The findings of the relicensure survey, conducted 10/11/21 through 10/14/21, 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

Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas:

OAR 411-054-0030 Resident Service Meals, Food Sanitation Rules; and

OAR 411-054-0070 Staffing Requirements and Training: Staffing.

The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the revisit to the re-licensure survey of 10/14/21, conducted 04/11/22 through 04/13/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

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

1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas:

OAR 411-054-0030  Resident Services Meals, Food Sanitation Rule; and

OAR 411-054-0070 Staffing Requirements and Training: Staffing.

The facility put immediate plans of correction in place during the survey and the situations were abated.   

2. During the relicensure survey, conducted 10/11/21 through 10/14/21, administrative oversight to ensure adequate care and services rendered in the facility was found to be ineffective, based on the severity and number of citations issued.

Refer to deficiencies in report.

See C155, C160, C200, C231, C240, C242, C243, C260, C262, C270, C280, C282, C310, C315, C360, C420, C422, C510, C513, C530, Z140, Z142, Z145, Z150, Z155, Z162, Z163, Z164, Z173, Z176.

Z176 (in survey but not included in POC template document)

1. Individualized identification frames are being added to each resident room.

2. Upon move in, resident room individualized identification frame will be placed outside the resident room.

3. Weekly with manager rounds.

4. Assistant Administrator and Administrator.

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of documentation or records for 7 of 11 sampled residents (#s 1, 3, 7, 8, 9, 10 and 11) whose records were reviewed. Findings include, but are not limited to:

During the survey resident records were reviewed and were found to be missing or were incomplete in multiple areas, including signed physicians' orders, hospital discharge paperwork, evaluations and monitoring, incident investigations, service plans, and RN assessments.

On 10/14/21, the need to ensure facility records were accurate and complete was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN). No further information was provided.

1. All residents have a chart and resident record. The pharmacy will do MAR-order-label audit in November 2021. Staff will be retrained on the system for reviewing orders. New orders will be placed in the 24-hour book after processed for nurse review. The incident reporting, investigation, and follow up process system has changed and staff will be trained. A service plan audit will be done and service plan schedule developed. The RN will be trained on RN assessments and documentation. The pharmacist will review the medications and MAR again in December.

2. See C231, C260, C270, C280, C310, C315.

3. Multiple times per week during clinical meeting. Monthly during the quality assurance meeting.

4. Assistant Administrator and Administrator.

3 a. General observations of the dining room and connected common area on 10/12/21, at approximately 8:40 am, showed Resident 6 was seated in a chair in the common area located directly across from the dining area. The dining area was separated from the common area by a half wall that was open on either side. The resident's breakfast was on a tray table in front of the resident.

Staff 2 (RN) was observed to set a bin of treatment supplies on the end table next to the resident, sit herself on the end table, and then place dressing items on the end table itself. The end table was not disinfected prior to placement of items on the surface. Staff 2 began a dressing change to the resident's toes. Gauze and cleansing spray were used to clean the toe wounds, the areas were measured, and Band-Aids were applied to the toes, as well as a gauze wrap placed around the toes to secure the Band-Aids.

Staff 2 placed the old Band-Aid/dressing and wrappers on the end table in between tasks. The tray table in front of the resident contained his/her partially eaten breakfast and drinks. The tray table was scooted out of the resident's reach while Staff 2 placed wrappers and some used items on the tray table. Staff 2 attached pieces of tape to the tray table and used the tape pieces to secure the gauze around the resident's toes. Staff 2 then lifted the resident's pant leg and removed a large soiled Band-Aid from an open shin wound, placed the bandage on the end table, and cleansed the shin. The resident's leg was wrapped with gauze wrap rather than a new Band-Aid due to irritation on the leg from the previous bandage.

Staff 2 removed the garbage and used dressings, put the resident's tray table back in front of him/her, and disinfected the end table. The resident's tray table was not disinfected until staff were directed to do so by the surveyor.

In an interview on 10/12/21, Staff 2 stated she periodically completed the dressing change in the common area location, but on some occasions the resident's dressing change was done in his/her apartment. Staff 2 stated one of the resident's toes had an open wound and the shin wound was also open; both wounds were diabetic ulcers. Staff 2 acknowledged the need for resident privacy and infection control during dressing changes.

The need to ensure resident privacy and appropriate infection control during dressing changes was discussed with Staff 1 (Administrator/RN) on 10/12/21. She acknowledged the findings.

b. General observations of the dining room and connected common area on 10/13/21 at approximately 9:30 am showed Resident 3 was seated in his/her wheelchair between the dining room and connected common area. The resident was wheeled back into the dining room and placed at a table by Staff 12 (CG/MT).

Staff 12 laid dressing change items, including antibiotic ointment, gauze rolls, spray cleanser, and gauze pads, on the table. The existing dressing and gauze roll was removed from the resident's right hand and put onto the table. The dressing did not appear to be soiled, and no open area was observed in the resident's palm. The resident's hand was extremely swollen and sore to the touch.

Staff 12 used gauze pads and cleansing spray to wipe out the resident's palm, with physical and verbal protest by the resident. Staff 12 placed ointment in the resident's palm, placed a full gauze roll into the resident's palm, and the whole hand was wrapped with a gauze wrap. The soiled items were removed from the table. Staff 12 did not disinfect the table prior to completing the dressing change or after removing the soiled items and garbage.

The surveyor directed Staff 12 to disinfect the table.  

The need to ensure that all staff implemented appropriate infection control practices and resident privacy for dressing changes was discussed with Staff 1 (Administrator/RN) on 10/13/21. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents regarding inadequate fencing surrounding a water feature in the secured memory care courtyard, and for 2 of 2 sampled residents (#s 3 and 6) and one non-sampled resident related to infection control. Findings include, but are not limited to:

1. The facility grounds were toured on 10/11/21 at approximately 1:30 pm. During the tour, a water feature was observed off the secured patio directly outside the memory care dining room area. The area where the water feature was located was approximately 10 to 12 feet wide and ran along a sloping down-hill pathway approximately 20 feet in length. The top portion of the water feature, nearest the patio, had a small pond area with water running from the pond to the bottom slope of the water feature. This area was surrounded by a chain link fence, approximately 35 inches high, with a 3 to 4-inch gap between the top of the fence and a metal bar, and the bottom perimeter of the fence. The chain link fence was not sufficient in height to prevent residents from climbing or falling over the fence into the pond or other areas where the water feature was located.

On 10/11/21 at 6:44 pm, the surveyor toured the area with Staff 1 (Administrator/RN). Staff 1 agreed the fence surrounding the water feature was not adequate in height to prevent residents from climbing over or falling into the water feature area.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was reviewed with Staff 1 on 10/11/21 and 10/14/21. Staff 1 acknowledged the findings and stated she would be contacting a contractor for an estimate on correcting the fence height.

2. During a tour of the interior of the facility, 10/11/21 at approximately 12:00 pm, the surveyor observed two shared resident bathrooms, located next to each other on the second floor of the Residential Care Facility (RCF), and identified the following concerns:

* Garbage cans in both bathrooms were uncovered. Items in each can consisted of tissue paper, toilet paper with brown matter, soiled gauze and tape, and a small plastic bag filled with brown matter. Several items had spilled over the top of the cans and onto the bathroom floors:

* The toilet paper rolls in each bathroom were empty. No other toilet paper was observed; and

* The toilet seat in one bathroom was smeared with brown matter. Brown matter was also observed on the wall to the right side of the toilet and on the bathroom floor directly in front of the toilet and near the garbage can.

During a tour of the building with Staff 1, on 10/11/21 at 7:00 pm, the surveyor and Staff 1 observed the bathroom still had not been cleaned. Staff 1 stated one resident on the RCF sometimes had trouble caring for his/her colostomy bag. Staff 1 stated she would have someone clean the bathroom right away.

The need to ensure the facility exercised reasonable precautions with regard to infection control was discussed with Staff 1 on 10/11/21. She acknowledged the findings.

1. Two contractors have been contacted and have provided bids for the fence work. A third bid will be sought and fences will be fixed. All common areas including bathrooms have garbage cans with lids. Garbages are emptied at the end of shift. All staff have task sheets. A second housekeeper was hired. Extra toilet paper is available. Training was provided to the RN regarding treatments to be done in the resident rooms/private area.

2. Restocking of toilet paper will be assigned to the housekeeper. A housekeeping checklist will be developed.

3. Weekly for the first two months and then monthly.

4. Administrator and RN.  

Based on observation, interview, and record review, it was determined the facility failed to ensure 6 of 6 sampled residents (#s 1, 7, 8, 9, 10, and 11) were protected from neglect, and failed to ensure 1 of 1 sampled resident (# 1) and multiple non-sampled residents received services in a manner that promoted privacy, respect, and dignity. Resident 11 experienced multiple falls with injuries. Residents 1, 7, 8, 9, and 10 experienced weight loss. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 02/2020 with diagnoses including dementia.

Observation and record review during the survey indicated Resident 11 experienced nine falls between 07/07/21 and 10/11/21. Seven of the falls resulted in injury.

There was no documented evidence the facility had evaluated previous fall interventions for effectiveness or developed new fall interventions subsequent to each fall.

The failure of the facility to evaluate fall interventions or develop new interventions resulted in physical injury to the resident, constituted neglect of care, and was considered abuse.  

Refer to C270, example 1.

The failure of the facility to evaluate or develop fall interventions for Resident 11 was discussed with Staff 1 (Administrator/RN) on 10/14/21. She acknowledged the findings.

2. During the survey, 10/11/21 through 10/14/21, the following residents were identified with significant to severe weight loss:

* Resident 1 had a 30-day weight loss of 10 lbs., or 8.0 % of their total body weight;

* Resident 7 had a 30-day weight loss of 16 lbs., or 7.27 % of their total body weight;

* Resident 8 had a 30-day weight loss of 15 lbs., or 12.8 % of their total body weight;

* Resident 9 experienced a weight loss of 11 lbs. or 5.7 % of his/her total body weight between 07/20/21 and 09/20/21; and  

* Resident 10 had a 30-day weight loss of 12 lbs., or 6.94 % of his/her total body weight.   

Record review and interviews showed the facility failed to have an effective system for monitoring resident weights, and failed to assess, develop interventions, or monitor interventions for effectiveness when a resident was identified with a significant or severe weight loss.

The facility's failure to evaluate, assess, or develop interventions to prevent further weight loss resulted in physical harm to the residents and constituted neglect.

The need to ensure the facility had an effective system for assessing residents with significant to severe weight loss, which included developing and monitoring interventions for effectiveness, was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/13/21 and 10/14/21. They acknowledged the findings. No further information was provided.

Refer to C270, examples 2 and 3.

3. Resident 1 was admitted to the facility in 08/2021 with diagnoses including dementia and Parkinson's disease.

On 10/12/21 at 3:07 pm the resident was observed sitting in his/her wheelchair at a table in the dining room of the memory care unit. During the observation, the resident attempted to independently eat a small cup of fruit, but was unable to hold the cup or the spoon and spilled both onto his/her lap. The resident then attempted to pick up the fruit from his/her lap to eat it, dropping the fruit back onto his/her lap and on the floor.

Between 3:07 pm and 3:28 pm three staff were observed to walk past the resident while s/he attempted to feed himself/herself, but failed to offer the resident assistance with eating or cleaning up the spilled fruit. At 3:28 pm a staff member removed the fruit cup from the resident's lap, but did not wash the resident's hands or clean up the fruit from the resident's lap.

The need to ensure services provided to residents were done in a way that promoted dignity and respect was discussed with Staff 1 (Administrator/RN) on 10/12/21. She acknowledged the findings.

4. Observations of non-sampled residents conducted during the survey revealed the following:

* Multiple residents wandered the memory care wearing only socks or were barefoot;

* Room 20 had an unpleasant and strong cat box odor present throughout the survey;

* One female resident was observed wearing a thin long-sleeved blue shirt without any undergarment. The resident's breasts were visible through the shirt; and

* On 10/11/21 and 10/12/21 at approximately 3:30 pm each day, multiple female and male residents were seen sitting in the common areas of the memory care wearing pajamas. These residents had been observed earlier in the day dressed in appropriate day clothes.

In interviews on 10/11/21 and 10/12/21, Staff 17 (CG) confirmed staff were responsible for cleaning the cat box in room 20. Staff 1 stated she could not think of a reason why residents would be wearing pajamas that early in the day.

The need to ensure residents were treated in a manner that promoted dignity and respect in a home-like environment was discussed with Staff 1 on 10/11/21, 10/12/21 and 10/14/21. She acknowledged the findings.

1. A fall assessment will be done and fall interventions added for Resident 11. Weight loss assessments are being done and interventions implemented for Resident 1, 7, 8, 9, and 10. Weight is being monitored weekly for residents with weight changes. Staff will be trained to assist Resident 1 with eating and observing dining needs. Residents will be evaluated for shoe use and service plans updated. Room 20 catbox is cleaned by staff daily and included in the staff task checklist. Staff will be trained for appropriate dressing and grooming of residents. Residents will be encouraged to dress in day clothes and not pajamas.

2. RN training on fall and weight assessments, interventions, and monitoring. Staff training during orientation and inservices on resident dressing and grooming. Competency evaluations on dressing and grooming for care staff. Service plan inclusion of preference for shoe use.

3. Daily, weekly, and monthly.

4. Administrator and RN.  

Based on interview and record review, it was determined the facility failed to ensure falls and injuries of unknown cause were promptly investigated to rule out abuse and reported to the local SPD as suspected abuse for 4 of 4 sampled residents (#s 1, 2, 6, and 11) whose incidents were reviewed. Findings include, but are not limited to:

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

The resident's service plan, dated 07/01/21, and interviews with care staff between 10/11/21 and 10/13/21 indicated the resident was dependent for most ADL care and could ambulate on his/her own. The resident was unable to direct his/her own care and had a history of falls.

Review of incident investigations and progress notes from 06/04/21 through 10/14/21 showed the following:

* A progress note dated 07/15/21 indicated the resident had a bruise to the right arm. There was no additional information about the injury.  

* A progress note dated 08/11/21 indicated the resident had a right forearm bruise and a left forearm bruise. There was no additional information about the injury.

Investigations of the 07/15/21 and 8/11/21 injuries of unknown cause were not completed to rule out potential abuse and were not reported to the local SPD office.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21 and 10/13/21. The staff acknowledged the findings.

The facility was asked to report both injuries of unknown cause to the local SPD office. Confirmation of the reports was provided prior to survey exit.

2. Resident 6 was admitted to the facility in January 2018 with diagnoses including dementia.  

The resident's service plan, dated 07/23/21, and interviews with care staff between 10/11/21 and 10/13/21 indicated the resident was dependent for most ADL care. The resident could ambulate with stand by assistance. The resident was unable to direct his/her own care and had a history of pounding on tables and chairs.

Review of incident investigations and progress notes from 07/01/21 through 10/14/21 showed the following:

* A progress note dated 07/01/21 indicated the resident had a skin tear to the right elbow. There was no additional information about the injury.  

* A progress note dated 08/25/21 indicated the resident had an abrasion to the right forearm and bruises to the left forearm and wrist. There was no additional information about the injury.

Investigations of the 07/01/21 and 08/25/21 injuries of unknown cause were not completed to rule out potential abuse and were not reported to the local SPD office as suspected abuse.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/13/21. The staff acknowledged the findings.

The facility was asked to report all the injuries of unknown cause to the local SPD office. Confirmation of the reports was provided prior to survey exit.

3. Resident 1 was admitted to the facility in 08/2021 with diagnoses including dementia and Parkinson's disease.

A review of resident's progress notes, facility investigations, and skin logs indicated the following:

* On 08/30/21 staff documented "On 08/20/21, caregivers found [residents name] outside sitting under the tree. Care partners asked [him/her] if [s/he] was ok and [s/he] said, yes I just wanted to sit down." A small skin tear was found on the resident's right arm. There was no further information about the incident or injury; and

* On 09/20/21 Staff 2 (RN) documented on a skin monitoring sheet "new/reopened from a fall" skin tear to resident's left arm. There was no additional information about the injury.

Investigations of the 08/21/21 and 09/20/21 injuries of unknown cause were not completed to rule out potential abuse and were not reported to the local SPD office.  

The survey team requested the facility report both injuries of unknown cause to the local SPD office. Confirmation of the reports was provided prior to survey exit.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/13/21 and 10/14/21. They acknowledged the findings.

4. Resident 11 was admitted to the facility in 02/2020 with diagnoses including dementia.

A review of the resident's progress notes, facility investigations, and skin logs indicated the resident had experienced multiple falls with injuries or had injuries of unknown cause, including the following:

* A progress note dated 07/17/21 indicated the resident was found on the floor with a cut to the top of his/her head. The resident was sent to the Emergency Department (ED) and diagnosed with a concussion;

* An additional progress note dated 07/17/21 stated: "[Resident] fell again and cut [his/her] chin.";

* On 08/12/21, Staff 2 (RN) documented on a skin monitoring sheet "Res fell onto butt lg [large] purple bruise." Additional skin monitoring sheets, dated 08/23/21 and 08/31/21, identified bruising to the resident's left hand and bruising to both the right and left hips "from falls";

* A progress note dated 08/31/21 indicated the resident had two falls on 08/09/21. The first fall resulted in a "superficial scrape to the top of [his/her] head," and the second fall caused a "shallow abrasion to the back of [his/her] head"; and

* A progress note dated 09/02/21 stated the resident was found on the floor next to his/her bed with "a decent size gash between [his/her] eyebrows." The resident was sent to the ED and received stitches.

There was no additional information about any of the falls or injuries in the resident record. There was no evidence the facility had conducted immediate investigations to rule out abuse or suspected abuse or reported the incidents to the local SPD.

The facility was asked to report all injuries of unknown cause to the local SPD. Confirmation of the reports was provided on 10/14/21, prior to survey exit.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/14/21. They acknowledged the findings.

1. The RN will do assessments and follow up of resident 1, 2, 6, and 11 for skin or fall concerns. The previous incident reports will be reviewed by the administrative team for training purposes. All staff will complete Oregon Care Partners Abuse and Neglect training. Consultant training for management team on abuse and neglect reporting and investigation.

2. The RN will assess all residents to ensure skin concerns are identified. A review of incident reports for the prior 60 days will be done. A new incident reporting, investigation, and intervention process will be developed and staff trained. All staff will complete Oregon Care Partners Abuse and Neglect during pre-service orientation.

3. Multiple times a week during stand up and clinical meetings. Monthly during the quality assurance meeting.

4. RN, Assistant Administrator, and Administrator.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The kitchen's basement pantry was observed in an unsanitary condition, which posed an immediate jeopardy situation that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

Observation of the kitchen on 10/11/21 at 1:20 pm revealed the following were in need of cleaning and/or repair:

* Multiple sections of laminate flooring were chipped and separating with pieces of flooring missing;

* Spills, splatters, and chips were noted on walls throughout the kitchen and breezeway and splatters were on the ceiling of the small dry storage area in the main kitchen;

* Debris and spills were noted inside multiple drawers and cupboards throughout the kitchen;

* A tall storage cupboard containing clean dishes had rusted shelves with spills and food debris. The cupboard doors were broken and would not close;

* Black and orange accumulation was noted along edges of baseboards around the kitchen and a section of baseboard was missing;

* Debris and dark accumulation was noted in floor drains;

* A three foot section of plastic baseboard in the center of the wall nearest the refrigerator was pulling away from the wall and had thick orange accumulation along the edges;

* Debris was noted under the shelves in the small upstairs dry storage and next to the refrigerator/freezer units in the kitchen;

* Rubber coating was peeling from the shelves in the silver refrigerator unit in the kitchen;

* The two oven units had broken doors and slider bolt locks had been installed to secure the doors when cooking; and

* The stove front was noted to have multiple missing panels. The wires for the unit were exposed and had thick dust and grease accumulated on the exposed surfaces.

Observations of the kitchen's basement pantry on 10/11/21 at 1:40 pm showed the following were in need of cleaning and/or repair:

* Multiple piles of rodent droppings were observed under shelving units and behind the refrigerator/freezer units;

* The top of the water heater next to the refrigerator/freezer units was covered in rodent droppings. There was a large plastic clip trap on top of the water heater unit as well;

* Rodent droppings and other debris was noted under shelving units in the back portion of the pantry area;

* Multiple large rodent traps previously observed under shelving units were later seen stacked on a food shelf next to a bin of scalloped potatoes. The facility was asked to dispose of the scalloped potatoes and immediately disinfect the shelf and bin that came in contact with the traps;

* Two irregularly shaped piles of a dark substance were noted under a shelving unit near the back of the storage area and in front of a refrigerator unit;

* Spills and debris were noted inside multiple refrigerator/freezer units located in the storage area;

* A walker with a torn seat and exposed foam was located near the water heater and freezer unit;

* Cobwebs and debris were observed hanging from the exposed ceiling pipes in the back portion of the storage area, nearest the water heater and refrigerator/freezer units;

* One shelving unit located near the entrance to the pantry area had untreated wood/particle board shelves. Spills were noted on the shelves;

* An open bag of cat food was stored outside the entry to the dry storage/pantry area. Additional animal food items were stored with lids in place, but spilled food surrounded the containers;

* The concrete floor in the pantry storage area was chipped, dinged, missing paint, and had chunks of floor concrete missing in multiple sections throughout the storage area;

At approximately 1:50 pm on 10/11/21, the observations were discussed with Staff 1 (Administrator/RN) and Staff 4 (Kitchen Supervisor). The staff were directed to get the rodent droppings cleaned up and the pest company contacted and wait for additional instruction.

At approximately 2:10 pm  on 10/11/21, observations were discussed with the other members of the survey team. At that time the Team Coordinator of the survey toured the kitchen and confirmed the findings. Facility staff had begun clean-up of the observed droppings, but had stacked multiple large, wooden rodent traps on a food shelf next to a bin of scalloped potatoes.

At approximately 2:55 pm on 10/11/21, the survey team contacted the Community Based Care Supervisor and shared concerns about the unsanitary condition of the basement pantry. A decision was made to close the kitchen until the unsanitary condition was rectified.

In an interview on 10/11/21 at 3:26 pm with Staff 1 (Administrator/RN) and two surveyors, Staff 1 was informed the kitchen would be shut down and was instructed to submit an immediate plan of correction to address the unsanitary conditions.

The facility submitted a plan of correction on 10/11/21 at 5:20 pm, which was approved by the survey team.

On 10/12/21 at 9:00 am a re-inspection of the kitchen and basement pantry was completed. At 9:20 am interviews were conducted with the facility's pest control company. Observations and interviews were reviewed with the survey team. The surveyor observed the kitchen and basement pantry area and found the unsanitary conditions had been corrected. On 10/12/21 at approximately 10:15 am the facility was informed they could re-open the kitchen and the immediate jeopardy situation was abated.

1. A bid is in process for the kitchen and dining room flooring. The kitchen has been cleaned and is scheduled for painting. Kitchen drawers and cupboards have been cleaned. The tall cupboard and shelves will be repaired. The baseboard in the kitchen will be repaired or replaced when the flooring is replaced. Baseboards have been cleaned. The kitchen floor drains will be cleaned. Shells in the small upstairs dry storage and kitchen refrigerator/freezer unit in kitchen were cleaned. New shelves for the silver refrigerator unit will be ordered. The stove will be replaced. No rodent droppings have been observed under shelving units or refrigerator/freezer units, or on top of the water heater. All rodent traps have been removed. Areas under shelving units were cleaned. All refrigerators and freezers have been cleaned. The walker was removed from the water heater area and was thrown away. Cobwebs and debris have been removed from ceiling pipes. Untreated wood/particle board shelves will be replaced. All cat food is stored in closed containers. The concrete floor will be repaired and repainted.

2. A kitchen cleaning schedule and checklist will be developed and implemented. A kitchen audit checklist will be developed and implemented. Staff will be trained on kitchen cleaning, food storage, and management.

3. Weekly for the first two months then monthly.

4. Kitchen Manager and Administrator.   

Based on observation, interview, and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:

The memory care community activity calendar listed the following:

a. 10/11/21:

* 11:00 am - Table Games

* 3:00 pm - Chair Exercise

* 4:00 pm - Music Hour

b. 10/12/21:

* 10:00 am - Giant Community Word Search

* 11:00 am - Giant Community Word Search

* 3:00 pm - Breast Cancer Awareness Coloring Pages

* 4:00 pm - Sensory Sensations

c. 10/13/21:

* 11:00 am - Giant Community Crossword Puzzle

* 3:00 pm - Game Day

* 4:00 pm - Spa Day

There were no scheduled or unscheduled activities observed on 10/11/21, 10/12/21, or 10/13/21. On those days residents were observed in their rooms, wandering around the unit, or sitting and sleeping in the common areas.

In an interview on 10/13/21, Staff 1 (Administrator/RN) indicated the activity director was on vacation, which was why no activities were occurring. The surveyor discussed the need for activities to be offered every day.  

The lack of an activity program was discussed with Staff 1 (Administrator/RN) on 10/13/21.  She acknowledged the findings.

On 10/14/21, the last day of the survey, residents of the memory care community were observed participating in activities in the common area.

1. Activities will be assigned to staff when the activity coordinator is not onsite. Staff will be trained in how to follow the activity calendar.

2. A staff activity schedule will be developed and staff assigned as a part of the shift assignment. Staff will be trained in how to lead activities.

3. Weekly and monthly.

4. Activity Coordinator and Administrator.  

Based on observation, interview, and record review, it was determined the facility failed to provide assistance with activities of daily living for 2 of 6 sampled residents (#s 2 and 6) who required ADL care. Findings include, but are not limited to:

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

The service plan, dated 07/01/21, indicated the following:

* Take the resident to the bathroom before and after meals, provide assistance changing wet undergarments; and

* "Needs foods cut up," check the resident often and cue/prompt to finish eating, encourage between meal snacks and fluids.

Observations of the resident and interviews with staff from 10/11/21 through 10/14/21 showed the resident was dependent on staff for most ADL care, including meal assistance, and required staff assistance for toileting, dressing, hygiene, and grooming needs. The resident was incontinent and noted as a "heavy wetter."

On 10/12/21 at 7:15 am the resident was observed sitting on the side of his/her bed in visibly wet pajamas. The pad on the resident's bed was soaked and yellow in color. A caregiver was found and directed to the resident's room to provide assistance.

On 10/13/21 at 7:10 am the resident was observed in visibly wet pajamas while seated in the common area. The resident was observed to stand up and sit down twice at which point a small section of standing liquid was visible on the seat of the chair. A caregiver was found and directed to the resident to provide care. The resident was removed from the common area and changed. The chair was disinfected.

Multiple continuous observations of the resident between 10/11/21 and 10/13/21, including two breakfast meals, three lunch meals, and two dinner meals, showed:

* The resident was not assisted to the restroom before and after meals for extended periods of up to two hours;

* The resident's meals were inconsistently cut up and snacks and fluids were not consistently provided throughout the day/evening between meals;

* The resident was observed attempting to repeatedly drink from a flower jug on the table with no intervention by staff;

* The resident was observed to repeatedly push a slice of bread all around the surface of the table, take a bite and then begin to rub the bread around the surface of the table again before taking another bite, with no intervention by staff;

* Staff did not cue or prompt the resident during meals to continue eating and take more bites; and

* The resident was observed to stand up/sit down/stand up repeatedly, in excess of 12 times in a 20 minute period, with no intervention by staff.

The need to ensure residents were provided sufficient assistance with ADL needs, including meal assistance, was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN). They acknowledged the findings.

2. Resident 6 was admitted to the facility in January 2018 with diagnoses including dementia.

The service plan, dated 07/23/21, indicated the following:

* Take the resident to the bathroom before and after meals, provide assistance changing wet undergarments; and

* Resident needs full assist with all ADLs, "may need to be fed meals," check the resident often, cue/prompt to finish eating, and provide snacks and fluids throughout and between meals.

Observations of the resident and interviews with staff from 10/11/21 through 10/14/21 showed the resident was dependent on staff for most ADL care, including meal assistance, and required staff assistance for toileting, dressing, hygiene, and grooming needs. The resident required two staff assistance with a gait belt for transfers. The resident was incontinent and could not direct his/her own care.  

Multiple continuous observations of the resident between 10/11/21 and 10/13/21, including two breakfast meals, three lunch meals, and two dinner meals, showed:

* The resident was not assisted to the restroom before and after meals for extended periods of up to two hours;

* The resident was not provided snacks and fluids consistently throughout the day/evening between meals;

* Staff did not check on the resident, cue or prompt the resident during meals to continue eating and take more bites; and

* The resident was observed to repeatedly pound on his/her leg, pound on the wooden arm of the chair, and pound on the table top, both in a gentle manner and a strong, heavy pounding. There was no staff intervention with the resident during the instances of pounding on tables and furniture to determine if there was assistance needed.

The need to ensure residents were provided sufficient assistance with ADL needs, including meal assistance, was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN). They acknowledged the findings.

1. Service plans for Resident 2 and 6 were reviewed by all staff. Service plan training for staff will be scheduled. Care staff will be retrained in providing incontinent care, anticipated and providing for resident toileting needs, meal assistance and cueing, providing snacks, and responding to behaviors.

2. Staff will read/review resident service plans during initial orientation and 30-day training. Staff will be observed providing services to ensure service plan consistency. Training will be provided in orientation on incontinent care, meal assistance, and responding to behaviors. A care staff inservice training will be provided by consultant on incontinent care, meal assistance, and responding to behaviors. The Dining with Friends Program will be re-implemented. Training records will be reviewed for completion of orientation and 30-day training. The RCC will observe observe care competencies for all care staff. New or updated service plans will be placed in the TSP for staff review.

3. Weekly for two months then monthly.

4. RCC and Administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, were reflective of residents' needs, provided clear direction to staff, were updated with resident changes, and/or were followed by staff for 5 of 6 sampled residents (#s 1, 2, 3, 6, and 11). Findings include, but are not limited to:

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

Observations of the resident and interviews with staff from 10/11/21 to 10/14/21 and review of the service plan, dated 07/01/21, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Transfer assistance, toileting schedule, and incontinence care;

* Walker use;

* Activities;

* Meal assistance, health shakes, and diet texture;

* Falls and safety interventions; and

* Pain.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21. They acknowledged the findings.

2. Resident 6 was admitted to the facility in January 2018 with diagnoses including dementia.

Observations of the resident and interviews with staff from 10/11/21 to 10/14/21 and review of the service plan, dated 07/23/21, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Transfer assistance, mobility assistance, toileting, and walker use;

* Meal assistance, diet texture, fluids, and straw use;

* Edema, elevating legs, and eye glasses;

* Range of motion exercises, hand contracture, and hand roll use; and

* Activities.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 09/2021 with diagnoses including dementia.

The resident's clinical record was reviewed and caregiving staff were interviewed. Staff reported there was a temporary service plan in the binder, but they had not seen an initial service plan.

A copy of the resident's initial service plan was requested from Staff 1 (Administrator/RN) and Staff 2 (RN) multiple times throughout the survey and was not provided. There was no documented evidence an initial service plan had been written for the resident.

The need to create an initial service plan and have it available to direct care staff was discussed with Staff 1 on 10/14/21. She acknowledged the findings and printed an initial service plan for the resident, stating she did not understand why it had not been placed in the service plan binder available to staff.

4. Resident 1 was admitted to the facility in 08/2021 with diagnoses including dementia and Parkinson's disease.

Observations of the resident and interviews with staff from 10/11/21 to 10/14/21, review of the service plan, dated 10/05/21, and temporary service plans indicated the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Catheter care and instructions;

* Weekly weights;

* Hearing aids;

* Behaviors and interventions;

* Environmental factors that impacted the residents behavior;

* How the resident expressed pain;

* Instruction to staff on how frequently to check on the resident who was unable to use the call light to ask for assistance;

* Fall risk and interventions; and

* Cognition, memory and level of confusion.

On 10/11/21 at approximately 1:10 pm, Resident 1's service plan was not in the facility service plan binders, and could not be located; therefore, the resident's service plan was not readily available to staff. At 1:18 pm Staff 3 (Administrative Coordinator) printed a copy of the service plan for surveyor to review.

The need to ensure resident service plans were accurate, updated with changes, and were available to and provided clear direction to staff on the delivery of services was reviewed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21 and 10/14/21. They acknowledged the findings. No further information was provided.

5. Resident 11 was admitted to the facility in 02/2020 with diagnoses including dementia.

Observations of the resident and interviews with staff from 10/11/21 to 10/14/21, review of the service plan, dated 05/12/21 (with hand written updates on 08/12/21 and 09/02/21), and temporary service plans indicated the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Fall interventions;

* Protective head gear;

* Hospice;

* Shower assistance;

* Toileting assistance; and

* Instruction to staff on how frequently to check on the resident, who was unable to use the call light to ask for assistance.

The need to ensure resident service plans were accurate, updated with changes, and provided clear direction to staff on the delivery of services was reviewed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21 and 10/14/21. They acknowledged the findings.

1. The service plans for Resident 1, 2, 3, 6, and 11 have been developed/updated. Service plans for all residents are available for staff in the service plan binders. A service update schedule is in place.

2. Review the service plan template and compare with regulations. Update the service plan as determined from review. All new service plans will be placed initially in the TSP book for staff review.

3. Weekly.

4. Assistant Administrator and Administrator.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who provided services, for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6, and 11) whose service plans were reviewed. Findings include, but are not limited to:

The current service plans for Residents 1, 2, 3, 4, 5, 6, and 11 lacked documented evidence they had been developed by a service planning team.

On 10/14/21 the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator/RN). She acknowledged the findings.

1. Documentation was added to the resident file of who was involved in the service plan review and development or update of the sevice plan for Resident 1, 2, 3, 4, 5, 6, and 11.

2. Documentation of who participates in the service planning team will be put in the resident progress notes.

3. With each new service plan and monthly.

4. Assistant Administrator and Administrator.

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

Observations of the resident, interviews with staff , review of the resident's 07/01/21 service plan, 06/01/21 through 10/11/21 progress notes, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Skin tears and bruises to multiple body parts;

* Falls, pelvic fracture, and pain;

* Agitation and combative behaviors; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21. The staff acknowledged the findings.

5. Resident 6 was admitted to the facility in January 2018 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 07/23/21 service plan, 07/01/21 through 10/04/21 progress notes, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Weekly weights, weight gain, and edema;

* Abrasions, skin tears, and bruises to multiple body parts;

* Diabetic ulcers to lower extremities and feet;

* Behaviors; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21. The staff acknowledged the findings.

6. Resident 4 was admitted to the MCC in 07/2019 with diagnoses including dementia with agitation, chronic obstructive pulmonary disease (COPD), and Diabetes.

Review of Resident 4's records for the last 90 days (07/11/21 to 10/11/21) indicated  the following:

* Progress notes described an episode on 07/27/21 where the resident was "very confused" and refused his/her medication. The note stated the RN was notified, but no further monitoring was documented;

* Records indicated on 08/26/21 the resident experienced an episode of "shortness of breath."  S/he was administered PRN inhalers and the physician was notified. However, no instructions were provided to staff regarding signs/symptoms to observe, and no further monitoring was carried out; and

* Progress notes showed the resident had a witnessed fall with injury on 08/29/21.  The entry stated the resident was "crying when [s/he] had to move or stand, and [his/her] right foot was painful and swollen." The resident was administered PRN oxycodone (for pain), but no fall interventions were developed and no further monitoring was documented.

On 10/14/21 the need to evaluate short-term changes of condition, implement interventions, provide instructions to staff, and monitor the conditions to resolution was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN). They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, monitored, and/or referred to the RN for an assessment for 6 of 8 sampled residents (#s 1, 7, 8, 9, 10, and 11), failed to monitor and document weekly progress of a short-term change of condition until the condition resolved, or monitor the effectiveness of interventions developed for 4 of 7 sampled residents (#s 1, 2, 4, 6, and 11). Resident 11 experienced multiple falls with injuries. Residents 1, 7, 8, 9 and 10 experienced weight loss. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 02/2020 with diagnoses including dementia and heart failure.

Resident's progress notes, dated 07/07/21 through 10/11/21, service plan, dated 05/12/21, with hand-written updates on 08/12/21 and 09/02/21, additional temporary service plans, skin logs, incident reports, and weight records were reviewed and identified the following:  

a. Between 07/07/21 and 10/11/21 the resident experienced the following falls and injuries:

* On 07/07/21 staff documented in progress notes the resident fell at 10:45 pm "trying to leave [his/her] room" after being put to bed. There were "no apparent injuries." There was no further documentation about the incident in the resident's record.

* On 07/08/21 staff documented the resident was found on the floor at 2:50 am with "no pants or underwear on" and had "no apparent injuries." There was no further documentation about the incident in the resident's record.

* On 07/17/21 resident was found on floor with a cut to the top of his/her head. S/he was sent to the Emergency Department (ED) and diagnosed with a urinary tract infection (UTI) and concussion. The resident was sent back to the facility on antibiotics. The resident had a second fall the same day and sustained a "cut to [his/her] chin." A temporary service plan (TSP), dated 07/17/21, for "New Medication" instructed staff to monitor for adverse reactions to the antibiotic, but provided no instruction to staff on monitoring for signs and symptoms of a concussion.

* In an 08/31/21 progress note, staff documented the resident had two falls on 08/09/21 which resulted in a "superficial scrape to the top of [his/her] head" and "shallow abrasion to the back of [his/her] head." TSP's were initiated on 08/09/21 instructing staff to monitor the injuries and chart each shift; however, there were no further documentation or monitoring instructions in the resident record.

* On 09/02/21 at 12:50 am the resident was found on the floor next to his/her bed with "a decent size gash between [his/her] eyebrows." The resident was sent to the ED and received stitches. On 10/01/21 Staff 2 (RN) documented "sutures out on 9/10/21 and wounds are healing..." No further information about the incident was documented.

* On 09/15/21, Staff 2 documented in a progress note "... bruises to bottom and right and left hips from various falls. Now all healed." Skin monitoring sheets for these injuries were dated as initiated on 08/10/21, however there was no other documentation in the resident's record of when the falls occurred or when the injuries were sustained.

* On 09/25/21, staff wrote in a progress note "Resident seems ok with wearing new head protection." There was no other documentation about the "head protection." On 10/14/21 the resident was observed wearing a brown padded cloth ring velcroed around his/her head. The resident had not been wearing the device during observations on 10/11/21, 10/12/21 or 10/13/21.  

* On 10/06/21 Staff 2 documented "Wounds and bruises all healed from a fall around 9/13 to include left foot, right middle toe, head, right and left hands, and right elbow. Alert charting closed." No further information about the incident was documented and there was no evidence the injuries had been monitored prior to this date.

* On 10/12/21 at 3:00 pm, during observations on the "Country" hallway of the memory care, the surveyor heard a loud thud in Resident 11's room. Two staff who were assisting another resident in the room next door heard the noise and went into Resident 11's room. The resident was observed on the floor next to his/her bed. Staff assisted the resident into his/her wheelchair. The resident had a cut on the right side of his/her face, just above the ear, that was bleeding.

The following fall interventions were documented in the resident's 05/12/21 service plan:

* 05/12/21 "has bed alarm to alert staff when [s/he] stands up";

* 08/12/21 "staff to answer alarm asap"; and

* 090/2/21 "frequent checks when out of bed," "make sure bed is in low position."

There was no documented evidence the facility had evaluated the falls in relation to the resident's condition, reviewed or monitored fall interventions for effectiveness, or consistently developed new fall interventions for any of the falls that occurred between 07/07/21 and 10/11/21.

The failure of the facility to evaluate the resident, review previous fall interventions for effectiveness, or develop new interventions to potentially prevent future falls or injuries placed the resident at risk for continued falls and/or injuries.  

b. On 07/17/21 the resident was diagnosed with a UTI and placed on antibiotics. A TSP dated the same date instructed staff to document each shift and monitor for any signs or symptoms of adverse reactions or complaints by the resident. The TSP was updated on 07/21/21, stating the resident had started on a new antibiotic; no further information was provided.

There was no documented evidence the facility monitored for the effectiveness of the antibiotics, staff were provided instructions to monitor for signs or symptoms related to a UTI, or the condition had been monitored to resolution.

c. A TSP dated 08/20/21 indicated the resident had "ingested lotion, peri wash and deodorant." Monitoring instructions included to watch for loose stool and vomiting, report to the medication aide. Staff were instructed to document each shift.

On 08/24/21, four days after the incident, Staff 2 wrote an "RN assessment," which instructed staff to:

* Monitor for airway clearance. Encourage fluids to flush system;

* Monitor for stomach issues such as nausea/vomiting;

* Monitor for diarrhea; and

* Keep peri-wash out of reach, remove deodorant and hand lotion from room.

There was no documented evidence the staff had monitored the resident's condition or charted on each shift as instructed on the 08/21/21 TSP or the 08/24/21 RN assessment.

d. On 09/22/21 staff documented the right side of the resident's face was "hot and swollen." "Hospice notified." On 09/26/21 antibiotics were prescribed for a "dental implant infection," and on 09/28/21 staff noted "no adverse effects to [his/her] antibiotic." On 10/01/21 staff wrote the resident had finished his/her antibiotics with no adverse effects "alert charting closed."

There was no evidence the facility had monitored the facial swelling or the infection to resolution.  

The need to ensure all short-term changes of condition were monitored, or monitored to resolution, was discussed with Staff 1 (Administrator/RN) on 10/14/21. She acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in 08/2021 with diagnoses including dementia, Parkinson's disease, and had a history of "unplanned" weight loss. The resident was also on Coumadin (blood thinner).

Observations of the resident, interviews with staff, and review of the resident's progress notes, dated 08/21/21 through 10/11/21, service plan dated 10/5/21, temporary service plans (TSP), skin logs, incident reports, and weight records were reviewed and identified the following deficiencies:

a. The resident's initial service plan, dated 08/19/21, instructed staff to record weekly weights for the first 30 days. There was no evidence the facility had taken or recorded weekly weights between 08/19/21 and 09/19/21.

* Between 09/01/21 and 09/30/21 staff documented the resident ate 50% or less of his/her meal 29 times. Fourteen out of the 29 meals staff recorded the resident ate nothing or only "bites." Between 10/05/21 and 10/11/21 staff documented the resident ate 50% or less of a meal 11 times. All meal logs were filed in the administrative support office once completed. There was no evidence the facility reviewed the logs prior to filing.

* On 10/12/21 at 3:00 pm Resident 1 was observed trying to feed himself/herself an afternoon snack, but was unable to do so independently and spilled the snack on his/her lap and floor. On 10/13/21 at 9:10 am staff were observed feeding the resident his/her breakfast in the resident's room.

* In interviews on 10/11/21 and 10/12/21, Staff 13 (CG) stated the resident needed assistance with dressing, eating, and transfers and that "other" staff emptied the resident's urostomy bag during the day. Staff 13 stated prior to a recent hospital stay (09/22/21 through 10/04/21) the resident had been ambulating independently and had been able to feed himself/herself without assistance.

* The resident's recorded weights for 08/20/21 and 09/20/21 were 125 lbs. On 10/12/21 the surveyor requested and received the resident's current weight of 115 lbs. The resident had a severe weight loss of 10 lbs., or 8% of his/her total body weight, within a 30 day period.

During an interview on 10/14/21, Staff 2 stated she reviewed resident weights monthly and "thought" staff had recorded weekly weights on Resident 1 when s/he had moved in, but was unable to locate the documentation. Staff 2 also acknowledged the resident's weight had not been taken when s/he returned from a 12-day hospital stay on 10/04/21. She confirmed she had not been aware of the resident's current weight loss.

The failure of the facility to monitor the resident's weights or thoroughly evaluate the resident upon return to the facility put the resident at risk for continued weight loss.

b. On 08/30/21 staff documented on an incident that occurred on 08/20/21, stating "...caregivers fond [sic] [residents name] outside sitting under the tree." The resident had a "small" skin tear to his/her right arm. Staff also documented the resident had started "exit seeking" during this time. There was no evidence staff had monitored the resident's exit-seeking behaviors between 08/20/21 and 08/30/21. There was no further information provided about the incident.

c. On 09/21/21 staff wrote " ...seems to be getting more quiet and sleeping more." On

09/22/21 a physician notified the facility of a "critical lab" indicating the resident was "bleeding somewhere." The resident was sent to the ED, diagnosed with a gastrointestinal bleed (GI), and returned to the facility on 10/05/21.

Staff 2 evaluated the resident on 10/05/21 and documented the resident was "unable to feed [him/herself]" or to ambulate independently. The evaluation included monitoring instructions for signs of pain, signs of a GI bleed, shortness of breath, tiredness, dizziness, or abdominal pain. Staff were instructed to assist the resident with ambulation, transfers, and meals.  

There was no documented evidence the facility had been monitoring the resident for any of the above conditions as of 10/11/21.

The need to ensure all short-term changes of condition were monitored, or monitored to resolution, and residents were monitored as instructed according to their condition was discussed with Staff 1 (Administrator/RN) on 10/14/21. She acknowledged the findings. No further information was provided.

3. On 10/12/21, the surveyor requested a copy of six months of weight records for all residents in the memory care unit. On 10/14/21 Residents 7, 8, 9, and 10 were identified with weight loss. A review of weight records revealed the following:

a. Resident 7 experienced a severe weight loss between 08/20/21 (220 lbs.) and 09/20/21 (204 lbs.) of 16 lbs., or 7.27 % of his/her total body weight. Resident 7 experienced an additional weight loss of 18 lbs, or 8.82% of his/her total body weight between 09/20/21 and 10/14/21.

b. Resident 8 experienced a significant weight loss between 08/20/21 (193 lbs) and 09/20/21 (182 lbs.) of 15 lbs., or 12.9 % of his/her total body weight.

c. Resident 9 experienced a significant weight loss between 07/20/21 (116 lbs.) and 09/20/21 (101 lbs.) of 11 lbs., or 5.7 % of his/her total body weight. Resident 9's weight on 10/14/21 was 122 lbs, a 20.79 % increase in a 30 day period.

d. Resident 10 experienced a significant weight loss between 07/2021 (173 lbs.) and 08/2021 (161 lbs.) of 12 lbs., or 6.94 % of his/her total body weight in a 30 day period. Progress notes indicated the resident had been put on a "weight loss protocol," which included monitoring the resident's weights weekly. Though facility staff had been documenting weekly weights, there was no evidence the weights had been reviewed or monitored.  

There was no documented evidence in the resident's records the weight loss had been evaluated and/or actions or interventions had been determined to address the weight loss, or that the facility was monitoring residents for subsequent weight loss.

During an interview on 10/14/21, Staff 2 (RN) stated she only reviewed weights monthly and confirmed evaluations had not been completed for all the residents noted above, and/or could not provide documented evidence the interventions that had been put in place were monitored for effectiveness.   

The facility's failure to evaluate residents' weight loss, and/or have an effective monitoring system in place to review residents' weights, or monitor interventions implemented for the weight loss put residents at risk for continued weight loss.

The need to ensure the facility had an effective monitoring system in place to review residents' weights, ensure residents identified with weight loss were evaluated and actions or interventions were developed and communicated to staff to address the weight loss was discussed with Staff 1 (Administrator/RN) and Staff 2 on 10/14/21. They acknowledged the findings. No additional information was provided.

1. RN assessments will be done on Resident 1, 2, 4, 6, 7, 8, 9, 10, and 11 based on the findings from the survey. A fall assessment will be completed for Resident 11, the previous interventions reviewed and updated, and the resident will be monitored. All staff will complete Oregon Care Partners Falls and Fall Prevention training. A 24-hour book is being used with TSPs. Training was provided 11/4/21 by consultant on change of condition and significant change of condition. Consultant provided the 2019 Change of Condition guidelines for review. Staff will be trained and observed documenting on meal logs. Meal logs will be reviewed weekly by the RN. Weekly weights will be reviewed by the RN and assessments completed weekly. Residents with skin/wound concerns will be assessed at the onset of the change of condition and at least weekly after. Med techs and care staff will be trained on change of condition, reading and following TSP interventions, and alert charting. A skin and weight audit will be done for all residents.

2. Staff training on short term and significant change of condition, and alert charting. RCC and RN will review TSPs and alert charting multiple times per week. A white board with active monitoring information e.g., weights, skin/wounds, significant changes, outside services will be put in place. TSPs will be monitored for staff signature. Med tech training every two weeks for the next two months then monthly. Daily shift meetings to review TSPs. Shift to shift communication documentation reviewed in clinical meeting. Consultant will train on short term and signficant change of condition with the health services team. Care staff will be trained during orientation on change of condition and monitoring.

3. Multiple times per week and monthly during the quality assurance meeting.

4. RN and Administrator.  

5. Resident 5 was admitted to the facility in 04/2019 with diagnoses including schizophrenia, autism, and diabetes.

The resident's 09/01/21 through 10/11/21 MARs, service plan dated 7/16/21, progress notes dated 07/15/21 through 10/11/21, and weight records from 04/13/21 through 09/09/21 were reviewed and Staff 2 (RN) was interviewed.

Weight records revealed the resident lost 12 lbs. between 07/14/21 and 08/17/21, or 5.58% of his/her total body weight in one month, which represented a significant change of condition.

In an interview with Staff 2, she stated she was "sure" an assessment had been completed. She provided a "Decline in Appetite" temporary service plan (TSP) initiated 08/18/21 for "weight loss trend - lost 9#/1 mo = 250#." The TSP was updated 09/16/21: "continued trend - lost 13#/3 mos - 204#." One individualized intervention was noted: "Give sugar free snacks before lunch and dinner."

There was no documented evidence the RN had completed a significant change of condition assessment.

The failure to complete an assessment for the resident's significant change of condition was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21. They acknowledged the findings.

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

Progress notes and physician communications dated 06/02/21 through 10/12/21, the 07/01/21 service plan, and interviews with care staff on 10/11/21 through 10/14/21, indicated the resident required full assistance with most ADL care. The resident was able to walk independently with his/her walker and transfer self from some surfaces. The resident could feed himself/herself, but staff were to ensure foods were cut up and prompt/cue the resident frequently during meals to ensure good intake.

Additionally, the resident experienced a fall on 09/12/21 and sustained a pelvic fracture with increased pain. The resident was no longer walking at the time of the injury due to the fracture and pain. The resident was encouraged to stay in bed to increase healing.

a. Review of the resident's weight records from 06/14/21 through 10/12/21 showed the following:

* The resident experienced an 11 lb. weight loss from 08/18/21 to 09/21/21, which constituted an 8.14% severe weight loss in one month.

* The resident experienced an 8 lb. weight gain from 09/21/21 to 10/6/21, which constituted a 6.45% severe weight gain in less than one month.

* Weekly weight tracking was incomplete. A current weight was requested on 10/12/21, which indicated the resident continued to be at 132 lbs, the same weight noted on 10/6/21.

An RN assessment dated 09/22/21 indicated the resident had lost 11 lbs in one month. Interventions within the assessment included:

* Dessert before lunch and dinner to encourage endorphin production;

* Encourage ice cream after lunch and dinner, encourage good nutrition, and offer alternates if the resident doesn't like what was served;

* Encourage high calorie snacks and protein drinks between meals;

* Staff to assist the resident in cleaning mouth/teeth; and

* Increase meal portions if resident eating over 80% of most meals.

A physician's order dated 09/21/21 indicated the resident was to receive Ensure health shakes three times a day. There was no documentation on the 9/01/21 through 10/12/21 MAR of the administration of the health shakes. The resident was not observed to receive the health shakes until 10/14/21.

Observations of the resident between 10/11/21 and 10/14/21 showed the resident ate primarily in the dining room. The resident did not independently seek out food or fluids during observations, but was able to feed herself/himself without assistance once items were provided. The resident's average intake was approximately 50% of the items provided.

Multiple continuous observations of the resident between 10/11/21 and 10/14/21, including two breakfast meals, three lunch meals, and two dinner meals, showed:

* The resident's meals were inconsistently cut up and snacks and fluids were not consistently provided throughout the day/evening between meals;

* The resident was observed attempting to repeatedly drink from a flower jug on the table with no intervention by staff;

* The resident was observed to repeatedly push a slice of bread all around the surface of the table, take a bite, and then begin to rub the bread around the surface of the table again before taking another bite, with no intervention by staff;

* The resident was not observed to receive ice cream after lunch and dinner, nor were alternates offered when the resident did not eat well;

* The resident was observed to fall asleep with his/her meal in front of him/her with no intervention by staff;

* Staff did not cue or prompt the resident during meals to continue eating and take more bites; and

* The resident was observed to stand up/sit down/stand up repeatedly while at the dinner meal, in excess of 12 times in a 20 minute period, with no intervention by staff.

The facility failed to ensure an RN assessment was completed timely for the potential weight loss and gain with documented findings, resident status, and resident-specific interventions made as a result of the assessment.

b. On 09/12/21 the resident experienced a fall and sustained a fracture. The resident went to the hospital on 09/13/21 and returned to the facility on 09/16/21. The resident did not have surgical repair of the pelvic fracture, weight bearing was allowed as tolerated, and bed rest encouraged for healing.

An RN assessment dated 09/22/21 indicated the resident began physical therapy services related to a pelvic fracture. Interventions within the assessment included:

* Be attentive when home health staff visit;

* Report recommendations to RN;

* Monitor for pain and, if noted, report to medication technician; and

* Assist with bed mobility and transfers to wheelchair/chair.

The facility failed to ensure an RN assessment was completed timely for the pelvic fracture which documented findings, resident status, and resident-specific interventions made as a result of the assessment.

The need to ensure an RN assessment was completed timely related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21 and 10/13/21. The staff acknowledged the findings.

4. Resident 6 was admitted to the facility in January 2018 with diagnoses including dementia.

Progress notes and physician communications dated 07/01/21 through 10/12/21, the 07/23/21 service plan, and interviews with care staff on 10/11/21 to 10/13/21 indicated the resident required full assistance with most ADL care. The resident could feed himself/herself after foods were delivered. The resident was on a puree diet and thin liquids. Staff were to check on the resident frequently and prompt/cue the resident during meals to ensure good intake. The resident additionally had a history of edema to the lower extremities and staff were to elevate the resident's legs whenever possible.

Review of the resident's weekly weight records from 06/14/21 through 10/12/21 showed the following:

* The resident experienced an 11 lb. weight gain from 06/14/21 to 07/16/21, which constituted a 6.54% severe weight gain in one month.

* The resident's current weight showed s/he had stabilized, with no additional gain.

Observations of the resident from 10/11/21 through 10/14/21 showed the resident's legs were slightly swollen. The resident was able to eat and drink on his/her own, with intake ranging from 50-100%. The resident was not assisted by staff with the meals observed. Staff did not interact with the resident during meals or provide cueing or reminders to continue with the meal. Alternate meal items, protein shakes, and snacks were inconsistently offered to the resident. The resident's legs were not seen in an elevated position during any observations during the survey.

The facility failed to ensure an RN assessment was completed timely for the weight gain with documented findings, resident status, and resident specific interventions made as a result of the assessment.

The need to ensure an RN assessment was completed timely related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21 and 10/13/21. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and/or updated the service plan for 9 of 9 sampled residents (#s 1, 2, 5, 6, 7, 8, 9, 10, and 11) who experienced a significant change of condition. Resident 11 experienced multiple falls with injuries. Residents 1, 7, 8, 9, and 10 experienced weight loss. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 02/2020 with diagnoses including dementia and heart failure.

A review of the resident's clinical records, including progress notes, dated 07/07/21 through 10/11/21, service plan, dated 05/12/21 with hand-written updates on 08/12/21 and 09/2/21, additional temporary service plans, skin logs, and incident reports were reviewed and identified the following:

Between 07/07/21 and 10/11/21, staff documented resident had fallen nine times. Seven of the documented falls resulted in injury. On 07/17/21 the resident was sent to the Emergency Department (ED) and diagnosed with a concussion. On 09/02/21 the resident was sent to the ED for treatment and stitches of a head wound.

There was no documented evidence the RN had assessed the status of the resident to determine if the resident had experienced a significant change of condition which contributed to the resident's fall risk, documented findings as a result of the assessment, or developed interventions related to the resident's repeated falls.

The failure of the facility to assess the resident's condition and develop interventions as a result of the assessment put resident at risk for continued falls with injuries.

Refer to C270, example 1

The need to ensure an RN assessment was completed to determine if the resident had experienced a significant change of condition, which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21 and 10/14/21. The staff acknowledged the findings. No further information was provided.

2. Residents 1, 7, 8, 9, and 10's weight records were reviewed on 10/12/21 and 10/14/21 and revealed the residents had experienced a significant change of condition related to weight loss.

* Resident 7 experienced a severe weight loss between 08/20/21 (220 lbs.) and 09/20/21 (204 lbs.) of 16 lbs., or 7.27 % of his/her total body weight. An additional weight loss of 18 lbs., or 8.82% of his/her total body weight, occurred between 09/20/21 and 10/14/21.

* Resident 8 experienced a significant weight loss between 08/20/21 (193 lbs.) and 09/20/21 (182 lbs.) of 15 lbs., or 12.9 % of his/her total body weight.

c. Resident 9 experienced a significant weight loss between 07/20/21 (116 lbs.) and 09/20/21 (101 lbs.) of 11 lbs., or 5.7 % of his/her total body weight.

d. Resident 10 experienced a significant weight loss between 07/2021 (173 lbs.) and 08/2021 (161 lbs.) of 12 lbs., or 6.94 % of his/her total body weight, in a 30 day period.

In an interview on 10/14/21, Staff 2 (RN) confirmed assessments had not been completed for the residents identified with weight loss.

The failure of the facility to assess residents with weight loss put the residents at risk for continued weight loss.

Refer to C270, example 3

The need to ensure an RN assessment was completed when a resident experienced a significant change in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator/RN) and Staff 2 on 10/13/21 and 10/14/21. They acknowledged the findings. No further information was provided.

1. RN significant changes of condition weight assessments are being done and interventions put in place for Resident 1, 2, 5, 6, 7, 8, 9,10, and 11.  TSPs are in place with monitoring instructions. Consultant training for RN, RCC, and Administrator on 11/4/2021 for signficant change of condition and monitoring. Consultant provided 2019 Change of Condition and Monitoring Guidelines. All staff will complete Oregon Care Partners Falls and Fall Prevention course. Med techs will be trained in notifying RN of significant change of condition.

2. Significant changes of condition will be reviewed in clinical meeting. The white board will be updated with information about the change and date of last assessment. Care staff will be trained during orientation on change of condition and monitoring.

3. Multiple times per week during clinical meeting.

4. RN and Administrator.  

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 2 of 2 sampled residents (#s 5 and 6) who were prescribed insulin injections. Findings include, but are not limited to:

Delegation records for Residents 5 and 6 revealed the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules, as follows:

a. Resident assessments lacked the following information:

* Rationale for why the task could be safely delegated to the CG; and

* Frequency the resident should be reassessed, including a rationale.

b. Initial and re-delegations for Staff 7, Staff 8, Staff 9, Staff 11, and Staff 12, all CG/MTs, lacked documentation in the following areas:

* Skills, abilities, and willingness of caregiver to perform the task;

* Evidence the caregiver was competent to safely perform the task; and

* Rationale for how often the caregiver should be re-evaluated.

c. There was a lack of documentation the RN took responsibility for delegating the task and ensuring supervision would occur for as long as the RN was supervising performance of the delegated task.

Delegation records and the need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/13/21. They acknowledged the findings.

1. The RN will complete RN delegation assessments for Resident 5 and 6, supervise each med tech who is currently delegated, and document evaluation and supervision. The RN will assess each resident who requires RN delegation and supervise each person currently delegated.

2. The consultant will provide RN delegation forms and training to the RN on RN delegation. A new RN delegation binder with resources will be put together.

3. Monthly.

4. RN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for medications for 2 of 6 sampled residents (#s 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 04/2019 with diagnoses including schizophrenia, autism, and diabetes.

In the acuity interview on 10/11/21, the resident was identified as self-administering his/her sliding scale and scheduled insulin. Review of the resident's 09/01/21 through 10/11/21 MARs revealed the following:

* Dosages inconsistent with the prescribed sliding scale for insulin were documented on three occasions; and

* There were blanks on the MAR, without explanation, for the resident's scheduled insulin on five occasions.

Interviews with staff revealed the resident self-administered his/her insulin, but staff "monitored" the resident to ensure the dose administered was correct.

The need for the MAR to be accurate was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/13/21. They acknowledged the findings.

2. Resident 4 was admitted to the MCC in 07/2019 with diagnoses including dementia with agitation.  Review of Resident 4's MAR, dated 9/1/21 to 10/11/21, indicated the following deficiencies:

* The MAR lacked parameters for PRN pain medications acetaminophen and oxycodone, regarding which to administer first; and

* The MAR lacked parameters for PRN bowel medications Dulcolax suppository, Fleets enema, Milk of Magnesia, and polyethylene glycol, regarding the sequential order of use.

On 10/14/21 the need to maintain an accurate MAR for all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator/RN).  She acknowledged the findings.

1. PRN parameters will be written for Resident 4 and 5. All resident MARs will be reviewed and prn parameters written as needed. Med techs will be trained on MAR documentation.

2. MAR exceptions and variances are reviewed in clincal meeting. Medical order processing will change to the order will be put in the 24-hour book after initial processing. The RN will review all prn parameter orders.

3. Multiple times per week during clinical meeting. Monthly audit of MAR.

4. RN and Administrator.

2. Resident 6 was admitted to the facility in January 2018 with diagnoses including dementia and chronic diabetic ulcers.

Observations of the resident, interviews with staff, review of the 09/01/21 through 10/12/21 MARs/TARs, the resident's 07/01/21 through 10/12/21 progress notes, skin sheets, and physician communications showed the following:

* On 08/06/21, a skin sheet was started for a diabetic ulcer noted to the resident's left lower leg. The area was noted as "red area, open sore mid shin." The skin sheet contained no treatment information and noted the area resolved as of 09/21/21.

A temporary service plan dated 08/06/21 referenced ulcers to the left lower leg and left toe and indicated "use wound cleanse spray, pat dry with 4 x 4 gauze, bandage when loose or soiled ..." No additional information was provided regarding the diabetic ulcer to the shin.

* On 08/24/21, a skin sheet was started for an open lesion noted on the left lower shin. The skin sheets contained no treatment information and noted the area resolved as of 10/05/21.

A temporary service plan dated 08/24/21 referenced two new open lesions to the left lower shin and indicated "report heat, redness, swelling or increase in size. Keep clean."  No additional information was provided regarding the wound to the shin.

* An observation of a dressing change to the resident's left shin was completed 10/12/21 at approximately 8:40 am. An existing bandage was in place and removed at the time of the dressing change. There was no skin sheet or temporary service plan in the resident's record related to the current shin wound.

On 10/12/21, a skin sheet was created for a diabetic ulcer to the resident's left shin and provided to the surveyor. The skin sheet contained no treatment information.

A temporary service plan dated 10/12/21 referenced a diabetic ulcer to the left shin and indicated "cleanse with wound spray. Pat dry with 4 x 4 gauze. Cover with bandage every 2 days or if loose or soiled."

There were no progress notes related to the shin wound/ulcer from 07/01/21 through 10/06/21. A progress note dated 10/07/21 indicated the resident had two lesions to the left lower shin, and a note dated 10/11/21 indicated the lesions to the resident's "shins looking better."

There was no indication physician's orders were obtained related to the shin wound. Additionally, there was no documentation that nursing orders for treatments were carried out for the shin wound. There was no documentation of any treatments to the resident's shin from 09/01/21 to 10/12/21.  

The need to ensure the facility obtained signed physicians orders for treatments, included clear instructions for staff, and documented treatments administered on the MAR/TAR was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21 and 10/13/21. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to keep an accurate treatment administration record (TAR) of all treatments ordered by a legally recognized practitioner and administered by the facility for 2 of 6 sampled residents (#s 3 and 6) with treatments in place. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2021 with diagnoses including dementia.

The resident's 09/22/21 through 10/11/21 MAR/TAR, temporary service plans (TSPs) dated 09/21/21 through 10/09/21, and progress notes dated 09/24/21 through 10/11/21 were reviewed, staff were interviewed, and observations were made of dressing changes.

The resident had a contracture of his/her right hand. Records indicated the resident was taken to the Emergency Department on 10/09/21 because his/her right hand was "swollen with abrasions." Upon return to the facility, a TSP was created instructing staff to keep the abrasion clean and "keep gauze in the hand with antibiotic ointment."

In an interview with Staff 12 (CG/MT) on 10/12/21, she stated she did not have any instructions on what to do about the resident's bandage. Later that day Staff 12 was observed changing the dressing on the resident's right hand.

There was no documented evidence of a treatment order for the wound on the resident's hand on the 10/2021 MAR/TAR.

The need for all treatment orders to be on the TAR was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21. They acknowledged the findings.

1. All skin/wound concerns are being reviewed for treatment orders. RN consultant training on 11/4/21 on treatment orders and progress note content.

2. RN and med tech training on skin/wound treatment orders and documentation in the MAR. Review of orders in clinical meeting.

3. Weekly.

4. RN and Administrator.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, which put residents at risk for serious harm. Findings include, but are not limited to:

The facility was licensed as a Residential Care Facility (RCF). The RCF portion of the building (Victorian Manor) was accessible through the main front door, or by walking through the memory care lobby, up three stairs, and through a coded entry door, and could house 15 residents, with 13 rooms located on the second floor. The memory care portion of the building was accessible through a side lobby entrance, and was divided into three hallways, "Sunny," "Memory," and "County." "Sunny" was located just off the lobby entrance and had the capacity to house 14 residents. "Memory" (with a capacity to house 16 residents) and "Country" (14 residents) were located up a ramp towards the back end of the building.

1. During the entrance conference on 10/11/21, the following was identified regarding resident care needs:

* The facility had a census of 45 residents, 35 residents in memory care and 10 residents in RCF;

* Three residents needed two-person assist with transfers or Hoyer;

* Two residents were on hospice; and

* Two residents were identified as needing meal assistance.

2. The staffing plan provided by the facility was as follows:

* Dayshift - 2 MTs and 5 CGs;

* Evening shift - 1 MT and 5 CGs; and

* Night shift - 0 MT and 3-4 CGs.

During an interview on 10/12/21 at approximately 6:01 pm, Staff 1 (Administrator/RN) stated she tried to schedule staff according to the staffing plan, with a minimum of three staff and one med tech on night shift, but acknowledged the facility had been running short staffed.

3. Time clock records, 09/16/21 through 10/11/21, were requested, reviewed, and compared to the facility's staff schedule and plan.

* Day shift was short one caregiver 19 times and two caregivers four times;

* Evening shift was short one caregiver four times, two caregivers 14 times, and three caregivers six times; and

* Night shift was short one caregiver nine times, and two caregivers four times.

There was no documentation to show MTs had worked the evening shift on 10/4/21 and 10/11/21, or that a MT had worked the night shift on 09/27/21, 10/04/21, 10/05/21, 10/08/21, or 10/10/21.

On 10/13/21 Staff 1 stated occasionally administrative staff had filled some shifts, but this had not been documented on the staffing schedule.

4. Observations and interviews conducted between 10/11/21 and 10/14/21 showed the following:

* Multiple residents in the memory care needed cuing or full meal assistance, and/or required the assistance of two staff for transfers;

* During interviews, several staff confirmed the facility was short staffed;

* Several newly hired staff stated they had not read resident service plans and/or when asked, stated they had "not really been trained" because of staffing shortages;

* On 10/13/21 approximately eight residents on "Country" hall were still in bed at 8:30 am. Many had been served breakfast in their rooms, but required assistance with eating their meal;

* Multiple times throughout the survey, common areas of the memory care were

left unsupervised with no staff present;

* On 10/11/21 evening shift, three caregivers and one MT were observed working on the floor. One caregiver floated between "Sunny," "Country and Manor," and "Victorian Manor."

* On day shift 10/12/13, three caregivers and two MT's were scheduled and observed working on the floor. Two caregivers worked on the "Memory and Country" side of the memory care, and one caregivers floated between "Sunny," "Country and Memory," and "Victorian Manor." At 8:35 am several residents were observed in bed sleeping or had been served a breakfast tray, but appeared unable to feed themselves independently. At 8:44 am, two caregivers began providing meal assistance to two residents in the residents' rooms. Other residents needing assistance waited approximately 20 to 30 minutes before staff were able to assist them with meals.  

On 10/13/21, at 12:55 pm, the survey team requested an immediate plan of correction to address the staffing shortages. At 2:20 pm a plan was received and accepted by the survey team, at which time the immediate jeopardy was abated.

The facility's failure to ensure adequate staffing in order to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 and Staff 2 (RN) on 10/13/21 and 10/14/21. They acknowledged the findings.

1. Four med techs and four care staff since the survey. Training is in process. Some employees have returned since survey after the vaccine mandate requirements have been fulfilled. The crisis team has been assisting the community as new employees are hired.

2. Continue to hire new employees and provide training.

3. Daily.

4. Assistant Administrator and Administrator.

Based on interview and record review, it was determined the facility failed to meet requirements for Fire and Life Safety instruction for staff, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 10/12/21 identified the following deficiencies:

There was no documented evidence that fire and life safety instruction was provided to staff on alternating months.

On 10/13/21 the need to ensure all requirements were met for fire and life safety instruction for staff, according to the OFC was discussed with Staff 1 (Administrator/RN). She acknowledged the findings.

1. A fire and life safety training schedule is being developed and will start in December 2021.

2. Training will be provided at the monthly all staff meeting.

3. Monthly.

4. Admininstrator.

Based on interview and record review, it was determined the facility failed to meet requirements for Fire and Life Safety instruction for residents, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 10/12/21 indicated the following deficiencies:

* There was no documented evidence that residents were instructed on fire safety procedures within 24 hours of admission; and

* Records showed no documented evidence that annual training on fire safety was provided to residents.

On 10/13/21 the need to meet requirements for fire and life safety instruction for residents, in accordance with the OFC was discussed with Staff 1 (Administrator/RN).  She acknowledged the findings.

1. All residents will be trained on fire safety procedures.

2. The training information will be included in the admission packet and the annual training date will be noted on the service plan.

3. Quarterly with the service plan.

4. Assistant Administrator and Office Manager.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair and failed to provide storage for all maintenance equipment, including yard maintenance tools, not provided by a third-party contract. Findings include, but are not limited to:

Observations of the secure outdoor area on 10/11/21 showed there were multiple drop-offs of 2-4 inches along pathway edges, and multiple metal garden tools were observed in an unlocked cabinet in the resident outdoor sitting area.

The need to ensure pathways and sitting areas in the resident outdoor area did not have potential safety hazards was discussed with Staff 1 (Administrator/RN) on 10/11/21. She acknowledged the findings.

1. Additional rock and dirt will be added to drop off areas. Dirt is already at the community. Resident gardening tools were removed from resident areas. Yard maintenance tools are now stored in a secure garden shed.

2. Training for maintenance personel on securing storing tools. Administrator walk through checklist. Manager rounds.

3. Daily and weekly.

4. Maintenance and Adminstrator.

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

Observations of the facility on 10/11/21 showed the following areas in need of cleaning or repair:

* Multiple walls and door frames in resident hallways had scrapes and gouges;

* Multiple door frames/doors at facility exits had chips, gouges, and/or scrapes;

* Two tables in the dining room had pieces of missing chrome plating at the table bases, exposing rust;

* Vinyl flooring in the memory care dining area had multiple black streaks and deep ruts;

* White laminate cupboards in the memory care dining room had spills, scrapes, food debris, or were missing the laminate, exposing wood;

* The counter in the memory care dining room had a worn area to the left of the sink and was not cleanable;

* Carpet leading up to the second floor of the Resident Care Facility (RCF) was worn and had multiple stains;

* Shared bathrooms on the second floor of the RCF had garbage cans that were overflowing and brown matter was visible on one toilet seat, the wall, and the floor in front of the toilet;

* Several pieces of furniture throughout the facility had worn areas which were not cleanable, or spots and stains; and

* Trays for drink service on the second floor of the RCF were covered in dried liquid spills and food crumbs.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator/RN) on 10/11/21. She acknowledged the findings.

1. Another maintenance person will be at the community by the first of December. An audit/list of all walls, door frames, tables, and cupboards that require repair will be completed. Flooring in dining area will be replaced. Counter in the dining room will be replaced. Carpet on stairs will be cleaned. New garbage cans with lids have been placed in resident bathrooms. Furniture will be repaired/clearned or replaced. Trays for drink service are now cleaned after every use.

2. A maintenance checklist and audit form will be developed for repair needs. Staff will be trained to notify maintenance of repair needs. Staff will be trained to clean serving carts and trays after each use.

3. Weekly.

4. Maintenance and Administrator.    

Based on observation and interview, it was determined the facility failed to ensure a separate area with closed containers was available which allowed for the storage and handling of soiled linens and clothing in order to preclude the potential for contamination of clean linens and clothing. Findings include, but are not limited to:

A tour of the facility's laundry room was conducted on 10/12/21 at 11:20 am. Directly inside the door of the laundry room were three large open bins with residents' dirty laundry piled into each bin. An uncovered small blue garbage can was observed under the utility sink next to the bins and contained wet clothing. Clean linens and clothing were observed hanging on clothing racks or stacked on open, uncovered shelves next to or across from the soiled items.

In an interview, 10/12/21, Staff 19 (Housekeeper) indicated staff rolled covered laundry carts with soiled linens and clothing into the laundry room, then sorted the soiled linens into open laundry bins according to towels, linens, and resident clothing.  Any laundry that had fecal matter on it was rinsed and placed in an open container under the sink, where the items were rinsed off.  All other soiled laundry was mixed into the bins according to item type.

The need for covered containers for soiled linens and clothing and a covered or enclosed area for storage of clean linens was discussed with Staff 1 (Administrator/RN) on 10/14/21 at 7:53 am. She acknowledged the findings.

1. All dirty and solied laundry will be put in plastic bags and then put in the laundry hampers. Staff will wear aprons with pockets to hold plastic bags for laundry, gloves, and hand sanitizer. A curtain will be installed to protect clean laundry. Laundry and trash containers will be removed from the hall and stored when not in use.

2. Staff will be retrained on bagging incontinence trash immediately and where to put garbage and dirty/soiled laundry. Care and housekeeping staff will be trained in how to bag resident laundry before it leaves the resident room. Staff wil be trained to process soiled laundry.

3. Weekly and monthly.

4. Assistant Administrator and Administrator.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight for the operation of the memory care community (MCC). Findings include, but are not limited to:

The licensee is responsible for the operation of the MCC and the provision of person-directed care that promoted each resident's dignity, independence, and comfort. That included the supervision, training, and overall conduct of the staff.

During the relicensure survey, conducted 10/11/21 through 10/14/21, administrative oversight to ensure adequate resident care and services was found to be ineffective, based on the severity and number of citations issued.

Refer to deficiencies in report.

See C155, C160, C200, C231, C240, C242, C243, C260, C262, C270, C280, C282, C310, C315, C360, C420, C422, C510, C513, C530, Z140, Z145, Z150, Z155, Z162, Z163, Z164, Z173, Z176.

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

Refer to C 155, C160, C 200, C 231, C 240, C 242, C 360, C 420, C 422, C 510, C 513, and C 530.

See C155, C160, C200, C231, C240, C242, C360, C420, C422, C510, C513, C530.     

Based on interview and record review, it was determined the facility failed to ensure the administrator of the MCC completed and documented at least 10 hours of annual continuing education requirements related to the care of individuals with dementia. Findings include, but are not limited to:

Review of facility records indicated the administrator of the MCC failed to complete the required 10 hours of continuing education credits annually, related to dementia care, as required by the licensing rules of the facility type.

On 10/14/21 the need for the administrator of an MCC to complete 10 hours of annual continuing education credits related to care of persons with dementia was discussed with Staff 1 (Administrator/RN). She acknowledged the findings.

1. The adminstrator is completing the 10 hours of dementia related training.

2. The administrator training requirements will be added to the training checklist.

3. Monthly.

4. Administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure sufficient dementia-trained staff were available in the memory care community to meet the scheduled and unscheduled needs of the residents. Findings include, but are not limited to:

Refer to C360.

Refer to 360.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4  newly hired staff (#s 8, 13, 17, and 18) completed all required pre-service orientation prior to beginning job duties and demonstrated competency in their job duties within 30 days of hire, and 4 of 4 long-term staff (#s 7, 9, 10, and 14) completed the required number of hours of annual training. Findings include, but are not limited to:

Staff training records were reviewed on 10/13/21 and revealed the following:

1. Staff 8 (CG/MT), Staff 13 (CG), Staff 17 (CG), and Staff 18 (CG), were hired 09/14/21, 09/20/21, 04/02/21, and 07/08/21, respectively. There was no documented evidence they had completed one or more of the following required pre-service orientation topics prior to beginning their job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Fire safety and emergency procedures; and

* Written job description.

2. There was no documented evidence Staff 8, Staff 13, Staff 17, or Staff 18 demonstrated competency in their job duties within 30 days of hire in the following areas:

* 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

* Other duties as applicable (e.g., administration of medications).

The need for staff passing medications to demonstrate competency in all job duties prior to performing their job duties was discussed with Staff 1 (Administrator/RN) on 10/13/21. Staff 1 indicated they had no documentation of competency demonstration for any staff.  She was informed Staff 8 would need to be removed from the schedule until this had been completed.

3. There was no documented evidence Staff 7 (CG/MT), Staff 9 (CG/MT), Staff 10 (CG/MT), or Staff 14 (CG), hired 05/26/17, 07/20/11, 08/14/17, and 09/15/98, respectively, completed the required 10 hours of annual in-service training related to the provision of care in CBC or the required six hours of annual in-service training related to dementia care.

The facility's failure to ensure staff completed all required training in a timely manner was discussed with Staff 1 on 10/13/21. She acknowledged the findings and reported Staff 8 would demonstrate competency in her job duties prior to her next scheduled shift.

1. An audit of all training files will be completed. The training plan will be reviewed by consultant including competency checklists. Staff will be assigned training. Training will be completed as assigned. Staff competency will be observed. An inservice schedule and topic list will be developed and assigned.

2. Regularly scheduled audit of training file.

3. Monthly.

4. Office Manager and Administrator.  

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

Refer to C 243, C 260, C 262, C270, C 280, C 282, C 310, and C 315.

Refer to C243, C260, C262, C270, C280, C282, C310, C315.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 5 of 7 sampled residents (#1, 2, 3, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3, 4, and 6's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator/RN) and Staff 2 (RN) on 10/12/21. They acknowledged the findings.

1. Resident 1, 2, 3, 4 and 6 service plans will be updated with individualized nutrition and hydration plans. All MC service plans will be updated with individualized nutrition and hydration plans.

2. Nutrition and hydration plans will be included in initial evaluation and service plan; and updated with any changes and quarterly.

3. With changes and quarterly.

4. Assistant Administrator, RN, and Administrator.

Based on observation, interview, and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the residents, and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 6 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to:

a. Resident 1 and 3's service plans, assessments ,and evaluations were reviewed. There was no documented evidence the facility had evaluated the residents':

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

There was no documented evidence of specific activity plans which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities.

b. No activities were observed to occur on the MCC on 10/11/21, 10/12/21 and 10/13/21; therefore, the facility failed to provide meaningful activities for residents that would promote or help sustain the physical and emotional well-being of the residents.

Refer to C 242.

The failure to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Administrator/RN) on 10/13/21. She acknowledged the findings.

1. Individual activity plans for Resident 1 and 3 will be developed. All residents will be evaluated for activity preferences. Individual activity plans will be developed for all residents. Staff will be assigned to do activities when the activity coordinator is not available.

2. Individual activity plans will be included in the initial and quarterly service plans.

3. With changes and quarterly.

4. Activity Coordinator, Assistant Administrator, and Administrator.  

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement and that fencing was no less than six feet in height. Findings include, but are not limited to:

A tour of the facility courtyard on 10/11/21 showed the following:

* Multiple metal patio chairs were easily moveable and not of sufficient weight or design to prevent potential elopement.

* Multiple sections of fencing around the perimeter of the secured outdoor area were less than six feet in height. The shortest sections were approximately 65 inches.

The fencing sections that were less than six feet in height were shown to and discussed with Staff 1 (Administrator/RN) on 10/11/21. The staff acknowledged the findings. Prior to survey exit Staff 1 provided a copy an email to a contractor and stated the facility would be addressing the fence height. Staff 1 also stated the patio chairs would be removed.

1. Metal patio chairs were removed. New seating furniture will purchased and secured so it cannot be moved. A contractor bid for adding to fence height is in process.

2. Manager audit checklist will include ensuring furniture is secured.

3. Weekly audit rounds.

4. Maintenance and Administrator.

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:

The MCC was toured on 10/12/21. Resident rooms lacked any individualized identification to assist residents in recognizing their room.

The need to ensure each resident room was identified for the resident was reviewed with Staff 1 (Administrator/RN) on 10/13/21. She acknowledged the findings.