrative Rules, OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching, and the DHS's Office of Licensing and Regulatory Oversight's RN Delegation in Community Based Care Settings Self-study Course. The Health Services Director is attending the Role of the RN Class 7.11 - 13 2023.

3. A compliance audit of the Delegation Binder will be performed and logged by the Regional RN by July 6th and quarterly x 2.

4. The Memory Care Administrator, the Health Services Director and Executive Director are responsible for compliance  

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

On 06/09/23, approximately 09:30 am, the surveyor obtained permission and observed Staff 5 (CG) provide incontinence care to Resident 1.

During the observation, Staff 5 failed to change gloves after removing a soiled incontinent product and wiping fecal matter from Resident 1's bottom area. Staff 5 touched the resident's shirts and pants and the resident's walker while wearing the same soiled gloves. When Staff 5 was finished providing care, Staff 5 removed the gloves but did not perform hand hygiene.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/09/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence care and handling soiled linen for 2 of 2 sampled residents (#s 1 and 2). Findings include but are not limited to:

1. Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.

a. On 06/07/23 at 9:30 am, the surveyor obtained permission to observe Staff 14 (MT) provide ADL care for Resident 2. During the observation, Staff 14 failed to change gloves after handling soiled clothing and incontinence products. Staff 14 proceeded to reposition the resident while wearing the same soiled gloves. When Staff 14 was finished providing care, Staff 14 removed his/her gloves but did not perform hand hygiene.

b. The MCC laundry room was on the assisted living side of the building and was toured on 06/07/23 at 11:30 am. Staff 14 explained the process for washing soiled clothing and linen. Soiled clothing and linen were placed in a plastic bag, tied, and then placed in a receptacle located in a hallway closet. Heavily soiled items were either rinsed out in the resident showers or transported to the flushing rim sink, which was located on the second floor in a locked janitor closet. Medication Technicians were the only staff with the keys. Observation of the hallway closet containing residents' laundry showed two uncovered receptacles, mixed with bagged soiled items and regular laundry.

The need to ensure staff followed infection control practices when providing incontinence care and the facility had a process for handling and laundering soiled linen and staff had access to the flushing rim sink was discussed with Staff 1 (Memory Care Director) and Staff 2 (ED) on 06/09/23. They acknowledged the findings.

1. Staff members # 5, #14, and all staff will be retrained Infection Prevention & Control and proper use of PPE training online and in house.

2.  New staff will complete Infection Prevention & Control and PPE training within 30 days of hire and will be retrained as needed.

3. Environmental Service Director will monitor & log proper function and cleanliness of the rinse sink weekly for 60 days and Quarterly thereafter. Memory Care Administrator and Resident Care Coordinator will monitor for staff compliance and provide ongoing training.  

4. Memory Care Administrator, Environmental Service Director, Executive Director, and Infection Control Specialist are responsible for compliance.

Addendum written 7.3.2023  

2. Additional keys have been made so now all staff have ready access to a key for the hopper room.

Training Outline for staff:

Frontier Policy #62 Soiled Linen

Purpose:   To maintain heavily soiled linen in a manner that does not contaminate other linen or property.

Policy:  It is the community policy to provide a method of containing heavily soiled linen and washing it in such a manner that maintains infection control.

Procedure:

1. Wear PPE when handling any material soaked in urine, feces or blood. (vomit)

2. Remove heavily soiled linen from the resident's apartment in a plastic bag.

3. Take the linen to the Soiled Utility Room and wash any fecal/bloody material off of the linen in the hopper, prior to washing in the washing machine.

4. Put the linen back in a plastic bag before transferring to the washing machine.

5. Any linen that has been saturated with feces, urine or blood, needs to be washed at the highest temperature, separately from all other linen.

6. Clean area of any fecal/bloody material before leaving the resident's room and the Soiled Utility Room.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for 1 of 2 sampled residents (#2). Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 11/2019 with diagnoses including vascular dementia,  depression and osteoporosis.

Resident 2 was hospitalized from 05/16/23 to 05/19/23 with aspiration pneumonia. The resident returned to the MCC on 05/19/23 with an after visit summary which included new medication orders and instructions.

The after visit summary dated 05/19/23 was reviewed and identified the following new medication orders and instructions:

* Amoxicillin 125 mg one tablet by mouth twice a day for five days;

* Ondansetron 4 mg one tablet by mouth every six hours as needed; and

* Potassium chloride 20mEq one tablet by mouth 2 times a day.

The facility was instructed to stop the following medications:

* Escitalopram 5 mg;

* Ferrous sulfate 325 mg;

* Loratadine 10 mg;

* Omeprazole 40 mg;

* Polymyxin B sulf-trimethoprim;

* Quetiapine 50 mg;

* Spiriva Respimat 2.5 mcg; and

* Tramadol 50 mg.

Review of the MAR revealed the resident did not receive the amoxicillian three out of the five days and potassium chloride was not transcribed onto the MAR nor was it administered. The facility continued to administer the medications they were instructed to stop from 05/19/23 through 05/31/23.

Interviews with Staff 1 (Memory Care Director) and Staff 3 (Health Services Director) during the survey revealed the following:

* The facility failed to follow or have signed physician orders;

* The PCP was not informed of the missed doses or that the facility had not stopped the above medications; and

* The facility RN had not been informed.

There was no evidence of professional oversight during this time period of starting and stopping medications.

On 06/09/23, the need to ensure a safe medication and treatment system was in place and adequate professional oversight of the medication and treatment administration systems was discussed with Staff 1, Staff 2 (ED), Staff 3 and Staff 4 (Nurse Consultant). They acknowledged the findings.  

1. Resident Corrections

#2 All medications have been reviewed by PCP, Hospice RN, Health Services Director, Memory Care Administrator and Med Tech.  MAR updated to reflect changes, ISP and alert charting initiated.   

2. Memory Care Administrator, Resident Care Coordinator, and Med Tech will be retrained in proper medication administration including following PCP orders, reporting missed doses, involving the Health Services Director when medication questions arise. The Health Services Director will review orders and MARS for the MC unit.

3. The Health Services Director will monitor compliance in QMar daily x7, weekly x4, and monthly there after.

4. Memory Care Administrator, Health Services Director, and Executive Director are responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and staff instruction for 2 of 3 sampled residents (#s 1 and 4) whose medications administration records were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 07/2018 with diagnoses including dementia.

Resident 1's physician orders and 05/01/23 through 06/06/23 MAR/TARs were reviewed and revealed the following:

* Calmoseptine ointment two times daily for skin breakdown due to picking;

* Triple antibiotic ointment three times daily for open sore; and

* Clobetasol ointment once a day for skin picking.

There were no resident specific parameters or instruction to direct staff which indicated where to apply these three ointments and the sequence of administration.

The need to ensure an accurate MAR and TAR that included resident specific parameters and clear instructions for staff when more than one treatment was prescribed for the same condition was reviewed with Staff 1 (Memory Care Director), Staff 2 (ED) and Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

2. Resident 4 moved into the facility in 05/2017 with diagnoses including Alzheimer's disease.

Resident 4's physician orders and 05/01/23 through 06/06/23 MARs were reviewed and revealed the following:

* Acetaminophen and Tramadol was prescribed as needed for pain. There were no resident specific parameters or instruction to direct staff which indicated when to administer the medications and the sequence of administration; and

* Calcium 500 mg and Mylanta was prescribed as needed for heartburn or upset stomach. There were no resident specific parameters or instruction to direct staff which indicated when to administer the medications and the sequence of administration.

The need to ensure an accurate MAR and TAR that included resident specific parameters and clear instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

1. Resident Corrections

#1 PCP contacted requesting resident specific parameters for topicals

#4 PCP contacted requesting resident specific parameters for administering PRN pain and antacids.

All MARs will be reviewed to ensure instructions are present by 7.6.23.

2. Memory Care Administrator and Resident Care Coordinator will be retrained re the need for clear orders and order instructions for Med Techs and the Health Services Director's role in determining instructions. Memory Care Administrator and Resident Care Coordinator will be trained re use of reports in QMar to verify all PRNs have instructions.  A training log will be used.  

The Licensed Nurse doing 3rd checks will be responsible for adding / ensuring resident specific instructions are present for all standing and PRN medications. The Med Techs will be retrained to expect resident specific instructions to be followed re the sequence of using PRN medication when 2 or more medications are available to a resident for the same purpose. Training Log and skills checklist will be used. Med Techs will be coached on the training when exceptions are identified.

3. Licensed Nurse will monitor compliance in QMar daily x7, weekly x4, and monthly there after.

4. The Memory Care Administrator, Health Services Director, and Executive Director are responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 1) who received as needed psychoactive medication. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2018 with diagnoses including dementia.

Resident 1's record indicated s/he had orders for PRN Zyprexa for "acute manic episode."

Resident 1's 05/01/23 through 06/06/23 MAR was reviewed during the survey and revealed the following:

* The PRN Zyprexa was administered four occasions; and

* No documentation non-drug interventions had been attempted with ineffective results prior to administering the medication.

On 06/08/23 and 06/09/23 Resident 1's record was reviewed with Staff 1 (Memory Care Director), Staff 2 (ED) and Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) and discussed the need to document non-pharmacological interventions tried with ineffective results prior to administering PRN psychotropic medication. They acknowledged the findings.

1. Resident corrections

#1 Memory Care Administrator updated PRN psychotropic instructions on 6.13.23 to include behaviors shown when in a manic episode, and 3 non pharmacologic interventions to attempt prior to giving PRN

2. Memory Care Administrator and Resident Care Coordinator will be trained on the requirements for PRN psychotropic medication orders and the Health Services Director's role in overseeing this. Memory Care Administrator and Resident Care Coordinator will be trained re reports in QMar to verify all psychotropics have proper instructions. Training will be logged. Staff will be retrained re the need for using resident specific non-pharmacologic interventions before giving PRN psychotropic medication for specific medical symptoms listed in QMar. Individualized non-Pharmacological interventions may be determined through interview of resident and those who know resident, staff and a review of various sections (Life History, Lifestyles, Medication, etc.) of the Multidisciplinary Eval in SPA.  Resident specific interventions to be tried will be added to QMAR and their use and response prior to administering the PRN psychotroph will be documented.  The Licensed Nurse doing 3rd checks will be responsible for adding/ensuring resident specific instructions are present for all standing and PRN medications.  

3. Memory Care Administrator or Licensed Nurse will monitor compliance in QMar daily x7, every 2 weeks x 8, and monthly there after.

4. The Memory Care Administrator, Health Services Director, and Executive Director are responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 2 sampled residents (#5) who were prescribed PRN psychotropic medications. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility on 02/01/24 with diagnoses including dementia.

Resident 5 had physician orders for quetiapine 25 mg one tablet daily as needed for agitation, and trazadone 50 mg one tablet at night as needed for insomnia.

Review of MARs and progress notes, from 02/01/24 through 02/26/24, revealed staff administered PRN quetiapine on six occasions and trazadone on three occasions. There was no documented evidence staff had consistently attempted non-drug interventions with ineffective results prior to administering the psychotropic medications.

In an interview on 02/27/24 at 12:35 pm, Staff 19 (MT/CG) reviewed the MAR and acknowledged staff were not consistently documenting non-drug interventions attempted prior to administering the PRN psychoactive medications.

The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 18 (MCC Director) on 02/27/24 at 2:30 pm. 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 1 of 2 residents reviewed (# 1). Findings include, but are not limited to:

Observations of Resident 1, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 1's ABST, revealed an inaccuracy of minutes assigned in the following areas:

* Transfer in or out of bed or a chair;

* Providing treatment;

* Monitoring behavioral condition or symptoms; and

* Safety checks.

During an interview with Staff 1 (Memory Care Director) on 06/08/23, she stated the ABST data was generated from the service plan. Staff 1 further stated there was no section to enter minutes on their ABST tool. She acknowledged the service plans for the sampled resident was not reflective; therefore, the ABST data was not accurate and potentially created inaccurate staffing calculations.  

Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1, Staff 2 (ED), Staff 3 (Health Services Director/RN), and Staff 4 (Regional RN) on 06/08/23 and 06/09/23. They acknowledged the findings.

Resident Corrections

#1 HSP will be updated to reflect the current residents needs/utilization of service.

2. MC Administrator and Resident Care Coordinator will review current Service Plans and reevaluate residents as needed to ensure current needs/utilization are reflected accurately.  

3. MC Administrator will review and post ABST reports daily to ensure accuracy.  MC Administrator will ensure staffing ratio is based on ABST tool recommendations.

4. MC Administrator and the Executive Director are responsible for compliance.     

Based on interview and record review, it was determined the facility failed to use the results of an acuity-based staffing tool (ABST) to develop and routinely update the facility's staffing plan in order to meet the 24-hour scheduled and unscheduled needs of residents. This is a repeat citation. Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 17 (ED) and Staff 18 (MC Director) on 02/27/24. Staff 18 demonstrated how the facility calculated staffing based on the minutes generated in their tool. She stated the ABST generated a staffing plan of 8.667 staff per day, and her current staffing plan was eight staff per day.

The need to use the results of an ABST to develop and routinely update the facility's staffing plan to meet the 24-hour scheduled and unscheduled needs of residents was reviewed with Staff 17 and Staff 18 on 02/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 5, 12, 13 and 15) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Review of training records with Staff 2 (ED) on 06/08/23 identified Staff 5 (CG), Staff 12 (CG), Staff 13 (CG) and Staff 15 (CG) lacked documented evidence competency was demonstrated in the following required areas:

* First aid/abdominal thrust training.

The need to ensure staff demonstrated competency in required training within 30 days of hire was discussed with Staff 1 (Memory Care Director), Staff 2, Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

1. Staff Corrections

#5, #12, #13, #15 First aid/abdominal thrust training will be provided.

2. A job specific competency checklist that identifies training required preservice and training within the first 30 days will be implemented. First Aid/abdominal thrust training has been scheduled for 7/28/23 and 7/29/23 and will be offered monthly thereafter.  The  job specific competency checklist will be maintained in a designated location until completed. The Scheduling Coordinator/designee will not schedule the new employee until the pre-service skills checklist is completed. Scheduling Coordinator/designee will not schedule the new employee beyond day 30 unless the required items identified on the job specific skills checklist have been completed and signed by the Memory Care Administrator or Resident Care Coordinator.

3. The Resident Care Coordinator will review the completed skills checklist for each new Resident Assistant and Med Tech and approve in writing that the employee may be added to the schedule. The Memory Care Administrator will compare the skills checklists, Resident Care Coordinator's written approval, and the schedule as each new employee is added to the HS team for 3 months, and quarterly thereafter.  

4. Memory Care Administrator, Scheduling Coordinator, Resident Care Coordinator, Health Services Director, and Executive Director are responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:

On 06/08/23, fire drill and fire and life safety records were reviewed from 01/2023 through 06/2023. The following deficiencies were identified:

1. There was no documented evidence the facility was providing fire and life safety training on alternating months for staff.

2. The evacuation/drill documentation did not contain information on:

* Date and Time of fire drill;

* Location of simulated fire origin;

* The escape route used;

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

* The member of staff participating;

* Evidence of alternate escape routes used;

* Evacuation time period needed; and

* The number of occupants evacuated.

The need to meet all requirements for fire drills and fire and life safety instruction was reviewed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

1. Environmental Services Director will perform and document life safety training for the community every other month and fire drills monthly per Frontier policy begnning July 23. Documentation of training will include attendance logs and material used for training. Drills will be performed according to regulation and will have every field of the designated form completed without fail.

2. Environmental Services Director will follow written plan for training and drills.  Exceptions to the written plan will be discussed with and approved by the ED in writing 10 days before month end.

3. The Executive Director will review fire drill and life safety training completion records monthly.

4.4. MC Administrator, Executive Director and Environmental Services Director are responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according the Oregon Fire Code and documentation of the fire drills included all required components. This is a repeat citation. Findings include, but are not limited to:

Fire drill records from 09/07/23 through 02/26/24 were reviewed and the following deficiencies were identified:

There was no documentation of fire drills conducted every other month, with all required components documented including:

* Date and Time of fire drill;

* Location of simulated fire origin;

* The escape route used;

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

* The member of staff participating;

* Evidence of alternate escape routes used;

* Evacuation time period needed; and

* The number of occupants evacuated.

During an interview with Staff 22 (Environmental Services Director) on 02/27/24, he stated there was no documentation of fire drills occurring in the memory care facility. Fire drills had been completed in the assisted living facility which was adjacent to the MCC, however, these did not include documentation related to the MCC, and did not involve evacuation of the MCC residents.

The need to ensure fire drills were conducted according to the Oregon Fire Code and documentation included all required components was reviewed with Staff 17 (ED) and Staff 18 (Memory Care Director) on 02/27/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and re-instructed annually. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed during the survey. The following deficiencies were identified:

* No documentation of fire and life safety training for residents upon admission and at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The need to ensure residents received fire and life safety training upon admission and at least annually, was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings. No further information was provided.

1. Fire and life safety training for residents will occur in July of 2023 and no less than annualy thereafter.  Residents and RPs will be notified of the training date by posting in the community.  New residents will be instructed on facility's fire and life safety procedures per OFC during lease signing.

2. Instruction on facility's fire and life safety will be included on the MoveIn Checklist. New residents will be instructed on facility's fire and life safety procedures per OFC during lease signing.

3. Environmental Services Director or ED will conduct and document annual training for residents.

4. The Executive Director will be responsible for ensuring annual re-training is completed by checking and reviewing documentation monthly.

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

Refer to C330, C361, C420 and C555.

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

The courtyard of the MCC was toured on 06/07/23. There were drop-offs of up to two inches along the edges of the pathways of the courtyard. This created a potential tripping hazard for residents.

The drop-off areas were shown to and discussed with Staff 1 (Memory Care Director) and Staff 2 (ED) on 06/09/23. They acknowledged the findings

1. Contractor will compact dirt in affected areas around walkways, and plant grass seed.

2. Contractor and Environmental Service Director will evaluate monthly for reccuring issues.

3. Project completed by POC date. Perform monthly checks of affected areas.

4. Environmental Services Director, MC Administrator and ED are responsible for compliance.

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

Observations of the memory care environment on 06/06/23 through 06/09/23 showed the following:

* Chipped, dinged, gouged, scratched, and scuffed walls and doors throughout the unit;

* Handrails on both sides of the hallway were scraped and chipped in multiple areas, and the area between the handrails and wall had a buildup of dirt and debris;

* Multiple pieces of furniture in the multi-purpose room had spills and splatters to the arms and seats, and armrests and legs were worn and scratched;  

* Two recliner chairs in the multi-purpose room had worn-out footrests with pieces of exposed padding;  

* Multiple resident toilets had stained, missing, or brownish spots on the caulking around the bases of the toilet;

* Flooring in multiple resident rooms between the bathroom and bedroom was missing a transition strip causing chips and cracks in the floor;

* Flooring between the community bathroom and multi-purpose room was missing a transition strip causing a large piece of flooring to have broken off;

* Multiple resident bathroom and closet doors had puncture holes caused by installed pin hinge door stops;

* The door handle on room 128's front door was broken, and there was a 2.5-inch hole in the bathroom door;

* There was a strong pervasive urine odor in room 125 that did not dissipate throughout the survey;

*  Flooring in the multi-purpose room was sticky during the survey;

* Multiple cupboards in resident rooms had missing knobs; and

* There were multiple dark stains throughout the hallway carpet.

The areas needing cleaning and/or repair were shown to and discussed with Staff 1 (Memory Care Director) and Staff 2 (ED) on 06/09/23. They acknowledged the findings.

1. Paint, patch and texture for walls, doors and other surfaces throughout the facility will be addressed weekly.

Spot cleaning in resident rooms and deep clean as necessary.

Furniture cleaning in common areas.

Monthly carpet cleaning service schedule for hallways as needed.

Replace two recliners that are worn out.

Address resident bathroom caulking around toliet areas.

All resident room doors will be assessed and replaced as needed.

Door handle for Rm 128 ordered and will be replaced.

To address RM 125 odor, remove and replace soiled hotel heaters

Replaced previous mop chemical solution despensor, to better regulate cleaning effectiveness in multipurpose areas.

All cabitnet door knobs are being replaced.

Hallway carpets to be cleaned bi-monthly.

Room floor threasholds to be replaced as needed.

2. An addional environmental services employee has been hired. Frontier Monthly Maintainance Schedule, 15 Min of Compliance, and MC Administrator reports of need will be used to ensure needed repairs are identified and addressed.

3. MC Administrator, Evironmental Services Director and Executive Director will meet weekly to review progress of ongoing maintenance program.  MCA and ED will monitor monthly reports and will walk the unit to ensure it remains in good repair.

4. MC Administrator, Evironmental Services Director and Executive Director are responsible for compliance.

Based on observation and interview, it was determined the facility failed to have an operational call system that connected residents' units to the care staff.  Findings include, but are not limited to:

On 06/08/23, the surveyor tested room 128's emergency call system located in the resident's bathroom. After five minutes, a CG walked into room 128. The surveyor asked Staff 7 (MT) how they were alerted to resident call lights. Staff 7 stated, when a resident pulls the emergency cord in the bathroom, it sends an alert to the pager; however, there was only one pager for the unit, and it was only the Medication Technicians who carried it.

In an interview on 06/09/23, Staff 2 (ED) stated he would order additional pagers for the care staff.

The need to ensure the facility provided a working call system that connects residents' units to the care staff was discussed with Staff 1 (Memory Care Director), Staff 2, Staff 3, (Health Services Director) and Staff 4 (Nurse Consultant) on 06/09/23. They acknowledged the findings.    

1. MC staff was provided with an extra pager connected to the call system, alarm on courtyard doors in place.

2. Weekly testing of call buttons and bathroom pull cords by MC Administrator or designee weekly x 3 then Environmental Services Director will implement Frontier Maintanence Schedule and 15 Min of Compliance and response to user report of malfunction.

3. Per Frontier Maintainence Schedule and user report of malfunction.

4. MC Administrator, Environmental Services Director, and Executive Director are responsible for compliance.

Based on observation and interview, it was determined the facility failed to have an operational call system that connected residents' units to the care staff. This is a repeat citation. Findings include, but are not limited to:

The emergency call system was tested on 02/27/24.

On 02/27/24, this surveyor tested room 125's emergency call system located in the resident's bathroom. After 90 seconds, a caregiver walked into room 125. The surveyor asked Staff 16 (CG) how they were alerted to the resident's call light. He stated that the emergency call went to pagers that were worn by staff in the separately-licensed assisted living facility (ALF). The ALF staff then radioed to the memory care staff that a resident needed assistance. Staff 16 stated that memory care staff do not wear pagers, and are only notified of an emergency call if the ALF staff members radio them.

In an interview with Staff 17 (ED) and Staff 18 (MC Director) on 02/27/24, they confirmed that this was their current system.

The need to ensure the facility provided an operational call system that connected residents' units to the memory care staff was discussed with Staff 17 and Staff 18 on 02/27/24. They acknowledged the findings.  

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, C231, C 361, C 372, C 420, C 422, C 510, C 513, C 555.

Please see POC attached.

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 C361, C420 and C555.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation training was completed and documented for 4 of 4 newly hired staff (#s 5, 13, 15 and 16) prior to beginning job duties and competency demonstration was completed within 30 days of hire for 4 of 4 newly hired staff (#s 5, 12, 13 and 15) whose training records were reviewed. Findings include, but are not limited to:

On 06/08/23 training records were reviewed with Staff 2 (ED). The following deficiencies were identified:  

1. Staff 5 (CG) and Staff 13 (CG), hired on 11/11/22 and 01/23/23, did not have documented evidence that pre-service dementia training had been completed in the following required areas prior to providing care and services independently:

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

In addition, Staff 5 had not completed pre-service orientation training of Infectious Disease Prevention.

2. Staff 15 (CG) and Staff 16 (Housekeeper), hired on 04/10/23 and 04/11/23, did not have documented evidence that pre-service dementia training had been completed in the following required areas prior to providing care and services independently:

*Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

*Strategies for addressing social needs and engaging person with dementia in meaningful activities; and

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

3. Staff 5 and Staff 13, did not have documented evidence of competency demonstration within 30 days of hire in the following:  

* Providing assistance with ADLs;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

In addition, Staff 5 had not completed the Role of service plans in providing individualized care.

4. Staff 12 and Staff 15, did not have documented evidence of competency demonstration within 30 days of hire in the following:  

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

The need to ensure newly-hired staff completed all required training prior to beginning their job duties and documented methods to determine competency of direct care staff was reviewed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

1. MC Administrator will oversee MC staffing coordinator facilitatation of scheduling for training.  

2. RCC and Staffing coordinator provide training for  caregiver or med tech ADL and dementia skills and are responsible for completing skills check list.

3. Staff training for First Aid and Abdominal Thrust will be scheduled monthly. Staffing coordinator reviews ongoing training and schedules. Resident Care Coordinator reviews training and skills checklist.

4. Memory Care Administrator reviews and signs off training record before staff begins duties.

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

Refer to C 252, C 260, C 262, C270, C 280, C 282, C 295, C 300, C 310, and C 330.

Please see POC C 252, C 260, C 262, C270, C

280, C 282, C 295, C 300, C 310, and C

330.

Based on 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 C330.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed based upon the resident's preferences and needs, and was included in the service plan for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 07/2018 with diagnoses including dementia and type II diabetes.

Review of the resident's nutrition and hydration plan in the 04/30/22 service plan listed the resident's favorite food and beverages. However, the service plan lacked staff instructions related to the resident's individual nutritional and hydration needs and the service plan had not been updated regarding the resident's nutritional status.

The need to ensure an individualized nutrition and hydration plan for each resident was developed based upon the resident's needs was discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

2. Resident 2 was admitted to the MCC in 11/2019 with a diagnosis of vascular dementia.

Observations made on 06/06/23 through 06/08/23 showed Resident 2 was dependent on staff for all ADLs and required full assistance from staff for eating and drinking.

Resident 2's 02/02/23 service plan lacked information and staff instructions related to individualized nutrition and hydration status, needs and preferences.

The section for diet and nutrition documented the resident was on a "puree diet, no eggs and no mayonnaise", that the resident liked sweets and s/he could participate in all snack and hydration passes.

The need to develop individualized service plans addressing residents' nutrition and hydration preferences and needs and document them on the service plan was discussed with Staff 1 (Memory Care Director) on 06/09/23. She acknowledged the findings.

1. Service Plans will be scrutinized for nutrition and hydration instruction and will be updated as needed with resident needs and preferences for snacks and beverages.

2. Hydration and nutrition is a required element of the Multidisicplinary Evaluation.  Information aquired during evaluation will be addressed by a Service Planning Team and added to the Service Plan.  Nutrition and hydration passes will be a scheduled event in the unit.

MC Administrator will verify needs and prefernces are included on every Service Plan. MC Administrator/designee will observe that nutrition and hydration passes are occurring as scheduled each day.

MC Administrator and Executive Director are responsible for compliance.   

Based on observation, interview and record review, it was determined the facility failed to develop an individualized activity plan for each resident based on their activity evaluation, for 2 of 3 sampled residents (#s 1 and 3) residing in the Memory Care Community. Findings include, but are not limited to:

1. Resident 1 resided in the Memory Care Community and had diagnoses including dementia.

Resident 1 was observed to require assistance from staff to initiate, attempt and participate in activities. The resident was on a recliner in the common area, sleeping most of the time. The resident was observed engaging in a ball toss activity for a few minutes on 06/07/23 and not engaging in any other individual or group activity during the survey.

The resident's records were reviewed during the survey and revealed the following:

* 04/30/22 The quarterly evaluation indicated the resident enjoyed arts and crafts.

The facility failed to evaluate Resident 1's activity interest, physical and cognitive abilities and limitations for the resident to participate in the activity program and failed to develop an individualized activity plan that detailed how, what, when and how often staff should offer and assist the resident with individualized activities.

On 06/08/23 and 06/09/23, the need to have an individualized activity plan for Resident 1 and the failure to provide an activity program based on individual needs and group interests were discussed with Staff 1 (Memory Care Director), Staff 2 (ED), Staff 3 (Health Services Director) and Staff 4 (Nurse Consultant) on 06/08/23 and 06/09/23. They acknowledged the findings.

2. Resident 3 was admitted to the MCC in 01/2023 with a diagnosis of dementia.

The facility failed to evaluate the resident upon move-in to the MCC. There was no documented evidence of a person-centered activity plan based on the following required elements:

* 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

* Identification of activities for behavioral interventions, if necessary.

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

On 06/09/23, the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.  

1. A person-centered activity plan for all MC residents will be performed within 30 days of move-in, with COC,  and every 90 days therafter.

2. The MC Lifestyle Director will participate in initial, 30d, quarterly and COC evaluations and be a member of each resident's Service Planning Team. Service Plans will be updated as needs and preferences come to the attention of the Lifestyles Director.  The Lifestyle Director will develop individual engagements for medical symptoms and/or if resident is unable to participate or not interested in scheduled activities.

3. A Service Plan Team will ensure every Service Plan has engagements the resident can and wants to participate in as well as medical symptom related activities as needed. The MC Administrator wil over see the Service Plans of every resident.

4. MC Lifestyle Director and MC Administrator are rsponsible for compliance.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:

The MCC secured outdoor recreation area was toured on 06/07/23. Several outdoor patio chairs, and furniture were not of sufficient weight and could be easily moved, which created a potential safety and/or elopement risk.

The need to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement was discussed with Staff 1 (Memory Care Director) and Staff 2 (ED) on 06/07/23 and 06/09/23. They acknowledged the findings.

1. The MC Administrator and Executive Director will evaluate the furniture in the outdoor for replacement or repair to ensure its not easily moveable and has adequate heft and support to be safe for residents.  A temporary weight may be used to secure the outdoor furniture.  

2. The Frontier Monthly Maintenance Schedule and 15 Min of Compliance will be implemented by the Environmental Services Director.  The MC Administrator and Executive Director will ensure that all future furniture purchases meet the regulation.

3. Environmental Service Director/designee will folllow the Frontier Monthly Maintenance Schedule and 15 Min of Compliance Schedule. The MC Administrator and ED will review the report monthly.

4. Environmental Service Director, MC Administrator and ED are responisble for compliance.