The findings of the re-licensure survey conducted 07/27/22 through 07/29/22 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 07/29/22, conducted 01/23/23 through 01/24/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

On 07/28/22, Staff 2 (Memory Care Director) and Staff 7 (LPN/Assisted Living Operations) were asked about the facility's quality improvement program. During the interview it was reported there was no documented evidence that the facility had conducted ongoing Quality Improvement Programs.

The need to ensure the facility had an effective method to evaluate services, resident outcomes and resident satisfaction was discussed with Staff 1 (ED), Staff 2, Staff 3 (Resident Care Coordinator), Staff 4, Staff 7 and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

Refer to the deficiencies in the report.

1. Implement QA program with 1st QA Meeting to take place on 8/18/22

2. QA program implemented by the Management/Clinical Team. Meetings to occur monthly and ensure the QA elements are audited per this POC and QA checklist. Refer to QA form and binder.

3. Monthly

4. Executive Director

Based on observation, interview and record review, it was determined the facility failed to investigate incidents to rule out suspected abuse or neglect of care for 1 of 1 sampled resident (#2), who was identified to have sustained injuries of unknown cause. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2017 with diagnoses including dementia.

Observations of the resident from 07/27/22 to 07/29/22 revealed the resident required staff assistance with transfers and incontinent care.

Progress notes dated 04/26/22 through 07/27/22 were reviewed and revealed the following:

* 06/05/22 - Bruise to the right hand; and

* 07/15/22 - Skin tear to the left hand.

Incident reports dated 05/10/22 through 07/21/22 were reviewed and revealed the following:

* There was no incident report for the 06/05/22 skin injury to investigate how the resident obtained the bruise on the right hand; and

* The 07/15/22 incident report was reviewed during the survey. It was noted the investigation did not reasonably conclude the injury of unknown cause was not the result of abuse or neglect of care. Also, the facility incident report lacked documentation of required investigative components including individuals present; a description of the event and follow-up action.

The need to ensure injuries of unknown cause were immediately and thoroughly investigated to rule out abuse and neglect or reported to the local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1 (ED) and Staff 2 (Memory Care Director) on 07/29/22. They acknowledged the findings. As requested, the injuries of unknown cause were reported to the local SPD office before the survey concluded. Confirmation the incident had been reported was received on 07/29/22.

1.Reported to APS 7/29/22

2.ED and HWD to review all Incident Reports daily at clinical meeting

3. IRs to be audited/reviewed at Monthly QA meeting

4. Executive Director & Health and Wellness Director

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to:

The facility had 23 residents. The main kitchen was in the assisted living unit where all food was prepared and transported to the memory care unit where meals were served.

1. On 07/27/22 and 07/28/22, during the main kitchen tour, the following was observed to be in need of cleaning:

* The inside of the conveyor toaster, had a thick layer of black matter;

* The ice maker lid and front on the ice machine was sticky to the touch;

* The floor between a free-standing refrigerator and an ice maker, had a thick layer of brown matter build-up;

* A free-standing fan, that was on, had accumulated dust;

* The wall behind the dishwasher had spillage and brown matter;

* The stove front, side and control knobs were sticky to the touch;

* The inside of the oven, the front and side of the oven had a thick layer of brown matter;

* The front and side of the dishwasher had accumulated gray matter;

* Inside the microwave there was dried food matter and debris; and

* The hood and vent above the dishwasher, had accumulated dust.

2. On 07/27/22 and 07/28/22, during a kitchenette tour in the memory care unit, the following areas were observed to be in need of cleaning or repair:  

* Coffee and beverages countertop had exposed bare wood and/or splintered wood;

* Laminated countertop had chips in multiple areas and was missing laminate at the edge;

* Cabinets and drawers throughout the kitchenette area were sticky to the touch; and

* Brown stain and dried food matter was inside cabinets where utensils were stored.

3. On 07/27/22 at 1:05 pm, Staff 21 (Dietary Director) checked the sanitizing buckets with a test strip to measure the concentration of the solution. However, when Staff 21 dipped the test strip in the solution, the test strip did not change color which indicated the solution did not have the required amount of sanitizing solution. Staff 21 stated the test strips were new and there were no previous records for testing the sanitizing solution.

4. On 07/28/22 between 12:00 pm and 12:15 pm, Staff 21 was observed, and the following was noted:  

* Staff 21 prepared quesadillas with plastic gloved hands in the MCC kitchenette area;

* During the preparation of the quesadilla, Staff 21 walked away from the prep line a few times and went to the food cart, a free-standing refrigerator and cabinet. Then Staff 21 touched the top of the food cart, the cabinet handles and the refrigerator handle with the gloved hands;

* Staff 21 went back to the prep line without changing gloves or washing her hands; and

* Staff 21 was observed to touch the quesadilla and to slide the quesadilla onto the plates with the same gloved hands.

During the observation, Staff 21 did not change her gloves nor wash her hands between dirty and clean tasks, which represented poor infection control practice during the meal preparation.

On 07/28/22 and 07/29/22, the main kitchen and kitchenette were toured with Staff 2 (Memory Care Director) and Staff 21.  The prep line observation was also discussed with staff. Staff acknowledged the areas needed cleaning and repair, and the lack of infection control practice during the meal preparation.

1A. All items will be addressed during a deep cleaning scheduled for 8/29/22. 1B. Items listed to be addressed by HKP/Maintenance by 9/12/22. 1C.Test strips replaced and working.1D. Immediate Correction & training provided to all kitchen staff on infection control practices.

2A & 2B. Implementation of daily, weekly, monthly, cleaning checklist. 2C.Kitchen staff re-training on how to use Sanitizer strips. Add to daily checklist. 2D.Monthly staff training on Proper Food Handling/Infection Control Practices

3. Monthly as part of QA program audits

4. DSM, MCU ED & ED

2. Resident 2 was admitted to the facility in 08/2017 with diagnoses including dementia.

Resident 2 was observed to utilize a wheel-chair for mobility and needed to be prompted or assisted for food intake during the breakfast and lunch meal.

Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey from 07/27/22 thru 07/29/22, revealed Resident 2's service plan was not reflective of the resident's status and did not provide specific directions to staff in the following areas:

* Health shakes/supplement status;

* Use of call light status;

* Use of barrier cream to buttocks; and

* Emergency evacuation ability.

On 07/29/22, the service plan was discussed with Staff 1 (ED) and Staff 2 (Memory Care Director). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and were reviewed and updated after a significant change of condition for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 02/2022 with diagnoses which included dementia. During the acuity interview on 07/27/22, Staff 4 (RN) reported the resident had weight loss and a significant change of condition.

Interviews with care staff and observations of Resident 3 during the survey revealed s/he needed assistance with catheter care, bowel care, was a one-to-two-person transfer, used a wheelchair and had decreased appetite.

Resident 3's service plan, dated 06/13/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Ambulation status and use of a wheelchair verses a walker;

* One-to-two-person transfer assistance verses stand by assistance;

* One-to-two-person assistance with bed mobility;

* Catheter care lacked clear instructions regarding frequency of care needs and infection control;

* Risk of dehydration;

* Skin integrity and monitoring;

* Pain management;

* Weight status, loss of appetite and meal/fluid monitoring;

* Environmental factors that impact mood or behavior: including, noise, temperature and clutter; and

* Evacuation status.

The need to ensure the service plan was reflective of Resident 3's current care needs, provided clear direction to staff and was updated after significant change of condition was discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4, Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1.Resident #2 and #3 service plans will be updated to reflect resident current needs per the OARS and updated with clear instructions regarding delivery of services.

2. ED, HWD, & RCC retrained on TSP and SP policy and procedure. Team will use a SP checklist and resident questionairre moving forwards to gather preferences and ensure all OAR requirements are included.

3. SP to be reviewed by ED and HWD upon admission, 30 day, quarterly and with any change of condition.

4. ED & HWD

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 was familiar with or provided services, for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:

Resident 2 and 3's clinical records and service plans were reviewed during the survey. There was no documented evidence the service plans were developed by a Service Planning Team.

The facility's system for ensuring resident service plans were developed by a service planning team was discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4 (RN), Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. Resident #2 and #3  care conferences to be scheduled once SPs properly updated. Team meeting to be documented in PCC under "Service Plan Notes"

2. Re-educated ED, HWD & RCC on Service Plan Team Meeting Process and Procedure. Management team provided updated Policy & Procedure on SPs & Team meeting procedure. Regional team to provide education on this process.

3. Monthly review with QA meeting. Any updated SPs for the month will be reviewed to ensure SP team meeitng has been completed and documented.

4. ED & HWD  

Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs, document weekly progress until the condition resolved or refer to the facility nurse to document the change and update the service plan as needed for 2 of 3 sampled residents (#s 2 and 3) reviewed for change of conditions. Findings include but are not limited to:

1. Resident 2 was admitted to the facility in 08/2017 with diagnoses including dementia.

Observation of the resident and interviews with direct care staff during the survey revealed the resident required staff assistance with transfers and incontinent care.

a. Resident 2's clinical records were reviewed and revealed the following:

* 05/08/22 - Received of antibiotic to treat urinary tract infection;

* 05/10/22 - Skin tear on the forearm;

* 05/10/22 - Red rash on the right upper thigh;

* 06/05/22 - Bruise to the right hand; and

* 07/15/22 - Skin tear on the left hand.

There was no documented evidence the resident's changes of condition were monitored, at least weekly, through resolution.

b. During breakfast and lunch meal service in the dining room on 07/28/22, Resident 2 was observed to eat less than 25% of oatmeal for breakfast and in bed during lunch; however, Staff 8 (CG) stated the resident had lunch in his/her room.

Resident 2's weight record was reviewed during the survey and revealed the resident had experienced significant weight changes, weight gain and weight loss, between 03/2022 and 07/2022.

From 03/2022 to 06/2022, Resident 2 had gained 10.4 pounds or 7.53 % of his/her body weight and from 06/2022 to 07/2022, the resident had lost 8.6 pounds or 6.23 % of his/her body wight, which represented a significant change of condition for the resident.  

The resident's 07/27/22 service plan directed staff  to offer as needed supplemental health shakes. During an interview with Staff 8 (CG) and Staff 10 (CG) on 07/29/22, they stated they were not sure when to provide the health shakes to the resident.

There was no documented evidence the resident's change of condition was evaluated or referred to the facility nurse to document the change and update the service plan as needed.

On 07/29/22, the above information was shared with Staff 1 (ED) and Staff 2 (Memory Care Director). They acknowledged the findings.

2.  Resident 3 was admitted to the memory care facility in 02/2022 with diagnoses including dementia.

Observations of the resident during meal service, interviews with direct care staff, review of progress notes, service plans, temporary service plans and weight records identified the following change of condition:

* Loss of appetite;

* Significant weight gain on 07/20/22; and

* Significant weight loss on 07/27/22.

During lunch meal service in the dining room on 07/27/22 and 07/28/22, Resident 3 was observed to eat less than 25% of the meal; however, did consume a supplemental health shake.

During an interview on 07/29/22 with Staff 10 (Personal Care Assistant), it was reported Resident 3 had a loss of appetite and would rarely eat lunch and dinner. Staff 10 reported s/he would drink a supplemental health shake, other than that s/he was unaware of any further interventions for the resident.

Review of Resident 3's weight records indicated the following:

* The resident had been weighed standing and other times weighed in a wheelchair which had the potential to result in varied weights recorded;

* There were six incorrect documentation's recorded on the weight record. On four of the six occasions the resident was not re-weighed to determine an accurate weight;

* Between 06/22/22 and 07/20/22, Resident 3 weighed 143.4 pounds which constituted a significant weight gain of 5.71% within one month; and

* On 07/27/22 (seven days from the previous weight recorded), Resident 3's weight was recorded as 130.4 pounds, a 13 pound weight loss within one week.

On 07/28/22 at 1:05 pm, surveyor observed, Staff 14 (MT), weigh Resident 3. The resident was weighed in a manual wheelchair that weighed 37 pounds. The resident's current weight was 131.2 (after subtracting the wheelchair weight).

During an interview with Staff 4 (RN) on 07/28/22, it was reported he was unaware of the significant change in Resident 3's weight on 07/20/22 and 07/27/22.

There was no documented evidence the above change of condition was evaluated timely, new actions or interventions developed and communicated to staff, and referred to the facility RN when needed.

The need to ensure the facility had a system in place to ensure accurate weight data was documented and referred to the RN when appropriate was discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4, Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. Resident #2 & 3 records will be updated r/t skin concerns and updated to reflect change of condition from weight loss.

2. New & existing skin issues to be discussed daily at clinical meeting and weekly per skin log. Re-education on skin documentation and weight monitoring provided to clinical team. PCC dashboard and weight reports procedure reviewed with RN and clinical team. Ongoing education with MCU RN on change of condition documentation and requirements. RN enrolled on "Role of the RN Class"

3. Daily in clinical meeting by ED, HWD, and RCC by reviewing whiteboard, alert charting, weight alerts. Sample audit monthly with QA program.

4. HWD and ED  

2. Resident 2 was admitted to the facility in 08/2017 with diagnoses including dementia.

Resident 2 was observed during the survey to be prompted or was assisted with food intake during the breakfast.

Resident 2's weight records were reviewed during the survey and revealed the following:

* 12/2021 - 138.0 pounds;

* 03/2022 - 138.2 pounds;

* 06/2022 - 148.6 pounds;

* 07/16/22 - 140.0 pounds; and

* 07/29/22 - 135.4 pounds (during the survey).

From 03/2022 to 06/2022, Resident 2 had gained 10.4 pounds or 7.53 % of his/her body weight and from 06/2022 to 07/2022, the resident had lost 8.6 pounds or 6.23 % of his/her body wight, which represented a significant change of condition.

There was no documented evidence the facility evaluated the resident condition related to weight gain and weight loss and reported to the facility RN for the assessment of the resident's significant weight changes.

It was confirmed during the survey that there was no RN assessment of the resident's significant weight changes which included findings, a description of resident status and a plan of care to address the weight changes.

On 07/29/21, the need to ensure the facility RN completed an assessment for the significant change of condition was discussed with Staff 1 (ED) and Staff 2 (Memory Care Director). They acknowledged the findings.

Refer to C 270, example 1 b.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed timely by a facility RN and the service plan was updated for 2 of 2 sampled residents (#s 2 and 3) reviewed for significant changes of condition. Findings include, but are not limited to:

Resident 3 was admitted to the memory care facility in 02/2022 with diagnosis of dementia. During the acuity interview on 07/27/22, Staff 4 (RN) reported the resident had weight loss.

a. A review of Resident 3's weight record noted the following:

* On 06/22/22, 135.2 pounds (wheelchair);

* On 07/20/22, 143.4 pounds (wheelchair), Resident 3 gained 8.2 pounds within one month; and

* On 07/27/22, 130.4 pounds (standing), Resident 3 lost 13 pounds within one week.

From 06/22/22 to 07/20/22, Resident 3 had gained 8.2 pounds or 5.71% of his/her body weight within one month, which represented a significant change of condition that required an RN assessment.

There was no documented evidence an RN assessment that documented the resident's current status, condition, and determined interventions based on the findings of the assessment was completed.

Refer to C 270, example 2.

b. On 06/16/22, Resident 3 returned to the facility from the hospital with a supra-pubic catheter surgical site and increased pain. This represented a significant change in condition that required an RN assessment.

There was no documented evidence the RN completed an assessment of the resident's significant change in condition and updated the service plan to provide clear instructions for staff regarding the residents change in status.

c. On 06/23/22, progress notes indicated Resident 3 was now receiving transfer assistance.

On 06/24/22 Staff 4 (RN) completed an evaluation which identified the resident had the following changes of condition:

* Foley catheter to Supra-pubic catheter;

* Two-person transfer assist; and

* Ambulation assistance with a wheelchair.

There was no documented evidence the RN updated the service plan to provide clear instructions for staff regarding the residents change in status and increase in care needs.

The need to ensure the facility had a system in place to identify significant changes of condition, complete timely RN assessments and update the service plan after a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4, Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. HWD will assess resident #2 & #3 for significant change and complete documentation to reflect review of systems, plan of care and interventions. Resident 3 SP updated for suprapubic catheter.

2. ED, HWD and RCC to read and review CBC slide on change in condition in OR to better understand the requirements. MCU RN enrolled in "Role of RN class". RN to review DHS guidelines for Significant unplanned weight loss. Staff training on obtaining accurate/consistent weights.

3. Review weights daily at clinical meeting. Clinical team to review and identify any change in condition to be addressed immediately. Monthly weight report in PCC to be reviewed at monthly QA meeting.

4. ED & HWD

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:

During the relicensure survey, conducted 07/27/22 through 07/29/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:

C 302: Systems: Tracking Controlled Substances;

C 303: Systems: Medication and Treatment Orders;

C 310: Systems: Medication Administration; and

C 330: Systems: Psychotropic Medication.

Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 07/29/22.

Please refer to section 302, 303, 310 & 330 below.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility and proper disposal of unused medications, for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Drug Disposition logs were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2017 with diagnoses including dementia.

Resident 2's 07/21/22 physician orders, 07/01/22 through 07/27/22 MAR and Controlled Substance Drug Disposition logs were reviewed during the survey and revealed the following:

a. Resident 2 had signed physician orders for diazepam 2 mg four times daily for anxiety, oxycodone 20 mg three times daily and methadone 5 mg twice daily for pain. Staff documented on the MAR, those medications were not administered to the resident on multiple occasions due to the resident was sleeping or other reasons. There was no documented evidence the unused medications were properly disposed.

b. Resident 2 had signed physician orders for oxycodone 20 mg three times daily and methadone 5 mg twice daily for pain. Staff documented those medications were dispensed on the Controlled Substance Disposition log on multiple occasions between 07/01/22 and 07/27/22. There was no documented evidence on the MAR the dispensed medications were administered to Resident 2.

Inconsistencies between the MAR and Controlled Substance Disposition logs and improper disposal of unused medications was reviewed on 07/29/22 with Staff 1 (ED) and Staff 2 (Memory Care Director). They reviewed the documentation and acknowledged the discrepancies.

1a. Proper med disposal has been reviewed with MTs, HWD, ED & RCC. 1b. Training with MTS regarding use of MAR simultaneously with Narcotic book.

2. A Narcotic Checklist to be created and utilized with a biweekly MAR/Narcotic audit to be completed by HWD and/or RCC.

3. Monthly review/audit of checklist with QA meeting. HWD to complete random narcotic audits per faciltiy policy.

4. RCC, HWD and ED

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 1 of 3 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2017 with diagnoses including dementia.

Resident 2's 07/21/22 physician orders and 07/01/22 through 07/27/22 MAR was reviewed during the survey and revealed the following:

a. Resident 2 had been prescribed a PRN order for Bisacodyl 5 mg 2 tablets as needed if no BM (bowel movement) in 48 hours and Bisacodyl suppository as needed if no BM in 72 hours or if the PRN Bisacodyl 5 mg tablet was ineffective.

Resident 2's 07/01/22 thru 07/27/22 bowel movement record revealed the following:

* 07/13/22 - 07/16/22, no BM was documented for four days and the resident was not administered the PRN Bisacodyl tablet within 48 hours as prescribed;

* 07/17/22 - 07/21/22, no BM was documented for five days and the resident was  administered the PRN Bisacodyl tablet on 07/20/22, on 4th day of BM, not within 48 hours as prescribed and did not administer Bisacodyl suppository when the PRN Bisacodyl 5 mg tablet was ineffective; and

* 07/23/22 - 07/27/22, no BM was documented for five days. The resident was administered PRN Bisacodyl tablet on 07/25/22 as prescribed, however, the resident continued to not have a bowel movement for an additional 48 hours. The facility failed to administered the Bisacodyl suppository when the PRN Bisacodyl 5 mg tablet was ineffective.

b. Resident 2 had a physician order to administer Morphine 5 mg every two hours as needed for pain.

The 07/01/22 through 07/27/22 MAR indicated the resident was administered Morphine 5 mg every hour as needed for pain, not every two hours as prescribed. The medication was administered to the resident on multiple occasions.

c. The resident's 07/21/22 physician order indicated the resident was administered diazepam 2 mg every six hours as needed for anxiety.

The 07/01/22 through 07/27/22 MAR indicated diazepam 2 mg every two hours was administered as needed for anxiety, not every six hours as prescribed. The medication was administered to the resident on multiple occasions.

On 07/29/22, the physician orders and the MAR were reviewed with Staff 1 (ED) and Staff 2 (Memory Care Director). They acknowledged the findings.

1a. Immediate Training with staff on following BM RX parameters. Training and review at next MT meeting

1b. Staff training on PRN RX Administration to include review of facility policy. RN to review PRN administration at next MT meeting

2. Staff training on MAR/TAR policies & procedures. RCC & HWD to review PRN reports at daily clinical meeting and address any issues immediately.

3. Daily at clinical meeting. Monthly at QA meeting.

4. RCC, HWD & ED

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific administration instructions and parameters for PRN medications, for 1 of 3 sampled residents (#3) whose MARs was reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the memory care facility in 2022 with diagnoses which included dementia, chronic pain and primary osteoarthritis of the left and right shoulders.

Residents 3's MAR reviewed from 07/01/22 through 07/27/22 identified the following:

* The MAR lacked resident-specific instructions for multiple PRN pain medications, including sequential order of use for PRN Tylenol 325 mg, PRN Hydrocodone 5-325 mg and PRN Morphine Sulfate.

In an interview on 07/28/22, Staff 4 (RN) reviewed the resident's MAR. He confirmed the multiple PRN pain medications lacked specific instructions for staff, including parameters for which one to give first, second and third.

The need to ensure accurate MARs were kept was discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4, Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. PRN parameters updated and reviewed by RN for resident 1, 2 & 3.

2.Comprehensive Medication review by RN. Pharmacy audit 9/8/22. RN consultant completing training/instruction on PRN parameters with MCU RN.

3. Review of new orders daily at clinical meeting per triple check process. Monthly audit of PRN medication orders review with QA meeting.

4. ED & RN

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were ineffective, for 3 of 3 sampled residents (#s 1, 2 and 3) who were administered PRN psychoactive medications. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2017 with diagnoses including dementia.

Resident 2's record indicated s/he had orders for PRN Diazepam for "anxiety" and PRN Seroquel for "agitation".

Resident 2's 07/01/22 through 07/27/22 MAR was reviewed during the survey and revealed the following:

* The MAR lacked clear instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety;

* No non-drug interventions were developed for staff  to attempt prior to administering the psychoactive medication; and

* The PRN Diazepam and Seroquel was administered on multiple occasions without document evidence non-drug interventions had been attempted with ineffective results prior to administering the medication.

On 07/29/22 Resident 2's record was reviewed with Staff 1 (ED) and Staff 2 (Memory Care Director) who acknowledged the findings.

2. Resident 1 was admitted to the memory care facility in 06/2022 with diagnoses including Alzheimer's disease.

Resident 1's record indicated s/he had orders for PRN Haloperidol for "agitation".

Resident 1's 07/01/22 through 07/27/22 MAR reviewed during the survey identified the following:

* The MAR lacked clear instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation;

* There were no non-drug interventions developed and documented for staff to attempt with ineffective results prior to administering the psychoactive medication; and

* The PRN Haloperidol was administered on 11 occasions without documented evidence non-drug interventions had been attempted with ineffective results prior to administering the medication.

3. Resident 3 was admitted to the memory care facility in 02/2022 with diagnoses including dementia.

Resident 3's record indicated s/he had orders for PRN Lorazepam for "anxiety" and PRN Olanzapine for "agitation".

Resident 3's 07/01/22 through 07/27/22 MAR reviewed during the survey identified the following:

* The MAR lacked clear instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation and anxiety; and

* There were no non-drug interventions developed and documented for staff to attempt with ineffective results prior to administering the psychoactive medication.

The need to ensure the MAR included clear instructions and non-drug interventions for PRN psychoactive medications was  discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4 (RN), Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. Resident 1, 2 & 3 will have MAR updated for all PRN psychotropic medications to include clear instructions and to include at minimum 3 non-pharmacological interventions.

2. Staff (MT, RCC, HWD & ED) training on requirements for Psychotropic medications. RCC and HWD to complete comprehensive audit of all resident pyschotropic medications and ensure the required instructions, and non-pharm interventions are in the MAR.

3. Daily review at clinical meeting. Monthly audit of psychotropic medication with QA meeting.

4. ED, RCC, and HWD

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 sampled newly hired direct care staff (#s 8, 9 and 16) completed the required abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to:

During the survey, training records were reviewed for Staff 8 (PCA) hired 02/01/22, Staff 9 (MT) hired 03/01/22 and Staff 16 (PCA) hired 06/10/22.

Staff 8, 9 and 16 did not have documented evidence they had received first aid and abdominal thrust training.

The need to ensure staff were trained in first aid and abdominal thrust within 30 days hire was discussed with Staff 1(ED) and Staff 2 (Memory Care Director) on 07/29/22. They acknowledged the findings.

1. Staff 8, 9, & 16 will complete required First Aid training and complete abdominal thrust training. Documentation of this training will be added to their employee file.

2. Audit of MCU direct care staff files to be completed ensure all training requirments are documented in employee files per regulation. Monthly audit of staff files to completed by BOM as part of QA meeting. BOM to maintain a spreadsheet to track routinely.

3. Monthly with QA program and with any new hires

4. ED and BOM

Based on interview and record review, it was determined the facility failed to ensure residents received re-instruction in fire and life safety training, at least annually after admission. Findings include, but are not limited to:

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

* There was no documentation of annual fire and life safety training provided to residents, at least annually following admission.

The need to ensure residents were re-instructed at least annually in fire and life safety training was discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4 (RN), Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. Fire and life safety training and documentation will be completed for current MCU residents/POAs.

2. Fire and life training form added to admission checklist and will be done upon admission and reviewed quarterly during SP team meeting.

3. Monthly audit of this documentation for new admits and anyone in SP review period at QA meeting.

4. ED & RCC

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the RCF common-use areas were maintained and the exterior of the building was clean and maintained. Findings include, but are not limited to:

The interior courtyard of the MCC was toured on 07/27/22 and 07/28/22.

* There were drop-offs of up to approximately two and three inches from the concrete surface to the planting bed along portions of the walkway throughout the interior courtyard. This represented a potential safety hazard for residents; and

* Two exterior doorways in the courtyard had an accumulation of insect cobwebs.

The need to ensure walkways were maintained and safe for residents and the exterior of the building was clean and maintained was reviewed with Staff 2 (Memory Care Director) and Staff 22 (Maintenance Director) on 07/28/22. They acknowledged the findings.

1. The drop-offs along walkway and cobwebs on exterior doors to be addressed and fixed by Housekeeping and/or Maintenance.

2. The courtyard will be added to monthly environmental rounds per QA meeting. Any items found will be addressed by the appropriate dept. Staff will utilize a checklist to identify potential safety or environmental concerns.

3. Monthly with QA program

4. ED and Maintenance Director

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

The surveyor toured the environment with Staff 2 (Memory Care Director) and Staff 22 (Maintenance Director) on 07/27/22 and identified the following:

* Multiple resident unit doors and/or jambs had scraped paint;

* Hallway walls and corners underneath the handrails had gouged areas;

* Red colored dining room walls had scraped paint;

* Multiple wood dining room chairs had gouges on the chair legs; and

* Multiple areas throughout the facility, including near resident unit 12, 14, and 23, had a pervasive odor throughout the duration of the survey.

The need to ensure the interior of the environment was kept clean and in good repair was discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4 (RN), Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. All items listed r/t wall, doors and odors will be addressed by Maintenance and Housekeeping.

2. These items/areas will be added to the environmental round checklist which will be completed monthly with QA meeting. Any issues identified will be addressed by appropriate department.

3. Monthly

4. ED and Maintenance

Based on observation and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units per their evaluated need. Findings include, but are not limited to:

Review of records for Residents 1, 2 and 3 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms.

The need to ensure all residents were evaluated for the ability to manage keys to their units and provided keys based on those evaluations was discussed with Staff 1 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4 (RN), Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. Resident 1, 2 & 3 will have a Key and Lock evaluation completed and given an apartment key if appropriate based on the evaluation.

2. Staff will complete a Key and Lock assessment per form provided by RN consultant on all MCU residents and provide resident a key based on the evaluation. This assessment will be added to admission process and re-evaluated quarterly and with any change of condition.

3. Monthly at QA meeting

4. ED

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to: C156, C231, C240, C372, C422, C510 and C513.

Refer to: C156, C231, C240, C372, C422, C510 and C513.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired staff (#s 8, 15, 16 and 17) had documentation of completed orientation, 4 of 4 sampled newly-hired direct care staff (#s 8, 15, 16 and 18) completed pre-service training and pre-service dementia training prior to performing any job duties, 4 of 4 sampled newly hired direct care staff (#s 8, 9, 15 and 16) completed demonstrated knowledge and performance in all required areas within 30 days of hire, and 2 of 3 sampled direct care staff (#s 10 and 19) failed to complete a minimum of 16 hours of annual in-service training on required topics, including 6 hours of annual in-service training on dementia care. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (ED) and Staff 20 (MT/Infection Control Specialist) on 07/27/22 and 07/28/22 and revealed the following:

1. Staff 8 (PCA) hired 02/01/22, Staff 15 (MT) hired 04/18/22, Staff 16 (PCA) hired 06/10/22 and Staff 17 (Housekeeping Assistant) hired 01/24/22, lacked documented evidence of having completed required orientation prior to performing any job duties.

2. Staff 8, 15, 16 and Staff 18 (PCA) hired 01/24/22, lacked documented evidence of having completed pre-service and pre-service dementia training prior to performing any job duties.

3. Staff 8, Staff 9 (MT) hired 03/01/22, Staff 15 and Staff 16, lacked documented evidence of having completed competency demonstrated knowledge and performance in all required areas within 30 days of hire.

4. Staff  10 (PCA) hired 08/21/20 and Staff 19 (PCA) hired 06/15/20, lacked documented evidence of having completed at least 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting with at least 6 hours of annual in-service training on dementia care.

The need to ensure newly hired staff completed all required orientation, pre-service and competency training prior to providing care and services independently and long term direct care staff completed a minimum of 16 hours of annual in-service training on required topics, including 6 hours of annual in-service training on dementia care was discussed with Staff 1 and Staff 2 (Memory Care Director) on 07/29/22. They acknowledged the findings.

1. All sample staff listed will have required training completed and doumented in their employee file per the regulation by 9/27/22.

2. Staff new hire checklist has been revamped to ensure it includes requirments for MCU. Completion of the checklist will be audited by BOM and RCC monthly  and with any new hires to ensure staff have completed all required orientation, pre-service and competency training prior to providing care and services. This will also ensure direct care staff complete a minimum of 16 hours of annual in-service training on required topics, including 6 hours of annual in-service training on dementia care.

3. Monthly and upon hire.

4.BOM, RCC and ED

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 C260, C262, C270, C280, C300, C302, C303, C310 and C330.

Refer to C260, C262, C270, C280, C300, C302, C303, C310 and C330.

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

Resident 1, 2 and 3's current service plans were reviewed during survey. Each of 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 (ED), Staff 2 (Memory Care Director), Staff 3 (Resident Care Coordinator), Staff 4 (RN), Staff 7 (LPN/Assisted Living Operations) and Staff 15 (RN Consultant) on 07/29/22 at 9:10 am. They acknowledged the findings.

1. Nutrition and hydration plans will be completed for resident 1, 2 & 3 with service plans updated to reflect current needs.

2. Staff will use the nutrition/hydration form from RN Consultant to gather personalized information for this focus on all MCU residents and update each of their SPs. This form will be used for any new admissions and updated with quarterly review and any change of condition for all residents.

3. Monthly audit and review with QA program.

4. RCC & ED

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

Observations and interviews indicated the residents were dependent on staff to initiate activities.

Residents 1, 2 and 3's service plans and Activities Assessment offered some information about the residents' historical and current interest, however, the facility had not fully evaluated the residents' in the following areas:

* 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 were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

On 07/29/22 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plans for each resident was discussed with Staff 1 (ED) and Staff 2 (Memory Care Director) who acknowledged the findings.

1. Resident 1, 2 & 3 SP and activities assessment will be reviewed and updated to include: 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.

2. Re-education on assessment and SP requirements for activities given to the Activities Director. Activity assessments and SPs to be reviewed/audited by AD & ED for all new admits, quartely and/or with change of condition for all residents to ensure facility provides meaningful activities based on a thorough evaluation and individualized activity plans for each resident.

3. Monthly and with any new admissions as part of QA program.

4. Activity Director & ED