The findings of the re-licensure survey, conducted 04/17/23 through 04/20/23, 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 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 re-visit to the re-licensure survey of 04/20/23, conducted 09/05/23 through 09/08/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 04/20/23, conducted 03/14/24, are documented in this report. It was determined the facility was in substantial 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.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings include, but are not limited to:

During the survey, conducted 04/17/23 through 04/20/23, quality improvement oversight to ensure adequate resident care, service and satisfaction was found to be ineffective.

In interview on 04/20/23, Staff 3 (ED 1) acknowledged the facility had not fully implemented a quality improvement plan in place.

Refer to the deficiencies in the report.

1. Quaility Assurance Program in place. Brought up to date from survey date.

2. Quaility Assurance system consists of 4 categories. Operations (employee training, consulants, RDO, APS compliance, Pinnacle reports, RETAIN results/plan, Town Hall, Orientation/training, stand-up, survey, MoveN siftware, Move-in process). Maintenance (Safety Committee, Fire Drills, Elopement Drills). Dining (Cleaning, food temp, DSD checklist, Dish temp, Meal serivce observe, water temp, thermometers, Diet sheet audit). Life Enrichement (Weekly QA checklist). Monthly meetings with QA team and input data. We in employ the Allen Flores Consulting Group who also will be assisting with support and training.

3. Monthly meetings to collect data from departments as scheduled in QA system.

4. ED monitors with department head input.  

Based on observation, interview and record review, it was determined the facility failed to ensure repeated incidents of being found on the floor were promptly investigated to rule out abuse/neglect and were reported to the local SPD office when unable to reasonably conclude the incidents were not abuse and/or neglect for 2 of 2 sampled residents (#s 1 and 2). Failure to thoroughly investigate to rule out abuse or neglect care put the residents at risk for further abuse and neglect of care. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2021 with diagnoses including dementia and a history of falling. Resident 2 required a wheelchair for mobility.

Observations of the resident from 04/17/23 to 04/20/23 showed the resident used a floor mat next to the bed and required a 2-person assist with transfers and bladder management.

Progress notes, incident reports and Temporary Service Plan (TSP) dated 12/31/22 through 04/06/23 indicated the following:

* 02/04/23: A fall, " ...slipped while peeing on floor";

* 02/09/23: A fall in the bathroom. "Sliped [slipped] in pee ..."; and

* 02/12/23: An  injury fall. Staff documented " ...no supervision while in bathroom ...ensure frequent checks are being done";

The resident had continued to fall or being found on the floor on:

* 03/06/23: Fall in the room "Trying to get out of bed" ... Staff documented "Ensure checks are being done when not in sight";

* 03/12/23: "found resident on the floor pants down in front of [his/her] wheelchair and urine on the floor ..."; and

* 03/18/23: A fall with injury. Staff documented that the resident was needing to go to the bathroom and rolled out of bed. The resident's upper right forehead had a raised red area that was the size of a quarter.

The 04/15/23 service plan indicated the resident was unable to transfer independently, required staff assistance with all transfers using a Hoyer lift. The resident was able to self-propel while in the wheelchair and needed frequent check/supervision as s/he was a fall risk and attempted to self-transfer.

Review of temporary service plans revealed they were pre-populated forms which instructed staff to "Cue and remind resident to call for assistance with ADL's, reaching for objects, answering the phone, etc., as needed and when dizzy or weak. Cue/remind encourage [the resident] to use walker or wheelchair for mobility if already in place, to decrease further risk of falls." In addition to the pre-populated instruction, staff documented "ensure frequent checks are being done"

Resident 2 experienced 20 falls between 01/17/23 and 04/06/23. There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result of abuse or neglect due to the possibility of not receiving timely bladder management and not completing frequent checks on the resident, and the facility lacked documentation of required investigative components including a description of the event and follow-up action.

On 04/19/23, Staff 1 confirmed the above incidents were not reported to the local unit, at which time the surveyor requested Staff 1 to immediately report the incidents. Confirmation that the incidents were reported was received prior to the survey team exiting from facility.

The need to investigate incidents of suspected abuse and neglect and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (Memory Care Director), Staff 3 (ED 1) and Staff 4 (ED 2) on 04/19/23 and 04/20/23. They acknowledged the findings.

Refer to C 270, example 1.

2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including dementia.

Review of the resident's 01/16/23 and 04/14/23 service plans, 01/06/23 - 04/16/23  progress notes, temporary service plans, and incident investigations, interviews with staff, and observations of the resident revealed the following:

Resident 1 had 36 documented falls during the time frame reviewed, multiple with reports of pain and/or injury, including the following:

* 01/06/23: Acute back pain with visit to the emergency department of the local hospital;

* 01/07/23: Right upper arm bruise which was "Blue in color and painful to the touch." On 01/08/23, the resident was sent to the emergency department of the local hospital and was diagnosed with a right humeral fracture.

* 01/11/23: "Two back to back falls" for which the resident was sent to the emergency department of the local hospital and diagnosed with right hip pain. Staff also documented the resident sustained a bruise on his/her forehead near the right eye and a bump on the back of his/her head;  

* 01/31/23: Bruise on right hip and chin;

* 03/02/23: Right wrist swelling;

* 03/08/03: "Bit [his/her] lip and cut it with [his/her] teeth";

* 03/26/23: Bruise on right hip, arm and knee;

* 03/29/23: Bruise above right eye;

* 04/13/23: Right arm pain;

* 04/15/23: "Complained of pain";

* 04/16/23: Skin tear above right eye. "Eye is completely swollen shut."; and

* 04/18/23: Bruise above right hip and on right hand.

During an interview with Staff 8 and Staff 9 (MC Care Partners) on 04/17/23, they reported the resident was mostly non-verbal and was only inconsistently able to respond to yes/no questions by squeezing staffs' hands.

Review of the facility record revealed the facility failed to investigate all falls, failed to ensure completed investigations addressed all required components to rule out abuse, and failed to include follow up actions to prevent future re-occurrences.

During interviews with Staff 1 (Memory Care Director) on 04/19/23 and 04/20/23, the need complete investigations which addressed all required components for incidents of abuse or suspected abuse, and to report to the local SPD if abuse was not reasonably ruled out, was discussed with Staff 1 on 04/19/23 and 04/20/23. She acknowledged the findings. The facility was directed to report the 36 falls to the local SPD. Documentation of the report was provided prior to exit.

1. Residents identified during survey have been reported to the Adult Protective Services and all requested documentation has been sent. Face to face interviews completed. The remaining resident files (charts) have been reviewed and are in compliance.

2. Incidents are investigated promptly to rule out abuse/neglect. If not able to rule out, incidents are reported to APS promptly. IDT team meets daily to review incidents and discuss/implement interventions and next steps needed to keep residents safe. Incident reports will reflect the investigation and interventions. Staff re-training required for all employees on the abuse and neglect reporting.

3. Daily (M-F with weekend plan in place) IDT monitor.

4. Wellness Director and ED

Based on observation, interview, and record review, it was determined the facility failed to investigate injuries of unknown cause and an allegation 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 2 of 2 sampled residents (#s 8 and 10) who were identified to have a physical injury of unknown origin and experienced a resident to resident altercation. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was moved into the facility in 05/2023 with diagnoses including Alzheimer's disease.

Observation of the resident and interview with staff, revealed the resident required staff assistance with showers two times weekly and toileting assistance including perineal care.

Review of the resident's 07/10/23 through 09/05/23 progress notes and 07/19/23 through 08/30/23 incident reports during the survey revealed the following:

* An 08/30/23 progress note indicated "Resident is being added to alert due to discoloration found on resident right buttocks, it is a dark purple in places with some yellowing in the center."

* The investigation was completed at the time of the incident and documented "noticed a large purple bruise on the right buttocks. Resident could not tell me [the writer] how it happened." However, in investigation, staff documented "Evaluation of skin appeared to be yellowing on edges indicating that the bruise was not recent. Previous fall same week was identified as the cause of the bruise. Therefore the bruise had been ruled out as abuse due to thin fragile skin and fall in same week."

Review of the corresponding incident report noted the resident had an assisted fall on 08/23/23. Staff documented on the resident's progress notes, dated 08/23/23 through 08/29/23, that the fall was non-injury fall and there was no new skin issue. A 08/29/23 progress note indicated the resident was removed from alert charting due to "no latent injury." The findings of the documented monitoring in the progress notes were inconsistent with the documented investigation following the fall on 08/30/23.

On 09/07/23 at 12:50 pm, the above findings were reviewed with Staff 18 (MC Administrator) and Staff 21 (MC LPN). Staff 18 confirmed she was not sure of the origin of the injury. The surveyor requested Staff 18 and Staff 21 to report the incident to local SPD office. Documentation was provided to the survey team to confirm it had been reported to the local SPD office on 09/08/23.

The need to ensure injuries of unknown cause were thoroughly investigated in order to rule out abuse and/or neglect or reported to the local SPD as suspected abuse when the injuries were not reasonably ruled out was discussed with Staff 4 (ED 2) Staff 18, Staff 19 (RN), Staff 21 and Staff 23 (Director of Operations) on 09/07/23 at 4:00 pm. They acknowledged the findings.

2. Resident 10 moved to the facility in 08/2023 with diagnoses including delirium, and dementia.

Observations of the resident, interviews with staff, and review of the resident's 08/02/23 service plan, temporary service plans, progress notes, and incident investigations were completed.

An incident report dated 08/26/23 revealed Resident 10 had been involved in a resident to resident altercation. Resident 10 had gone into another resident's room. The incident report stated that the resident "hit" Resident 10 in the leg with the resident's walker. The report stated "swelling" was noted on Resident 10's right shin.

The investigation was completed at the time of the incident, however, based on the investigation it was noted "no physical or emotional harm was found within hours of the incident" and "abuse/neglect has been ruled out." The altercation was not reported to the local SPD office.

During an interview on 09/06/23 with Staff 21 (MC LPN) and Staff 18 (MC Administrator), Staff 18 stated the incident "should have been reported" based on their investigation of the resident hitting Resident 10. This surveyor requested Staff 18 (MC Administrator) and Staff 21 (MC LPN) report the incident to the local SPD office. Documentation was provided to the survey team to confirm it had been reported to the local SPD office on 09/06/23.

The need to ensure resident incidents were reported to the local SPD office when the facility failed to protect residents from harm was discussed with Staff 4, Staff 18, Staff 19 (RN), Staff 21 and Staff 23 (Director of Operations) on 09/07/23 at 3:20 pm. They acknowledged the findings.

1. Residents identified during survey have been reported to the Adult Protective Services and all requested documentation has been sent. Face to face interviews completed. The remaining resident files (charts) have been reviewed and are in compliance.

2. Incidents are investigated promptly to rule out abuse/neglect. If not able to rule out, incidents are reported to APS promptly. IDT team meets daily to review incidents and discuss/implement interventions and next steps needed to keep residents safe. Incident reports will reflect the investigation and interventions. Staff re-training required for all employees on the abuse and neglect reporting.

3. Daily (M-F with weekend plan in place) IDT monitor.

4. Wellness Director and ED

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests. Findings include, but are not limited to:

At the time of the survey, the facility was home to 29 residents, who resided in the Memory Care Community.

During the survey, 04/17/23 through 04/20/23, there was a lack of scheduled activities that occurred in the facility.

An activity calendar for the facility was requested on 04/17/23 during the entrance conference and Staff 1 (Memory Care Director) provided the activity calendar during the survey.

Review of the activity calendar with Staff 1 on 04/19/23, Staff 1 stated there was no activity calendar for the memory care community. Staff 1 further stated the activity calendar which was provided to the survey team was for the Assisted Living Community, not for the Memory Care Community.

Throughout the survey from 04/17/23 to 04/20/23, residents sat in common areas for a long periods of time, sleeping, while a television played continuously, walked the halls, or remained in their rooms, unengaged in individual and/or group activities.

On 04/19/23 and 04/20/23, failure to provide an activity program based on individual needs and group interests was reviewed with Staff 1, Staff 3 (ED 1) and Staff 4 (ED 2). They acknowledged the findings. Staff 1 stated the facility just hired a new activity staff person to improve the activity program.

1. New dedicated Memory Care Activity Director hired and trained. Activity calendar completed for the remainer of April and all of May. ED approved.

2. Daily Activity Calendars are completed monthly with goals of having person centered and group activities with physical, mental, psychosocial, and recreational activities. Activities calendars must be approved by ED prior to implementing. Scheduled actvities will occur as planned. If unable to complete, calendars will be updated and residents will be notified. Activitiy Director will offer a replacement activity.

3. Monthly Calendar processing with ED appoval. Ongoing monitoring with spot checks to ensure activities are occurring as planned.

4. Activty Director and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 3) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 moved into the facility in 04/2023.

The new move-in evaluation failed to address the following required elements:

* Customary routines including sleeping, eating and bathing;

* Physical health status including visits to health practitioner(s) ER, hospital or NF in the past year;

* Cognition, including decision making ability;

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

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

* Nutrition habits and fluid preference;

* List of treatments;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Complex medication regimen;

* Elopement risk of history;

* Drug use, not prescribed by a physician; and

* Environmental factors that impact the resident's behavior including noise, lighting, room temperature.

The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (Memory Care Director), Staff 3 (ED 1) and Staff 4 (ED 2) on 04/19/23 and 04/20/23. Staff acknowledged the findings.

1. All residents' found out of compliance have been reviewed, updated, and corrected. All evaluations wil be reviewed at least quarterly and changes of condition. The remaining resident charts have been reviewed and are in compliance.

2. Care plan meetings completed weekly for the  following weeks expiring care plan/evaluations. Care plan team will consist of the RN, ED, direct care staff, family, and the resident, as able. Training of the clinical team regarding the move in process, evaluations requirements, and significant changes. Implement a move-in checklist and signifcant change communication form.

3. Wellness Director or delegate will review evaluation schedule, schedule care plan meetings, and enter information into the system.

4. Wellness Director/Delegate/ED

Based on interview and record review, it was determined the facility failed to ensure the initial move-in evaluation contained all required elements for 1 of 1 sampled resident (#10) who was recently admitted to the facility.  This is a repeat citation. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 08/2023 with diagnoses which included delirium and dementia.

The initial evaluation, dated 07/28/23, failed to address the following required elements:

* Personality: including how a person copes with change and challenging situations;

* Recent losses;

* Unsuccessful prior placements; and

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

The need to ensure the initial evaluation included all of the required elements was discussed with Staff 4 (ED2), Staff 18 (MC Administrator), Staff 19 (RN), Staff 21 (MC LPN) and Staff 23 (Director of Operations). The findings were acknowledged.

1. The residents chart/care plans, found out of compliance have been reviewed, updated, and corrected. The remaining resident charts have been reviewed and are in compliance.

2. Resident care plans will match initial and ongoing assessments by second review process. Interim changes to the care plan will be docuemnted on the apporpriate form. Employess are instructed to review, sign and follow the newest plan.Training of the clinical team regarding the move in process, evaluations requirements, and significant changes. Review the move-in checklist and signifcant change communication form with all care staff and nursing. Corrections will include the OAR required information.

3. Wellness Director or delegate will review evaluation schedule, schedule care plan meetings, and enter information into the system. Both ED and nursing will complete ongoing monitoring for caregiver compliance.

4. Wellness Director/Delegate/ED

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, implemented, and provided clear direction to staff regarding the delivery of services for 4 of 4 sampled residents (#s 1, 2, 4 and 6) and failed to review the service plans quarterly as required for 2 of 2 sampled residents (#s 4 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2019 with diagnoses including dementia and history of falling.

Observations of the resident, interviews with staff, and review of the current service plan during the survey, from 04/17/23 thru 04/20/23, revealed Resident 2's service plan was not reflective of the resident's status and lacked clear instructions in the following:

* Use of floor matt;

* Level of toileting assistance status; and

* Fall interventions.

On 04/19/23 and 04/20/23, the service plan was discussed with Staff 1 (Memory Care Director), Staff 3 (ED 1) and Staff 4 (ED 2). They acknowledged the service plans were not reflective of the resident's status and lacked clear instructions.

2. Resident 6 was admitted to the facility in 07/2017 with diagnoses including dementia.

a. Observations of the resident, interviews with staff, and review of the current service plan during the survey, on 04/20/23, revealed Resident 6's service plan was not reflective of the resident's status in the following:

* Finger food status.

b. The resident's service plan was last updated on 11/08/22, therefore not updated quarterly.

On 04/20/23, the service plan was discussed with Staff 1 (Memory Care Director), Staff 3 (ED 1) and Staff 4 (ED 2). They acknowledged the service plan was not reflective of the resident's status and not updated quarterly as required.

3. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

The resident's 01/16/23 and 04/14/23 service plans, and 01/01/23 through 04/17/23 temporary service plans were reviewed. Interviews with staff and observations of the resident were conducted. The following was noted:

Resident 1's current service plan was not reflective related to the following:

* Fall mat by bedside;

* Hospital bed;

* Hospice bath aide;

* Ability to communicate; and

* Use of a wheelchair for mobility.

The facility failed to ensure the interventions identified on the service plan related to the use of a gait belt when transferring the resident, and daily assistance to don eyeglasses, were implemented. Staff were observed on multiple occasions to transfer the resident without a gait belt. The resident was not observed to wear glasses during the survey

The failure of the facility to ensure the interventions identified in the service plan were reflective of the resident's care status and needs and implemented was discussed with Staff 1 (Memory Care Director) on 04/19/23. She acknowledged the findings.

4. Resident 4 was admitted to the facility in 03/2022 with diagnoses including dementia.

Review of the resident's most current service plan accessible to staff, dated 11/30/22, had not been updated quarterly as required.

The need to ensure service plans were completed quarterly was discussed with Staff 1 (MC Memory Care Director.) She acknowledged the findings.

1. All residents' found out of compliance have been reviewed, updated, and corrected, using the care plan team of RN, caregiver, family, and resident. All evaluations out of compliance are reviewed and are in compliance. The remaining resident charts have been reviewed and are in compliance. Signatures of the care planning team are documented.

2. Care plan meetings completed weekly for the  following weeks expiring care plan/evaluations. Care plan team will consist of the RN, ED, direct care staff, family, and the resident, as able. Training of the clinical team regarding the move in process, evaluations requirements, and significant changes. Implement a move-in checklist and signifcant change communication form.

3. Wellness Director or delegate will review evaluation schedule, schedule care plan meetings, and enter information into the system.

4. Wellness Director/Delegate/ED

2. Resident 8 moved into the facility in 05/2023 with diagnoses including Alzheimer's disease.

Observations of the resident, staff interviews and review of the service plan, dated 06/12/23 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Use of CPAP (continuous positive airway pressure) machine at night for sleep apnea; and

* Risk of falls and interventions.

The need to ensure Resident 8's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 4 (ED 2) and Staff 18 (MC Administrator) on 09/07/23 at 12:50 pm. They reviewed the service plan and acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and provided clear instruction to staff for 2 of 4 sampled residents (#s 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 04/2023 with diagnoses including dementia.

Interviews with care staff and observations of Resident 9 during the survey revealed s/he was dependent on staff for all ADL care.

Resident 9's current service plan, revised on 07/10/23, was not reflective of the resident's current status in the following areas:

* Transfers;

* Personal hygiene;

* Communication; and

* Mobility including assistive devices.  

The need to ensure service plans were reflective of the resident's current status was discussed with Staff 4 (ED 2), Staff 18 (MC Administrator), Staff 19 (RN), Staff 21 (MC LPN), and Staff 23 (Director of Operations) on 09/07/23 at 3:20 pm. The findings were acknowledged.

1. All residents' found out of compliance have been reviewed, updated, and corrected, using the care plan team of RN, caregiver, family, and resident. All evaluations out of compliance are reviewed and are in compliance. Signatures of the care planning team are documented.

2. Care plan meetings completed weekly for the  next weeks expiring care plan/evaluations. Care plan team will consist of the nursing, ED, direct care staff, family, and the resident, as able. Training of the clinical team regarding the move in process, evaluations requirements, and significant changes. Additional training and follow up on the move-in checklist and signifcant change communication form.

3. Wellness Director or delegate will review evaluation schedule, schedule care plan meetings, and enter information into the system.

4. Wellness Director/Delegate/ED

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes were evaluated, specific resident interventions determined and documented, and the conditions monitored with weekly progress noted until resolved for 2 of 2 sampled residents (#1 and 2) who experienced short term changes in the area of skin, medication changes, weight changes and repeated falls; and failed to evaluate and monitor service planned interventions for 3 of 3 sampled residents (#s 1, 2 and 4) who had repeated falls. Resident 1 and 2 continued to have falls with injuries. Findings include, but are not limited to:

1. Resident 2 was admitted to the memory care facility in 09/2021 with diagnoses including dementia and history of falling. Resident 2 required a wheelchair for mobility.

During the acuity interview on 04/17/23, Staff 2 (MC Resident Care Coordinator) reported the resident had fallen multiple times in the past 90 days when s/he attempted to transfer without staff assistance.

A 03/10/23 quarterly evaluation indicated the resident had an emergency visit for a fall with injury, left iliac crest (a bone on the top of the hip). The resident required hands on assistance at all times while ambulating and with transfers or bed mobility. The resident was incontinent of bowel and required routine assistance or cueing.

Observations of the resident from 04/17/23 to 04/20/23 showed the resident used a floor mat next to the bed and required a 2-person assistance with transfers and bladder management.

a. Progress notes, incident reports and Temporary Service Plan (TSP) dated 12/31/22 through 04/06/23 indicated the following:

* 02/04/23: Had a fall, " ...slipped while peeing on floor";

* 02/05/23: Had returned to the community with a diagnosis of closed fracture for a fall;

* 02/09/23: A fall in the bathroom. "Sliped [slipped] in pee ...";

* 02/11/23: A fall, "...ensure proper checks are being done.";

* 02/12/23: Had an injury fall " ...no supervision while in bathroom ...";

* 03/01/23: A fall " ...while trying to use toilet";

* 03/06/23: A fall in the room "Trying to get out of bed" ... "Ensure checks are being done when not in site";

* 03/10/23: A fall in the bathroom. Staff documented the resident was in the restroom, on "[his/her] bottom in front of [his/her] toilet";

* 03/11/23: "taking [him/herself] to bathroom and fell ..."; and

* 03/12/23: "found resident on the floor pants down in front of [his/her] wheelchair and urine on the floor ...".

The resident had continued falls or being found on the floor on:

* 03/18/23: Had a fall with injury. Staff documented the resident stated s/he was needing to go to the bathroom and rolled out of bed. The resident upper right forehead had a raised red area that was the size of a quarter;

* 03/19/23: "trying to stand up to pee" and fell;

* 03/21/23: The resident said s/he had to pee and fell in the room. Staff documented "check on resident every hour to ensure safety and see if [s/he] needs any help";

* 04/02/23: The resident needed to use the bathroom and fell; and

* 04/05/23: A fall. Staff documented "needed to use restroom/slid off bed."

A 04/15/23 service plan indicated the resident was unable to transfer independently, required staff assistance with all transfers using a Hoyer lift. The resident was able to self-propel while in the wheelchair, and need frequent checks/supervision as s/he was a fall risk and attempted to self-transfer.

Review of temporary service plans revealed they were pre-populated forms which instructed staff to "Cue and remind resident to call for assistance with ADL's, reaching for objects, answering the phone, etc., as needed and when feeling dizzy or weak. Cue/remind encourage the resident to use walker or wheelchair for mobility if already in place, to decrease further risk of falls."

There was no documented evidence the facility thoroughly reviewed each incident in order to determine if service planned interventions in the area of incontinent management and safety checks were followed and evaluated for effectiveness to prevent continued falls. The resident experienced 20 falls between 01/17/23 and 04/06/23 and some resulted in physical injuries including a closed fracture, skin tears and bruises. Failure to evaluate, determine specific resident interventions, and communicate the interventions put the resident at risk for continued falls with injuries.

On 04/19/23 and 04/20/23, the above findings were reviewed with Staff 1 (Memory Care Director), Staff 3 (ED 1) and Staff 4 (ED 2). They acknowledged findings.

b. Resident 2's clinical records were reviewed during the survey and revealed the following:

* Falls on 02/11/23, 03/01/23, 03/06/23, 03/10/23, 03/11/23, 03/12/23, 03/15/23, 03/18/23 03/19/23, 03/21/23, 03/29/32, 04/02/23, 04/04/23, 04/05/23 and 04/06/23;

* 01/30/23: Redness to the side of pubic mound;

* 02/02/23: Redness on pubic region;

* 02/04/23: Received a new diagnosis of osteoarthritis;

* 02/05/23: Emergency visit after a fall and received a new diagnosis of a closed fracture;

* 02/10/23: Discoloration on left thigh;

* 02/18/23: Edema on lower extremities;

* 02/19/23: A fall and skin tear on the left shin;

* 02/20/23: Emergency visit due to oozing on the left shin area and received a new diagnosis of a fungal infection on groin area;

* 02/22/23: A new medication, Lasix (diuretic);

* 03/05/23: An assisted fall with skin tear on left elbow;

* 03/08/23: Received a new diagnosis of hernia;

* 03/08/23: Bruise on the right buttock;

* 03/09/23: Received an antibiotic to treat infection on leg;

* 03/25/23: Skin tear on right shin;

* 03/31/23: Change in behavior; and

* 04/04/23: Received an antibiotic to treat infection on leg.

There was no documented evidence the resident's conditions were monitored through resolution.

On 04/19/23 and 04/20/23, the above findings were reviewed with Staff 1 (Memory Care Director), Staff 3 (ED 1) and Staff 4 (ED 2). They acknowledged findings.

2. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

The resident's 01/16/23 and 04/14/23 service plans, 01/06/23 - 04/17/23  progress notes, temporary service plans, outside provider notes, RN assessments, and incident investigations were reviewed. Multiple staff were interviewed and the resident was observed. The following was noted:  

a. During the acuity interview, Staff 2 (MC Resident Care Coordinator) stated the resident had fallen multiple times in recent months when s/he attempted to transfer without staff assistance, including a fall from which s/he sustained a right humeral fracture.

Between 01/06/23 and 04/17/23, facility staff documented Resident 1 experienced 36 falls. The following included complaints of pain or injury:

* 01/06/23: Acute back pain with visit to the emergency department of the local hospital;

* 01/07/23: Right upper arm which was "Blue in color and painful to the touch." On 01/08/23, the resident was sent to the emergency department of the local hospital and was diagnosed with a right humeral fracture.

* 01/11/23: "Two back to back falls on 1/11" for which the resident was sent to the emergency department of the local hospital and diagnosed with right hip pain. Staff also documented the resident sustained a bruise on his/her forehead near the right eye and a bump on the back of the resident's head;  

* 01/31/23: Bruise on right hip and chin;

* 03/02/23: Right wrist swelling;

* 03/08/23: "Bit [his/her] lip and cut it with [his/her] teeth";

* 03/26/23: Bruise on right hip, arm and knee;

* 03/29/23: Bruise above right eye;

* 04/13/23: Right arm pain;

* 04/15/23: "Complained of pain";

* 04/16/23: Skin tear above right eye. "Eye is completely swollen shut."; and

* 04/18/23: Bruise above right hip and right hand.

Review of Resident 1's 1/16/23 and 04/14/23 quarterly service plans instructed staff to complete safety checks four times per shift and assist the resident with transfers. No other fall prevention interventions were identified on the quarterly service plans.

Review of temporary service plans, created between 01/06/23 and 04/16/23, after multiple falls revealed they were pre-populated forms which instructed staff to " Cue and remind resident to call for assistance with ADL's, reaching for objects, answering the phone, etc., as needed and when feeling dizzy or weak. Cue/remind encourage the resident to use walker or wheelchair for mobility if already in place, to decrease further risk of falls."

During interviews with Staff 17 (MC Med Tech) and Staff 11 (MC Care Partner), they reported the resident was able to squeeze their hands at times to respond to yes or no questions, but was mostly non-verbal and unable to communicate his/her needs.

Resident 1's 04/14/23 service plan stated the resident was unable to use a call light.

The following interventions were also implemented on the temporary service plans mentioned above:

03/08/23: "Watch resident ...stay with [him/her] so [s/he] doesn't try to stand and walk by him/herself";

03/10/23: "15 minute checks" when in bed;

03/18/23: " Lay down after dinner ...frequent checks while sleeping";

03/20/23: "Keep an eye on resident to help prevent falls";

03/23/23: "Place resident in bed after dinner";

03/26/23: "Frequent checks";

03/28/23: "Make sure the resident is first checked in the morning"; and

04/13/23: "Make resident first check in the morning."

04/15/23: "Keep an eye on resident throughout the night and make sure [s/he] has help getting up," and "Give him/her [sic] figit blanket to prevent/help reduce anxiety."

There was no documented evidence the facility determined and documented additional fall prevention interventions after the other 27 falls.

On multiple occasions on 04/17/23 and 04/18/23, Resident 1 was observed to stand from his/her wheelchair and attempt to transfer without staff assistance. The resident sustained a bruise above his/her hip posteriorly following a witnessed fall on 04/18/23 when s/he attempted to transfer unassisted.

Resident 1, identified to have had frequent falls during the acuity interview, and experienced 36 falls from 01/06/23 - 04/18/2; 12 of the falls included complaints of pain and/or injury. There was no documented evidence the facility evaluated whether the resident's fall prevention interventions were effective to minimize future falls and the resident continued to fall.

At 04/18/23, Staff 4 (ED 2) instructed staff to provide 1:1 supervision to Resident 1. This was observed for the remainder of the survey. Prior to exit on 04/20/23, the facility provided a statement which indicated the resident would be provided with 24 hour supervision until s/he was evaluated to no longer require that level of supervision.

b. Review of Resident 1's 09/30/22 through 03/28/23 weight records revealed the resident weighed 125 lbs on 12/28/23 and 106.5 lbs on 02/28/23. This represented an 18.5 lb or 14.8% weight loss.

There was no documented evidence the facility evaluated the resident when the weight loss occurred, determined what actions and interventions were needed for the resident, and referred the resident to the RN for assessment. The RN was unavailable for interview during the survey.

Staff 19 (MC Medication Tech) and Staff 17  reported the resident was able to feed him/herself prior to his/her fall with right humeral fracture on 01/06/23 and now needed full staff assistance.

The resident was observed to be fed by staff on 04/17/23 and 04/18/23.

A service plan update on 01/10/23 instructed staff to cue the resident to finish his/her meals and to provide assistance with eating.

Documentation of the resident's weight on 03/28/23 indicated his/her weight had remained stable.

c. Review of the progress notes revealed the resident sustained the following skin injuries which were not monitored at least weekly through resolution:

* 01/07/23: Bruising to right upper extremity, chest, and "side" following fall with right humeral fracture;

* 01/24/23: "Discoloration" on right wrist;

* 01/31/23: Bruise on right hip;

* 03/03/23: Bruise on right forearm;

* 03/27/23: Bruise on right arm and knee; and

* 04/05/23: "Discoloration" under right eye and right thigh.

The need to evaluate fall prevention interventions for effectiveness to prevent future falls, to refer the resident to the RN following a significant change of condition, and to monitor short-term changes of condition was discussed with Staff 1  (Memory Care Director) on 04/19/22 and 04/20/23. She acknowledged the findings.

Refer to C 231 example 2.

2. Resident 4 was admitted to the facility in 03/2022 with diagnoses including dementia and a history of falls with a fracture.

Review of the resident's 01/01/23 through 04/17/23 facility record revealed the following:

Resident 1's 11/30/22 service plan stated the resident required stand-by assistance with transfers due to fall risk and instructed staff to perform frequent checks for safety during the night.

The resident's 02/21/23 quarterly evaluation stated the resident was unable to use the call system.

The resident experience falls on 01/14/23, 01/26/23, 01/30/23, 02/11/23 and 03/16/23. S/he sustained a "scrape' and bruise to the right knee from the fall on 01/14/23, and complained of knee pain following the 01/30/23 fall.

Review of temporary service plans completed following the falls revealed they were pre-populated forms which instructed staff to " Cue and remind resident to call for assistance with ADL's, reaching for objects, answering the phone, etc., as needed and when feeling dizzy or weak. Cue/remind encourage the resident to use walker or wheelchair for mobility if already in place, to decrease further risk of falls." The 02/11/23 temporary service plan also instructed staff to ensure the resident slept in his/her bed. No additional fall prevention interventions were determined and documented in the resident's record.

The need to develop resident-specific actions and interventions following short-term changes of condition and to monitor the effectiveness of fall prevention interventions was discussed with Staff 1 (Memory Care Director) on 04/20/23. She acknowledged the findings.

1. All residents' found out of compliance have been reviewed by the RN. Changes of conditions evaluated, have been documented and communicated with the family and resident's physician. Alll other remaining resident charts have been reviewed and are in complaince. Signatures of the care planning team are documented.

2. Significant Change form implemented for staff to communicate with the nursing department. Nursing will evaluate the reported reported changes, document the changes, and complete a new care plan for staff reference and instruction.

3. Daily monitoring of the resident chart notes to identify possible changes in condition. The new implemented Significant Change form are reviewed as soon as possible for follow up.

4. Wellness Director/Delegtate/ED

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for the resident following a change of condition and document on the progress of the condition at least weekly until resolved for 2 of 4 sampled residents (#s 8 and 11) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility 05/2023 with diagnoses including Alzheimer's disease.

Resident 8's facility observation notes dated, 07/10/23 through 09/05/23 and incident reports, dated 07/19/23 through 08/30/23 were reviewed and revealed the following:

* 07/20/23: Increased trazodone dose for insomnia;

* 07/17/23: Started a new medication, buspirone, for anxiety;

* 07/27/23: An assisted fall;

* 07/31/23: A fall;

* 08/03/23: A fall;

* 08/05/23: A fall with a new skin issue, "a raised area to right back side of [her/his] head, this is about 2 inches long and oval shaped";

* 08/11/23: A new skin issue, open area to the lower left shin;

* 08/30/23: A new skin issue, discoloration on the right buttock; and

* 08/31/23: A fall with "a red area on [his/her] right bottom area."

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident following each change of condition, communicated actions to staff, and documented on the progress of the condition at least weekly until resolved.  

The need to document changes of condition which included determining what actions were needed for the resident and documenting the status of the condition at least weekly until resolved was discussed with Staff 4 (ED 2) and Staff 18 (MC Administrator) on 09/07/23 at 4:00 pm. Staff acknowledged the findings.

2. Resident 11 moved into the facility 05/2023 with diagnoses including Alzheimer's disease.

Resident 11's facility observation notes dated, 07/10/23 through 09/05/23, were reviewed and revealed the following:

* 08/09/23: A skin issue, scratches on left collar bone; and

* 08/09/23: Started a new medication, hydroxyurea (to treat cancer).

There was no documented evidence the facility documented on the progress of the condition at least weekly until resolved.

The need to document the status of the condition at least weekly until resolved was discussed with Staff 4 (ED 2) and Staff 18 (MC Administrator) on 09/07/23 at 4:00 pm. Staff acknowledged the findings.

1. All residents' found out of compliance have been reviewed by the RN. Changes of conditions evaluated, have been documented and communicated with the family and resident's physician. Signatures of the care planning team are documented.

2. Significant Change form used so staff are able to communicate with the nursing department quickly and effectively. Nursing will evaluate the reported reported changes, document the changes, and complete a new care plan for staff reference and instruction. Alert charting and follow up documentation to care and resident changes made promptly.

3. Daily monitoring of the resident chart notes to identify possible changes in condition. The new implemented Significant Change form are reviewed as soon as possible for follow up.

4. Wellness Director/Delegtate/ED

2. Resident 6 was admitted to the facility in 07/2017 with diagnoses including dementia.

During the acuity interview on 04/17/23, Staff 2 (MC Resident Care Coordinator) reported the resident required as needed assistance with feeding.

Resident 6's weight record was reviewed during the survey and revealed the following:

* 10/2022 - 120.5 pounds;

* 01/2023 - 127.0 pounds; and

* 03/2023 - 134.0 pounds.

From 10/2022 to 03/2023, Resident 6 had gained 13.5 pounds or 11.20 % of his/her body weight, which represented a change of condition.

There was no documented evidence the RN conducted an assessment of the resident's weight gain which included findings, a description of resident status and a plan of care to address the weight gain.

EA) which included findings, resident status, and interventions made as a result of the assessment.

On 04/20/23, the need to ensure the facility RN completed an assessment for the significant change of condition was discussed with Staff 1 (Memory Care Director), Staff 3 (ED 1) and Staff 4 (ED 2). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 3 sampled residents (#s 1 and 6) who experienced a significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

Review of the resident's 01/01/23 through 04/17/23 progress notes, service plans, temporary service plans, hospital discharge summaries, weight records, and RN assessments revealed the following:

a. Resident 1 was sent to the Emergency Department of the local hospital on 01/08/23 due to increased right upper extremity pain and decreased range of motion following falls on 01/06/23 and 01/07/23. S/he was diagnosed with a right humeral fracture.

In a progress note written by the RN on 01/09/23, she identified the resident's diagnosis of right humeral fracture, but failed to document an assessment which included findings, resident status, and interventions made as a result of the assessment.

During interviews with Staff 9 and Staff 11 (MC Care Partners), they stated the resident was able to walk with a four-wheeled walker and feed him/herself prior to the right humeral fracture. They indicated the resident no longer walked and now required full assistance with feeding. The resident was observed to use a wheelchair for mobility and to be fed by staff during the survey.

b. Review of Resident 1's weight records revealed the resident's weight was 125 lbs. on 12/28/23 and 106.5 lbs on 02/28/23. This represented an 18.5 lb or 14.8% weight loss in two months, which was severe.

There was no documented evidence the RN completed an assessment following the resident's significant weight loss. The RN was unavailable for interview during the survey.

The failure of the facility to ensure an assessment was completed when Resident 1 experienced significant changes of condition, which included a fracture and a severe weight loss, was discussed with Staff 1 (Memory Care Director) on 04/19/23. She acknowledged the findings.  

1. All residents' found out of compliance have been reviewed, updated, and corrected, using the care plan team of RN, caregiver, family, and resident. All evaluations out of compliance are reviewed and are in compliance.  The remaining resident charts have been reviewed and are in compliance. Signatures of the care planning team are documented.

2. All residents charts and documented notes are reviewed for possible significant changes in condition. The newly implemented Significant Change forms are review and addressed as soon as possible. This includes the monitoring and reporting of resident weights showing a significant increase or decrease. Needed changes are completed through care plan team process. Significant Change care plans implemented and are communicated with staff.

3. Daily review by the community nursing department and ED.

4. Wellness Director/Delegate/ED

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

On 04/19/23, approximately 12:45 pm, the surveyor obtained permission and observed Staff 11 (MC Care Partner) and hospice bath-aid provide incontinence care to Resident 2.

During the observation, Staff 11 failed to change gloves after removing a soiled incontinent product and wiping urine from Resident 2's perineum. Staff 11 touched cabinet handles to retrieve the resident's barrier cream and applied the barrier cream to the resident's bottom while wearing the same soiled gloves.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Memory Care Director), Staff 3 (ED 1) and Staff 4 (ED 2) on 04/20/23.

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

1. During an observation on 04/17/23 at 12:50 PM, Staff 10 (MC Med Tech) was observed to drop one of Resident 1's pills on the floor and then pick it up and administer it to him/her.

2. During an interview with Staff 16 (MC Care Partner) on 04/16/23, the staff stated he put laundry soiled with fecal matter directly in the washing machine without first using the hopper.

The need to ensure proper infection control strategies were used for the protection of  residents was discussed with Staff 10 following the incident, and with Staff 1 (Memory Care Director) on 04/19/23. They acknowledged the findings.

1. Direct one on one training occurred with caregivers identified during survey that were non-compliant with infection control standards. The remining staff files were reviewed and are in compliance with the rule.

2. All staff will receive updated re-inservicing of the infection control standards. Annual training of infection controls occurs on the employee anniversary date. New employees are educated of all infection controls standards at hire.

3. Ongoing observation of the infection control system is part of the Quaility Assurance (QA) program. Monthly QA meeting occur to discuss systems including infection control. Allen Flores Consulting Group supports and assists with ongoing traininig, including systems.

4. Wellness Director/designee/HR/ED

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

Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

Review of the 04/05/23 physician order summary and the 04/01/23 - 04/17/23 MAR revealed the following:

* Hydroxyzine was ordered to be administered nightly for sleep. The MAR indicated the medication was not administered 04/12/23 - 04/16/23.

* The physician summary indicated PRN Lorazepam (anxiety) had been discontinued on 04/05/23. The medication was administered on 04/09/23, 04/15/23, and 04/16/23.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Memory Care Director) on 04/19/23. She acknowledged the findings.

1. All residents' chart (MARS) found out of compliance have been reviewed and needed clarifications have been sent to prescribing physician. The remaining resident charts (files) have been reviewed and are in compliance. Returned documention by physician will be implemented and documented. Orders are sent to the contract pharmacy for MAR input.

2. Each resident chart and MAR are reviewed to  confirm all needed orders are correct and in place. Resident presribed orders are verified, sent to the pharmacy for review and MAR imput. Second checks against original order, are completed by staff. Quarterly review by pharmacy and physican will ensure proper orders are in place and correct.  

3. WD/designee will review for compliance weekly x3 months then monthly. WD/designee will complete med pass observation of each Med-tech each quarter.

4. Wellness Director/ED follow up

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 2 sampled residents (#s 1 and 2) whose medications administration records were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 09/2021 with diagnoses including dementia.

Resident 2's physician orders and 04/01/23 through 04/17/23 MARs were reviewed and revealed the following:

* Acetaminophen and Morphine 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 sequence of administration.

The need to ensure an accurate MAR 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 3 (ED 1) and Staff 4 (ED 2) on 04/20/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

Review of the resident's 04/05/23 physician order summary, and 04/01/23 through 04/17/23 MARs revealed the following:

* Hydrocodone, acetaminophen, and morphine were ordered to be administered to the resident as needed for pain. There were no parameters listed on the MAR which instructed staff regarding the sequence to administer the medications.

* Milk of Magnesia was ordered to be administered to the resident daily as needed. There were no parameters on the MAR which defined "as needed."

The need to ensure the MAR included resident specific parameters and instructions for the administration of PRN medications was discussed with Staff 1 (Memory Care Director) on 04/19/23. She acknowledged the findings.

1. All residents' orders found out of compliance have been reviewed, updated, and corrected. Residents that were identified to be self administer have been evaluated and orders sent for physican approval. Documented requests for parameters sent to prescribing physcian for those resident orders missing the required parameters. The remaining resident charts have been reviewed and are in compliance.

2. Review all orders for proper parameters are prescribed for compliant administration. Review all new orders to ensure and request parameters as needed. All self adminstration residents will have a quarterly Self Medication Assessment completed. Care plans and eMARs, will reflect self medicatiuon approval.

3. New orders reviewed and parameters are confirmed to be in placed as soon as possible. Self admin order approvals are monitored quarterly.  

4.Wellness Director/designee  

Based on observation, interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and to obtain a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#7) who self-administered as needed inhaler. Findings include, but are not limited to:

Resident 7 moved into the memory care facility in 06/2021 with diagnoses including Alzheimer's disease and chronic obstructive lung disease.

During the acuity interview on 04/17/23, Staff 2 (MC Resident Care Coordinator) reported the resident self-administered his/her as needed inhaler.

Resident 7's 04/01/23 thru 04/20/23 MAR showed staff administered the inhaler to the resident. However, on 04/20/23, Staff 17 (MC Med Tech) reported the resident self-administered the inhaler and the facility did not keep the inhaler.

On 04/20/23 at 12:05 pm, an inhaler was observed in Resident 7's room on the bedside table. Resident 7 stated s/he used the inhaler when s/he had breathing issue.

The resident's clinical records were reviewed and the following deficiencies were identified:  

* There was no physician order for self-administration of the inhaler; and

* There was no documented evidence the facility evaluated Resident 7's ability to safely self-administered the inhaler.

On 04/20/23, Staff 1 (Memory Care Director) confirmed there was no evaluation related to self-administration of the inhaler for Resident 7 and there was no the physician orders for self-administration of the inhaler.

The failure to obtain physician's order and evaluate the resident's ability to self-administer medications was discussed with Staff 1, Staff 3 (ED 1) and Staff 4 (ED 2). They acknowledged the findings.

1. All residents' orders found out of compliance have been reviewed, updated, and corrected. Residents that were identified to be self administer have been evaluated and orders sent for physican approval. The remaining resident charts were reviewed and are in compliance. Self Medication Administration evaluation completed as needed. Physician orders are sent to physician, documented, and placed in eMAR.

2. Self medication requests will receive a Self Medication Administration evaluation. Physician approval requests sent and documented  All self adminstration residents will have a quarterly Self Medication evaluation completed. Care plans and eMARs, will reflect self medicatiuon approval.

3. Self Medication orders are second checked upon prescribed eMar entry. Self admin order approvals are monitored quarterly.  

4.Wellness Director/designee  

Based on interview and record review, it was determined the facility failed to ensure medications that were administered PRN to treat a resident's behavior had written, resident-specific parameters for 1 of 1 (#1) sampled resident who received psychotropic medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

Review of the resident's 04/14/23 service plan and the 04/01/23 through 04/17/23 MAR revealed the following:

The MAR instructed staff to administer Lorazepam as needed for anxiety. There was no information identified on the MAR or in the service plan as to how the resident expressed anxiety. The medication was administered five times between 04/01/23 and 04/17/23.

The need to document how the resident expressed anxiety was discussed with Staff 1 (Memory Care Director) on 04/19/23. She acknowledged the findings.

1. The residents MAR and care plans identified during survey as being out of compliance, have been review, parameters obtained and care plan updated. The remaining resident charts were reviewed and are in compliance.  

2. An audit of all residents with psychotropic medications will be conducted, parameters obtained, and care plans updated as required. New orders of psychotropic medications will be reviewed to ensure proper parameters are set before administering the medication. Additional training of staff will occur with ongoing monitoring.

3. Medications orders are reveiwed and confirmed to be correct during the 3-step verification process of new orders.

4. Wellness Director/designee/ED

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 2 of 2 sampled residents (#s 8 and 10) who were prescribed PRN psychotropic medication. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was moved into the facility in 05/2023 with diagnoses including Alzheimer's disease.

Review of Resident 8's 08/10/23 through 09/09/23 MAR and current physician orders revealed PRN psychotropic orders for the following:

* Buspirone 10 mg, three times daily as needed for anxiety;

* Haldol 2 mg, every six hours as needed for aggressive and disruptive behaviors; and

* Trazodone 50 mg as needed nightly for insomnia.

The facility administered the medications to the resident on multiple occasions.

The MAR lacked resident-specific parameters for staff describing how the resident expressed anxiety and aggressive behaviors.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and aggressive behaviors prior to administration of the medication was discussed with Staff 4 (ED 2), Staff 18 (MC Administrator) and Staff 21 (MC LPN) on 09/07/23 and 09/08/23. Staff acknowledged the findings.

2. Resident 10 was admitted to the facility in 08/2023 with diagnoses including delirium and dementia.

MARs dated 08/10/23 - 09/09/23 and current physician orders reviewed noted Resident 10 had a physician's order for trazadone 50 mg tablet by mouth one time daily at bedtime as needed for insomnia.

Review of MARs from 08/10/23 - 09/09/23 revealed staff administered PRN trazadone on 19 occasions. The MAR listed non-medication interventions as "other". There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.

In an interview on 09/06/23 at 3:00 pm, Staff 21 (MC LPN) reviewed the MAR. She acknowledged staff did not document non-drug interventions attempted prior to administering the PRN.

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 4 (ED 2), Staff 19 (RN), Staff 21 and Staff 23 (Director of Operations) on 09/06/23 at 3:20 pm. They acknowledged the findings.

1. The residents MAR and care plans identified during survey as being out of compliance, have been review, parameters obtained and care plan updated. Review of all PRN psychotropic medication have required parameters.   

2. An audit of all residents with psychotropic medications will be conducted, parameters obtained, and care plans updated as required. New orders of psychotropic medications will be reviewed to ensure proper parameters are set before administering the medication. Additional training of staff will occur with ongoing monitoring. Care plans will be updated describing how residents express anxiety and aggressive behaviors for those with PRN psychotropic medications, including non-pharmacological interventions.

3. Medications orders are reveiwed and confirmed to be correct during the 3-step verification process of new orders.

4. Wellness Director/designee/ED

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed including a thorough review by an RN, PT or OT prior to use, and instruction to caregivers on the correct use and precautions of the devices for 1 of 1 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

Review of the resident's  04/14/23 service plan, 01/06/23 through 04/17/23 progress notes, observations of the resident, and interviews with staff revealed the following:

The 04/14/23 service plan indicated the resident had a history of transferring him/herself without staff assistance.

On multiple occasions on 04/17//23 and 04/18/23 the resident was observed to pull him/herself up to standing without staff assistance.  

On two of the occasions observed, the resident attempted to stand and transfer with his/her feet straddled over the elevated foot rest of the recliner. The remote control for the chair was noted to be in the side pocket of the chair.

During interviews on 04/18/22, Staff 8 and 9 (MC Care Partners) reported the resident was unable to use the remote control to the chair and was not able to communicate his/her needs.

There was no documented evidence the facility registered nurse, a physical therapist or occupational therapist had conducted a thorough assessment of the recliner as a supportive device with restraining qualities and provided instruction to caregivers related to the correct use and precautions related to it's use.

The findings were discussed with Staff 1 (Memory Care Director) on 04/19/23. She acknowledged the need to ensure an assessment was completed and staff instructed prior to use of the chair.

1. The resident identified by survey to not have an evaluation for use of a device with restraining quailities, has been evaluated and identified as not able to lower the leg rest on the living room recliners without assistance. Care plan updated to make an attempt tp redirect away from the recliner to alternative chair. If resident insists on sitting in the recliner, staff are not to assist with leg rest. Monitoring and redirection of leg rests operation by staff. remaining charts in compliance.

2. Residents will be evaluated for any supportive devices used that possibly have restraining quailities. Alternative devices will be evaluated before use of possible restraining devices. RN/PT assessments will be completed if alternative device is not appropriate. Care plans will reflect staff instruction and monitoring.

3.Ongoing of current residents and with each new move-in.

4. Wellness Director/designee/QA/ED    

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

1. During a review of the facility's ABST from 04/17/23 through 04/20/23, it was determined the tool failed to include all of the 22 required ADL components to include:

* Multiple staff required to assist with transferring and completing tasks.

2. Review of two sampled residents' records (#s 1 and 2) revealed the following:

A. Resident 2 was admitted to the facility 09/2021 with diagnoses including dementia.

During the acuity interview on 04/17/23, it was reported that Resident 2 required assistance in most of ADLs and 2-person assist with transfer using a Hoyer lift.

Review of Resident 2's service plan, dated 04/15/23 and 01/17/23 through 04/06/23 progress notes and interview with multiple care staff noted the ABST failed to accurately reflective the time spent for Resident 2's current ADL care needs in the following areas:

* Transferring in or out of bed or chair;

* Assisting with leisure activities; and

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

* Safety checks; and

* Additional care services including multiple staff required to assist with transferring and completing tasks.

The ABST tool was reviewed and discussed with Staff 1 (Memory Care Director) on 04/20/23. Staff acknowledged the findings.

B. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

Review of Resident 1's 01/16/23 and 04/14/23 service plans, 01/06/23 through 04/16/23 progress notes and interview with multiple care staff noted the ABST failed to accurately reflective the time spent for Resident 1's current ADL care needs in the following areas:

* Bowel and bladder management;

* Assistance with eating;

* Leisure activities; and

* Safety checks and fall prevention.

The ABST tool was reviewed and discussed with Staff 1 (Memory Care Director) on 04/20/23. Staff acknowledged the findings.

1. Ensure all care plans are up to date and correct. Input ADL cares into the ABST program.

2. Care plans will be kept up to date and correct. Changes in care, change in condition (from baseline), new resident admissions, and Dc'ed residents will be entered into the ABST program. Maintain proper staff according to the staffing tool.  

3. Minimum weekly reviews of the ABST program and when there is any new resident admissions, change in care, change in condition (baseline), and Dc'ed residents.

4. Nursing department manages the ABST program and it's contents. The Executive Director, monitors the program for correctness.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and to provide fire and life safety instruction to staff on alternate months, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records dated 12/2022 through 04/2023 were reviewed on 04/19/23 and 04/20/23. The following was identified:

1. Fire and life safety training was not provided to staff on alternate months.

2. Fire drills were not consistently completed every other month.

3. Fire drill documentation did not consistently include one or more of the following required elements:

* Location of simulated fire origin;

* Escape route used;

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

* Evacuation time-period needed; and

* Evidence alternate routes were used during the fire drills.

The need to follow all OFC requirements pertaining to staff instruction in fire and life safety, fire drills and documentation was discussed with Staff 1 (Memory Care Director) and Staff 5 (Maintenance Director) on 04/19/23. They acknowledged the findings. No additional information was provided.

1. Fire drills completed and up to date. Staff training on the fire drill process, evacuation plan, simulated fire, and documentation.

2. Bi-monthly (every 2 months) fire and evacuation drills are completed, with ED reviews to ensure complainace. Bi-monthly staff in-servicing of fire and life safety are completed on months when fire drills are not scheduled.

3. Monthly reviews of documented drills are completed by the ED and the Director of Maintenance.

4. Director of Maintenance is responsible for assigning and completing the required fire drills and evacuation as required. This includes the required in-servicing for all employees.   

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 at least 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:

* Documentation of instruction to residents on general safety procedures, evacuation methods, responsibilities during the fire and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission; and

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

The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually, was discussed with Staff 1 (Memory Care Director) and Staff 5 (Maintenance Director) on 04/19/23. They acknowledged the findings. No additional information was provided.

1. Residents have received the annual training of the Life Safety program including fire drills and evacuation plan.

2. New residents will receive the fire drill and evacuation plan within 24 hrs of move in. All residents will receive fire and life safety (including fire drils and evacuation) annual re-training with any updates. Those residents needing special assistance will be identified and the care plans will reflect evacuation plans for each residents.

3. Monthly QA meeting will review compliance of the Fire and life Safety program.

4. Maintenance Director/ED

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

In an interview on 09/07/23, Staff 4 (ED 2) and Staff 5 (Maintenance Director) were asked how the facility provided periodic re-training on fire safety to residents in the MCC. They acknowledged the facility did not currently have a process for providing re-training to the residents and documenting the training.

1. Residents have received the annual training of the Life Safety program including fire drills and evacuation plan.

2. New residents will receive the fire drill and evacuation plan within 24 hrs of move in. All residents will receive fire and life safety (including fire drils and evacuation) annual re-training with any updates. Those residents needing special assistance will be identified and the care plans will reflect evacuation plans for each residents. Meetings and training will be documented for reference.

3. Monthly QA meeting will review compliance of the Fire and life Safety program.

4. Maintenance Director/ED

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

Refer to C 231, C 252, C 260, C 270, C 330, C 422, C 513, Z 155, and Z 164.

Refer to C231, C252, 2260, C270, C330, C422, C513, Z155, AND Z164

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

1. During a tour of the environment on 4/17/23, the following areas were noted to be in need of cleaning and repair:

* Multiple chairs on the Sunset and Silver units had fabric which was heavily stained;

* There was a missing light fixture on the ceiling in the TV area on the Silver unit;

* Multiple dining room chairs and tables on both units had scratches and gouges;

* The entrance doors and doors to the secure courtyards had chipped paint;

* The walls in the commercial laundry room had chipped paint and gouges in the drywall;

* The wooden bench in the Sunset secure courtyard had areas where the wood had rotted;

* The commercial laundry room and guest bathroom floors had areas where the seams had separated, and the laundry room flooring was pulling away from the wall at the coved base and torn by the dryer; and

* There was brown matter on the rim of the hopper sink.

2. A strong, pervasive odor of urine was detected in the common areas on the Sunset unit during multiple observations of the environment on 04/19/23 and 04/20/23.

The need to ensure the environment was maintained clean, in good repair, and free from unpleasant odors was discussed with Staff 1 (Memory Care Director) on 04/20/23. She acknowledged the findings.

1. The identified enviromental concerns found during the recent survey visit have been addressed. Soiled incontinent program developed to to reduce odors. Staff trained on how to request maintenance needs promptly. Upholstery cleaned, scraps/dings painted, hopper cleaned, light fixtures replaced, bench fixed, and floor concerns addressed.

2. Enviromental walk throughs daily will identify needs such as lighting and other concerns. Staff trained on reporting process of maintenance needs. Direct Supply TELS system used to track all repairs with a back-up paper maintenance request form. Odors will be addressed as soon as possible. Staff are to follow the soiled incontinent process. Urine found on floors will be promptly cleaned.

3. Daily walk-through of all areas by maintenance. ED monitoring of compliance.

4. Maintenance Director/ED   

Based on observation and interview, it was determined the facility failed to maintain all interior and exterior materials and surfaces necessary for the health, safety, and comfort of the residents clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

The MCC was toured on 09/06/23 at 12:20 pm. The facility consisted of two separate units, each with 24 resident rooms, called the "Silver Oaks" and "Sunset Oaks" units. The following issues were identified:

Silver Oaks:

* One red fabric chair outside room 107 had debris stuffed down in the cushions; and

* The outdoor wooden bench was rough to the touch which could result in residents getting splinters.

Sunset Oaks:

* Two brown microfiber material chairs and two red fabric chairs near the patio door had dried stains; and

* The outdoor wooden bench was rough to the touch which could result in residents getting splinters.

The items needing cleaning or repair were discussed with Staff 4 (ED 2) and Staff 5 (Maintenance Director) on 09/07/23. They acknowledged the findings.

1. The identified enviromental concerns found during the recent survey visit have been addressed. Staff re-trained on how to request maintenance needs promptly. Upholstery cleaned, scraps/dings painted, hopper cleaned, light fixtures replaced, exterior benches sanded and resurfaced, and floor concerns addressed.

2. Enviromental walk throughs daily will identify needs such as lighting, cleaning, repair, and other concerns. Staff re-trained on reporting process of maintenance needs. Direct Supply TELS system used to track all repairs with a back-up paper maintenance request form.

3. Daily walk-through of all areas by maintenance. ED monitoring of compliance.

4. Maintenance Director/ED

Based on observation and interview, the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used to launder soiled linens and soiled clothing. Findings include, but are not limited to:

Staff 17 (MC Care Partner) reported linens and clothing soiled with urine were laundered in the residential washers on the memory care units.

The facility laundry soap did not contain a disinfectant and one was not added to the washers when the soiled linens were laundered.

The need to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used to launder soiled linens and soiled clothing was discussed with Staff 1 (Memory Care Director) on 04/20/23. She acknowledged the findings.

1. Staff are trained on the soiled linen and soiled clothing process. Disinfectant in place at each washer with instructions. Staff trained on proper hopper use, when and how to use.

2. Initial (at hire) and annual training on all laundry services following the required infection control process. Disinfectant remains in place and will be used as instructed. Clean linens are stored covered as required.

3. Weekly monitoring will ensure proper processing of the soiled linens and garments.

4. Maintenance Director/ED  

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

During a tour of the environment on 04/17/23 at 12:20 pm, it was revealed the exit doors to the secure outdoor courtyards did not have a functioning alarm system to alert staff when residents exited the building.

The findings were discussed with Staff 1 (Memory Care Director) and Staff 5 (Maintenance Director) immediately. Staff 5 fixed the door alarms directly. The doors were then noted to be alarmed for the remainder of the survey.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 and Staff 5 on 04/17/23. They acknowledged the findings.

1. Exit door alarms have been repaired. Doors are working properly. Training completed with all employees on the Atmost call system, which includes identification of the notification, response, timeliness, monitoring, and rounding. Handheld responders inplace with back up plan.

2. New employees are trained on the Atmost alarm call (monitoring) system. Batteries required for the system will be changed on a preventive maintenance schedule. Front desk monitoring and back up notification on the call/door system to ensure staff reply quickly to calls.

3. Monthly battery changes prompted by preventive maintenance schedule. Reports are pulled to monitored for response times. Call/door alarm system tested weekly.

4. Maintenance Director with ED follow up

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 limited to:

Refer to C 156, C 231, C 361, C 420, C 422, C 513 and C 555.

Refer to non-healthcare related area survey citations.   

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 limited to:

Refer to C231, C 422 and C 513.

Refer to C231, C422, and C513.

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 8, 12, 13 and 18) prior to beginning job duties, competency demonstration was completed within 30 days of hire for 3 of 3 newly hired staff  (#s 8, 12 and 13), and documented evidence of the required 16 hours of annual in-service, including six hours of dementia care training for 4 of 4 long-term staff (#s 6, 7, 10 and 11) whose training records were reviewed. Findings include, but are not limited to:

On 04/18/23 training records were reviewed with Staff 1 (Memory Care Director). The following deficiencies were identified:  

1. Staff 8 (MC Care Partner), Staff 12 (MC Care Partner), Staff 13 (MC Med Tech) and Staff 18 (Cook), hired on 03/09/23, 11/09/22, 10/06/22 and 01/30/23 respectively, did not have documented evidence that pre-service orientation had been completed in the following required areas prior to providing care and services independently:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention:

* Fire safety and emergency procedures;

* Food handler's certificate (for Staff 13); and

* Evidence Staff 12 and Staff 18 were provided a written job description.

In addition, Staff 18 had not completed pre-service dementia training in the following areas:

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

* Techniques for understanding, communicating and responding to distressful 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.

2. Staff 8, Staff 12 and Staff 13, 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;

* General food safety, serving and sanitation; and

* First Aid/Abdominal Thrust training (for Staff 8 and Staff 13).

3. Staff 6 (MC Care Partner), Staff 7 (MC Care Partner/Med Tech), Staff 10 (MC Med Tech) and Staff 11 (MC Care Partner), did not have documented evidence of completing the required a minimum of 16 hours of in-service training annually, based on anniversary date of hire, on topics related to the provision of care for persons in a CBC, including training on chronic diseases in the facility population with six of the 16 hours being dementia care topics.

The need to ensure newly-hired staff completed all required training prior to beginning their job duties, documented methods to determine competency of direct care staff, and on-going required 16 hours of annual training including six hours related to dementia care training was reviewed with Staff 1 (Memory Care Director) on 04/19/23. She acknowledged the findings.

1. All employee files are audited to ensure each employee has 16 hours of approved training including six (6) hours of Dementia training. Pre-service and 30 day orientation training completed with return demostration of skills.

2. New employee checklist form used for onboarding. Employees are expected to complete assigned coursework, including six (6) hours of Dementia training and Infection Control, using Oregon Care Partners/Relias. Annual training occurs on anniversary date of hire. Prior to beginning their job responsibilities, employees will complete an orientation of Residents' rights and the values of community-based care, Abuse and reporting requirements, Standard precautions for infection control, Fire safety and emergency procedures, and All staff must receive a written description of their job responsibilities.

3.New employee files are monitored at 30 days for the required training during onboarding. Employee files are monitored monthly to track the completion of the 12 hour trainings which include 6 hours of Dementia and infection control training.

4. HR Director/ ED monitors compliance. .

Based on interview and record review, it was determined the facility failed to ensure all newly-hired direct care staff completed the required pre-service training and direct care staff completed a total of 16 hours of in-service training annually, including six hours of dementia care training. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed with Staff 20 (Business Office Director) and Staff 21 (MC LPN) on 09/06/23. The following were identified:

a. There was no documented evidence the facility was providing training to newly-hired direct care staff on the following required topics:

* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);

* Family support and the role the family may have in the care of the resident; and

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment.

Staff 20 acknowledged he was not aware of those training requirements.

b. The facility lacked a system for documenting and tracking ongoing staff training to ensure direct care staff completed a total of 16 hours of in-service training annually, including six hours of dementia care training, calculated from each staff person's anniversary date of hire.

Though the facility offered training on the provision of care during monthly staff meetings, it was not documenting the duration of training on the specific topics. Staff 20 added the facility planned to assign online training as well but had not begun that process yet. Staff 20 had developed a spreadsheet to track training, but had yet to implement it.

The need to ensure all training was provided to newly-hired staff and long term staff as required was reviewed with Staff 4 (ED 2) and Staff 18 (MC Administrator) on 09/07/23. They acknowledged the findings.

1. All employee files are audited to ensure each employee has 16 hours of approved training including six (6) hours of Dementia training. Pre-service and 30 day orientation training completed with return demostration of skills.

2. New employee checklist form used for onboarding to ensure the required ttraining are completed. Annual employee training to be completed including six (6) hours of Dementia training and Infection Control, using Oregon Care Partners/Relias. Annual training occurs on anniversary date of hire. Prior to beginning their job responsibilities, employees will complete an orientation of Residents' rights and the values of community-based care, Abuse and reporting requirements, Standard precautions for infection control, Fire safety and emergency procedures, and All staff must receive a written description of their job responsibilities.

3.New employee files are monitored at 30 days for the required training during onboarding. Employee files are monitored monthly to track the completion of the 12 hour trainings which include 6 hours of Dementia and infection control training.

4. HR Director/ ED monitors compliance. .

Based on observation, interview and record review, it was determined the facility failed to ensure health service were consistently provided. Findings include, but are not limited to:

Refer to C 242, C 252, C 260, C 270, C 280, C 295, C 303, C 310, C 325, C 330 and C 340.

Refer to healthcare related area C 242, C 252, C260, C 270, C280, C295, C 303, C 310, C 325, C 330, and C 340.

Based on observation, interview, and record review, it was determined the facility failed to ensure health service were consistently provided. Findings include, but are not limited to:

Refer to C 252, C 260, C 270 and C 330.

Refer to healthcare related area C 242, C 252, C260, C 270, C280, C295, C 303, C 310, C 325, C 330, and C 340

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 1 of 2 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

Review of the resident's nutrition and hydration plan in the 04/14/23 service plan revealed it failed to identify the resident had experienced a severe weight loss between 12/28/22 and 02/28/23, failed to provide clear instruction to staff related to the resident's abilities, and failed to identify specific preferences for food provided by the facility kitchen.

The need 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 was discussed with Staff 1 (Memory Care Director) on 04/19/23 and 04/20/23. She acknowledged the findings.

1. Resident care plans reviewed to ensure dietary needs are in place as needed and as prescribed. Needed dietary weight loss / gains have interventions put in place.

2. Each residents and the resident's preferences are evaluated for daily meal program for nutrition and hydration.Individualized nutritional plan for each resident are documented in the resident's care plan. Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills, will be evaluated for needs, placed with utensils, and documented in the care plan. Monthly weight loss or gains are reported to nursing for evaluation. Dietary care plan changes implemented with physician follow up.

3. Monthly monitor of resident weights with needed interventions placed in care plan.

4. Wellness Director/ED/Dietary Director.   

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 2 sampled residents (#s 1 and 2) residing in the Memory Care Community. Findings include, but are not limited to:

1. Resident 2 resided in the Memory Care Community and had diagnoses including dementia.

Resident 2 was observed to require assistance from staff to initiate, attempt and participate in activities. The resident was either in the bed without TV on or in a wheelchair in the common area, sleeping most of the time. The resident was observed not engaging any individual or group activity during the survey.

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

* 03/10/23 The quarterly evaluation indicated the resident liked to have sports on his/her television. The resident also liked when care partners and staff updated him/her on game scores; and

* The resident's 04/15/23 service plan indicated the resident used to be a basketball coach and enjoyed watching college basketball.

The facility failed to fully evaluate Resident 2'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 04/19/23, the need to have an individualized activity plan for Resident 2 and the failure to provide an activity program based on individual needs and group interests were discussed with Staff 1 (Memory Care Director). Staff 1 stated they just hired a new activity staff and was in the process of implementing activities program. She acknowledged the facility needed to improve their system for developing and implementing individualized activity plans for the residents.

Refer to C 242.

2. Resident 1 was admitted to the facility in 09/2022 with diagnoses including dementia.

Review of the resident's 04/14/23 service plan identified multiple activities the resident liked, but there was no documented evidence the facility had completed an activity evaluation which addressed the following:

* 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.

The need to ensure an individualized activity evaluation was completed for Resident 1, and an activity plan developed based on that evaluation, was discussed with Staff 1 (Memory Care Director) on 04/19/23. She acknowledged the findings.

1. Activity Interest forms are completed for those residents and their families that participated with the request. Care plans reviewed and updated with activity interests and plan. This includes individual plans.

2.  Activity Interest forms completed at move-in for each resident, to identify meaningful activities that promote or help sustain the physical and emotional well-being of residents. Activities include person centered during waking hours. Activity Interest Forms identify past and current interests, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, any adaptations necessary for the resident to participate, and identification of activities for behavioral interventions. An individualized activity care plan developed for each resident based on their activity evaluation. The daily activity calendar will be followed as posted.

3. Weekly monitoring of activities as scheduled.

4. The ED approves monthly calendar and ensures activities occur as planned, including 1 on1 activities.

Based on observation, interview, and record review, it was determined the facility failed to evaluate each resident for activities and develop an individualized activity plan for each resident based on the activity evaluation, for 4 of 4 sampled residents (#s 8, 9, 10 and 11) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms or walked around the facility. All residents were diagnosed with some type of dementia.

Due to a history of negative behaviors toward other residents, Resident 8 spent most of his/her time in his/her room, and staff did not actively encourage the resident to join activities with other residents. Resident 9 needed a lot of assistance from staff for all his/her ADLs and was completely non-verbal. Resident 10 was recently admitted to the facility; the activity plan was simply to invite the resident to activities. Resident 11 spent his/her time in his/her room except for meals. The resident was observed during the survey watching TV, reading or working on word puzzles.

The activity section of Resident 8, 9, 10 and 11's current service plans were reviewed. Though there was some information about each resident's past or current interests, the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for participation; and

* Activities that could be used as behavioral interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. There were no instructions for providing activities for residents who did not participate in group activities.

The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed with Staff 4 (ED 2), Staff 18 (MC Administrator) and 24 (MC Activities) on 09/07/23. They acknowledged the findings.

1. Activity Interest forms are completed for those residents and their families that participated with the request. Care plans reviewed and updated with activity interests and plan. This includes individual plans.

2.  Activity Interest forms completed at move-in for each resident, to identify meaningful activities that promote or help sustain the physical and emotional well-being of residents. Activities include person centered during waking hours. Activity Interest Forms identify past and current interests, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, any adaptations necessary for the resident to participate, and identification of activities for behavioral interventions. An individualized activity care plan developed for each resident based on their activity evaluation. The daily activity calendar will be followed as posted.

3. Weekly monitoring of activities as scheduled.

4. The ED approves monthly calendar and ensures activities occur as planned, including 1 on1 activities

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area which allowed them to exit/return without staff assistance. Findings include, but are not limited to:

During a tour of the environment on 04/17/23 at 12:20 pm, the door to the secure outdoor area on the Silver unit was locked on the outside, preventing re-entrance without staff assistance.

Staff 1 (Memory Care Director) and Staff 5 (Maintenance Director) were alerted immediately. Staff 5 fixed the door at that time. The need to ensure the exit doors were operational and allowed residents to both exit and return without assistance was discussed with Staff 1 and Staff 5. They acknowledged the findings.

1. Both outdoor courtyard doors were fixed immediately. All other memory care doors were checked for proper operation.

2. PM check implemented for the Maintenance Director to check all doors for proper operation, including alert system that notifies staff that a resident has exited into the courtyard. Staff educated on door system and expected performance.

3. Weekly Maintenance Director PM monitoring. Memory Care staff monitoring occurs daily.

4. Maintenance Direct/ED/caregivers

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height. Findings include, but are not limited to:

The MCC was toured on 09/06/23 at 12:20 pm. The facility consisted of two separate units called the "Silver Oaks" and "Sunset Oaks" units. Each unit had a fenced, outdoor area, which residents could freely access.

Measurement of the fences at various locations indicated the height varied from five foot six inches to six feet on the Silver Oaks unit and five foot four inches to six feet on the Sunset Oaks unit. Height was measured from the top of the fence panels to the planting surface immediately adjacent to the fence, which consisted of bark chips.

The need to ensure the fences surrounding the outdoor areas was at least six feet in height was discussed with Staff 4 (ED 2) and Staff 5 (Maintenance Director) on 09/07/23. They acknowledged the findings and said they would address the issue.

1. Obtaining quotes to add the additional required inches to the perimeter fences of the outdoor recreation areas. Enhanced resident monitoring of these areas until fencing is in complaince.

2. Monitor the outdoor fencing for complaince and address issues and or concerns to keep these areas in complaince.

3. Daily walk-throughs of the area to identify concerns and monthly measuring of the fences to ensure ongoing complaince.

4. Maintenance Director and ED.  

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:

During a tour of the environment on 04/17/23, it was noted all but four occupied rooms in the memory care units lacked identifying information to assist residents with locating their rooms. Though resident names were posted, there were no additional individual identifiers to assist residents in recognizing their room.

These findings were discussed with Staff 1 (Memory Care Director ) on 04/20/23. She acknowledged the findings.

1. All memory care door entries were evaluated for the required personalized identification. Those doors out of compliance, have been placed with room number, resident name, and a picture of the resident.

2. Implemented move-in task that requires individual personalized identification for apartment doors. This includes, however is not limited to, room number, resident name, resident picture, and possibly a person item. Staff monitoring will ensure that these items stay as placed, including replacing as needed or requested.

3. Daily monitoring by staff to ensure the indentifying minimums are in place, room number, resident name, and resident piucture.

4. CRD/ED/daily care staff