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

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 06/26/24, conducted 10/21/24 through 10/23/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

During the relicensure survey, conducted 06/24/24 through 06/26/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations.

Refer to deficiencies in the report.

1.  See POC for all individual tags. Administrator in place 40 hours per week and Executive Director at Community has returned from LOA and is also in community 40 hours/wk.  Regional Director of Operations has submitted ARS for license over Memory Care while recruiting new Memory Care Administrator.

2.  All team have been trained on the expectation of posting designation whenever administrator is out of the community with specific name of individual who is acting as designee and education has been provided on the rule.  Clear communication with designees has been provided.

3.  Setting this expectation at time of general orientation with new team members of the requirements for posting designee when administrator is out of the facility.  Reviewing that system is being followed according to rule on a minimum of weekly.

4.  Memory Care Administrator and Executive Director will be responsible for maintaining this system

Based on observation and interview, it was determined the facility failed to ensure residents' right to a safe and homelike environment and to receive services in a manner that protects privacy and dignity for 3 of 3 sampled residents (#s 1, 2 and 3) and multiple unsampled residents. Findings include, but are not limited to:

1. Resident 2 and Resident 3 moved into the memory care facility in 02/2024 and 06/2022 with diagnoses including vascular dementia and Alzheimer's dementia, respectively.

a. Resident 2 and 3's most current service plans were reviewed and observations were conducted from 06/24/24 to 06/25/24 and the following was identified:

* The residents' service plan indicated s/he preferred to be called by their first name. Staff were observed multiple times calling the resident "sweetheart" and "honey".

b. During the survey, staff were observed communicating details about unsampled residents' care needs and/or status over their walkie-talkies, using individual resident's names in the dining room and/or common areas.

On 06/24/24 at 12:46 pm, staff were observed communicating details about Resident 3's care needs and status over their walkie-talkies in the dining room where other residents were present, using his/her name.

The need to ensure the resident's right to privacy and dignity was upheld was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/25/24 and 06/26/24. They acknowledged the findings.

2. Resident 1 moved into the facility in 12/2023 with diagnoses including vascular dementia.

a. During an observation on 06/26/24 at 11:53 am two caregivers provided ADL incontinent care in Resident 1's hospital bed. Resident 1's roommate was in the room at the time and was watching the staff provide care. There was no curtain or divider for privacy and the caregivers failed to use a blanket to cover the residents upper torso which was exposed while they were removing and replacing the resident's incontinent brief.

Additionally, prior to care beginning the surveyor had to request the caregivers close the apartment door and the blinds covering the apartment window.

After care was provided the surveyor asked both caregivers how they were supposed to protect Resident 1's privacy when providing care. Staff 6 (RCC) stated,"honestly, I've never really thought about that."

b. On 06/26/24 at 4:10 pm, Staff 6 was observed walking backwards while escorting Resident 1 in the wheelchair. The surveyor requested the caregiver turn the resident around and direct the wheelchair facing forward for safety reasons and to allow the resident to see where s/he was going.

The need to ensure resident's were treated with dignity and respect and had a safe and homelike environment was discussed with Staff 1 (Interim ED/Regional Director Of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

1.  An inservice has been conducted with all staff regarding resident rights and protection. The inservice included training in the following areas:          

1.a. Calling residents by their name or preferred name as identified on service plan, and not using terms of endearment such as honey, sweetie, dear.  

1.b. Not speaking about residents in front of other residents, including over walkie talkies and in all common areas.   

2.a. Privacy during care, including closing apartment blinds, apartment door and/or bathroom door and ensure resident is covered when providing dressing, bathing and incontinence care.

2.b. Reviewed resident rights related to seeing what direction they are going and training not to push in wheelchair backwards.

2.  All staff to receive training on resident rights and protection upon hire. This training will again be reviewed and discussed at general orientation to ensure staff understand the importance of resident rights, including privacy and dignity.  Training provided on an ongoing basis with frequent oversight and coaching in real time. Ordered privacy screens and ear pieces for walkie talkies and ensuring wheelchairs have appropriate footrests to aid in ambulation.

3.  Weekly spot checks will be done throughout shifts to ensure compliance as well as quarterly care observation forms as part of our monthly continuous quality improvement program (CQI).

4.  Memory Care administrator and Executive Director will be responsible for maintaining this system.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident altercations, elopement, and inappropriate verbal and physical behaviors were immediately reported to the local SPD or AAA office as suspected abuse and the facility failed to ensure unwitnessed falls with injuries were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the falls with injuries were not the result of abuse for 2 of 3 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the memory care community in 02/2024 with diagnoses including vascular dementia.

The resident's service plan, dated 06/05/24, incident investigation reports, progress notes from 03/18/24 through 06/23/24, observations of the resident, and interviews with care staff during the survey indicated the resident was confused and used inappropriate language with a resident.

a. The resident's clinical record revealed the following:

* 06/08/24 - "Resident reached out to touch another residents private area...";

* 06/18/24 - "Making inappropriate sexual comments towards a ... resident and trying to grope [his/her] crotch.";

* 06/20/24 - "very inappropriate with a ... resident." "...resident kept asking [him/her] to leave [him/her] alone...yelling at [him/her].";

* 06/21/24 - "resident was touching another resident on [his/her] legs and arm even after the [resident] asked [him/her] to stop. [the resident] continued."

On 06/24/24 at 2:15 pm, Staff 2 (Regional RN) reviewed the above documentation and Staff 2 reported the incidents should have been investigated. The survey requested Staff 2 to report to the local SPD office.

On 06/25/24 at 10:47 am, confirmation the reports had been sent to the local SPD office was provided.

b. The resident's clinical record revealed the following:

* 03/22/24 - The resident was involved a resident to resident altercation in which a resident "grabbed onto [his/her] shoulder and wheelchair and then pushed [him/her] into the door."; and

* The incident report, dated on 03/22/24, indicated the incident had been reported to "APS." However, there was no documented evidence the incident was reported to the local SPD office. The surveyor requested Staff 1 (Interim ED/Regional Director Of Operations) and Staff 2 report the incident to the local SPD office.

On 06/26/24 at 9:10 am, confirmation the reports had been sent to the local SPD office was provided.

c. The resident's clinical record revealed the following:

* 06/09/24 - The resident was "out in the parking lot." Staff documented on the 06/09/24 incident report that the incident "will be placed [with] APS." However, there was no documented evidence the incident was reported to the local SPD office. The surveyor requested Staff 1 and Staff 2 report the incident to the local SPD office.

On 06/26/24 at 9:10 am, confirmation the reports had been sent to the local SPD office was provided.

The need to ensure all suspected incidents were immediately reported to local SPD office was discussed with Staff 1 and Staff 2 on 06/25/24. They acknowledged the findings.

2. Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia.

The resident's service plan, dated 06/14/24, incident investigation reports, progress notes from 04/10/24 through 06/24/24, observations of the resident, and interviews with care staff were conducted during the survey.

* On 04/22/24 the resident had an unwitnessed fall with head injury to the left temple/forehead. The resident was sent to the emergency department. The facility completed an investigation and noted abuse and neglect had been ruled out as staff responded to the incident quickly; and

* On 05/04/24 the resident had an unwitnessed fall with head injury to the back of his/her head. Emergency medical technicians evaluated the resident in the facility however, s/he was not transported to the emergency department. The facility completed an investigation and noted abuse and neglect had been ruled out as the resident was independent with ambulation and transfers in/out of chairs. Staff responded immediately once fall occurred.

The resident was unable to explain what happened to cause both falls. The current service plan had the following fall intervention:

* Staff to provide safety checks every two to three hours.

The investigation failed to ensure the service plan fall intervention was being followed by staff, therefore the facility failed to reasonably conclude the unwitnessed falls with head injuries were not the result of abuse.

The facility was requested to report the unwitnessed falls with injuries to the local SPD office. The facility provided verification of reporting prior to survey exit.

The need to ensure investigations reasonably concluded unwitnessed falls were not the result of suspected abuse or report to the local office was discussed with Staff 1 (Interim ED/Regional Director Of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

1. A full record review was completed for resident's #1 and #2, including a review of all incidents in the past quarter and verification that any reportable events were reported to APS. Service plans have been updated with current interventions and reprinted to be reviewed by all direct care staff.

2. Memory Care Administrator, Executive Director and Licensed Nurses reviewed the abuse and neglect reporting guidelines and the need for thorough and timely investigations and documentation that includes a review of the service plan and investigation as to whether previous interventions were being followed to help rule out abuse and neglect. Staff have been inserviced on the IR and reporting and investigation process.

3. Incident reports will be reviewed as part of daily standup to ensure proper response and investigation. Investigation to include a review of any previous interventions that were on the service plan and whether or not they were being followed. If unable to rule out abuse and neglect, incidents will be reported to APS. Additionally, as part of the rotating monthly CQI process, residents with frequent falls will be reviewed to ensure appropriate interventions are in place, on the service plan, and are being followed.

4. Memory Care Administrator and Executive Director are responsible for maintaining this system.  

Based on observation, interview, and record review, it was determined the facility failed to ensure an initial evaluation addressed all the required elements for 1 of 1 newly admitted resident (# 4) whose initial evaluation was reviewed. Findings include, but are not limited to:

Resident 4 moved into the memory care community in 05/2024 with diagnoses including dementia.

The resident's initial evaluation was reviewed and it failed to address the following required elements:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* Physical health status including visits to health practitioners, emergency room, hospital or nursing facility in the past years and vital signs if indicated by diagnosis, health problems or medications;

* Mental health issues including history of treatment and effective non-drug interventions;

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

* List of treatments including type, frequency and level of assistance needed;

* Complex medication regimen;

* Recent losses;

* Unsuccessful prior placements; and

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

The need to ensure the initial evaluation included all required elements was discussed with Staff 1 (Interim ED/Regional Director of Operations) on 06/25/24. Staff acknowledged the findings.

1.  Reviewed Resident #4's evaluation and service plan and verified that all required components were addressed and included.

2.  Reviewed move-in LOC evaluation process with clinical team and the need to fill in all of the information on the evaluation prior to admission and it will then pull over to the service plan appropriately.

3.  Evaluation and service plan will be created for all new residents using our LOC evaluation and will be reviewed prior to admission to ensure all required components were included. Audits will be done weekly to ensure all new admissions have been completed correctly and include all required components.

4.  Memory Care Administrator and Executive Director will be responsible for maintaining this system.

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 to staff regarding the delivery of services, and/or were implemented for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 06/2022 with diagnoses including Alzheimer's dementia, anxiety, and a history of falls. The resident's service plan available to staff, dated 06/11/24, and Interim Service Plans were reviewed, observations of the resident were made, and interviews with staff were conducted. The resident's service plan was not reflective and/or was not implemented in the following areas:

* Staff assistance with toileting every two to three hours;

* Transfer assistance; and

* Communication abilities, including ability to verbalize basic wants and needs around toileting, hunger, and thirst.

The need to ensure service plans were reflective and implemented was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

2. Resident 2 moved into the memory care community in 02/2024 with diagnoses including vascular dementia.

The resident's 06/05/24 service plan, 05/24/24 through 06/08/24 Interim Service Plans were reviewed, observations were made, and interviews with caregivers were conducted during the survey.

Resident 2's service plan was not reflective, did not provide clear direction to staff and/or was not implemented in the following areas:

* Oral health status;

* Use of glasses;

* Ted hose status;

* Medication management status;

* Activities and life enrichment;

* Staff assistance with toileting every two to three hours;

* Assistance needed for dressing; and

* Personal hygiene status.

The need to ensure service plans were reflective of the resident's needs, provided clear direction to staff and implemented was discussed with Staff 1 (Interim ED/Regional of Operations) and Staff 2 (Regional RN) on 06/25/24. The findings were acknowledged.

3. Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia. The resident's service plan available to staff, dated 06/14/24, and interim service plans were reviewed, observations of the resident were made, and interviews with staff were conducted.

The service plan was not reflective of the resident's needs as identified in the evaluation and lacked clear direction for staff regarding the delivery of services in the following areas:

* Evacuation status;

* Life enrichment and activities;

* Communication;

* Bathing;

* Ambulation;

* Transfers;

* Eating status and assistance needed;

* Dietary needs including puree diet;

* Use of a divided plate, two handled cup with a lid and a cup with a lid and straw; and

* Weight loss and interventions.

The need to ensure service plans reflected the resident's needs as identified in the evaluation and provided clear direction for staff regarding the delivery of services was discussed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

1. Service plans for resident 1-3 have been updated to include all required information and to be reflective of current needs, preferences and interventions, including clear instructions to staff and have been printed for staff to review. Staff training has been completed that includes implementation of service plans.

2. To prevent recurrance, all current resident service plans will be audited for accuracy. Direct care staff will be reeducated regarding the importance of implementing current service plans and reporting any discrepancies. A form was implemented for care staff to document any discrepancies between resident service plans and actual care needs. Form is to be turned into Memory Care Administrator at end of each shift so that service plans can be updated and reflective.

3. Service plans will be evaluated and reviewed by all departments upon admission, at 30 days, quarterly and with significant change of condition.

4. The Memory Care Administrator and Executive Director will be responsible for maintaining this system.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed, communicate the interventions to staff, and monitor progress of the conditions to resolution for 1 of 3 sampled residents (#1) reviewed for changes of condition. Resident 1 experienced repeated falls with injuries. Findings include, but are not limited to:

Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia.

The resident's clinical record, and interviews with staff were conducted during the survey.

a. Reviewed "significant change of condition comprehensive assessment" for increased confusion and weakness, dated 04/26/24, and the "MC Level of care and service plan" [quarterly evaluation] dated 05/06/24 and corresponding quarterly service plan dated 05/08/24 indicated the following:

* Did not use assistive devices for ambulation;

* Was independent with ambulation, bed mobility and transfers; and

* Safety checks every 2-3 hours while resident was in his/her room and anticipate needs;

* Escort to/from dining room for meals and assist with seating placement; and

* Ensure a clutter free environment, bed in low position, personal items and pendant within reach, and non-glare low light at night time.

Review of progress notes, dated 04/10/24 through 06/24/24 and interim service plans (ISP's) for the same time period identified the following changes of condition:

The resident had seven falls on 04/16/24, 04/22/24, 05/04/24, 05/06/24, 05/08/24, 05/13/24 and 05/22/24. Three of the seven falls had skin and/or head injuries. Although interventions were identified after each subsequent fall there was no documented evidence the facility monitored the fall interventions for effectiveness and the resident continued to have the following additional falls:

* 05/30/24 - Unwitnessed fall without apparent injuries;

* 05/31/24 - Fall with head injury during ADL care; and

* 05/31/24 - Unwitnessed fall (second fall on the same day).

Following the 05/30/24 and two falls on 05/31/24, there was no documented evidence the facility determined what resident-specific actions or interventions were needed to try to reduce future falls and communicated the determined actions or interventions to staff. The facility failed to review previous fall interventions for effectiveness and the resident subsequently sustained another unwitnessed fall with injury to the head, left knee and left elbow on 06/07/24 and was sent to the emergency room. Upon return the resident had a decline in ADL ability and required full assistance with dressing, toileting, transfers with one person, on occasion two-person, perform incontinent care only when [s/he] was in bed or on the toilet due to increasing weakness, unsteadiness and declining cognition, and was admitted to hospice seven days later on 06/14/24.

On 6/16/24 the resident had another unwitnessed fall without apparent injuries.

An ISP written on 06/16/24 revealed no new fall prevention interventions, and the facility failed to review previous fall interventions for effectiveness and/or develop new fall interventions as needed.

During observations on 06/24/24 from approximately 9:15 am to 4:20 pm and 06/25/24 from approximately 9:10 am to 4:30 pm, Resident 1 was observed in bed. On 06/26/24, Resident 1 required a two-person transfer to a wheelchair and was escorted to the dining room.

During an interview with Staff 10 (MT) on 06/24/24 and Staff 12 (CG) on 06/25/24 it was reported the resident had not returned to baseline since the recent falls, had increased confusion, weakness, had been mostly bedfast since approximately the past two weeks and was admitted to hospice care on 06/14/24.

Following the 05/30/24 and two falls on 05/31/24, there was no documented evidence the facility evaluated, determined what resident-specific actions or interventions were needed to try to reduce future falls and communicated the determined actions or interventions to staff.

The facility failed to review previous fall interventions for effectiveness and/or develop new fall interventions and the resident continued to have a fall with an injury.

The need to ensure resident-specific actions or interventions for changes of condition were determined, documented, and communicated to staff on each shift, were monitored, at least weekly, through resolution and fall interventions were reviewed for effectiveness was discussed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24 at 3:20 pm. They acknowledged the findings.

b. The following skin injuries lacked documented evidence the facility evaluated, determined what resident-specific actions or interventions were needed, communicated the determined actions or interventions to staff, and documented weekly progress through resolution:

* 04/16/24 - Right side of head and right ear;

* 04/22/24 - Left temple/forehead, top of scalp;

* 05/04/24 - Back of the head ("small lump");

* 05/06/24 - Bruise to the right outer ankle and top of scalp; and

* 06/07/24 - Back of the head, left knee and left elbow.

Observations of the resident on 06/24/24 through 06/26/24 identified multiple areas of previous skin tears on the resident's bilateral legs and arms. The skin injuries were scabbed at the time of survey.

During an interview on 06/26/24 at 11:35 am, the above skin areas were discussed with Staff 3 (RN-Health Services Director). Staff 3 reported she did not do any skin monitoring but would look for any documentation regarding weekly monitoring for the above skin injuries. No further information was provided.

The need to ensure resident-specific actions or interventions for changes of condition were determined, documented, and communicated to staff on each shift, were monitored, at least weekly, through resolution and fall interventions were reviewed for effectiveness was discussed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24 at 3:20 pm. They acknowledged the findings.

1. Change of condition assessment for resident #1 updated by RN. Service plan has been updated and interventions have been reviewed for effectiveness. Service plan includes clear direction to direct care staff on current interventions. Memory Care Administrator and LNs reviewed regulations related to monitoring of change of condition, including effectiveness of interventions.

2. To prevent recurrence, staff will be reeducated on our alert charting guidelines and when to notify the RN. 24 hour summary will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will then trigger a LN assessement, which will include any changes to the plan of care. The change of condition will be monitored until resolved or a new baseline is determined. When a change of condition is determined to be a significant change, a comprehensive nursing assessment will be triggered for the RN to complete and the condition will be monitored until resolved or a new baseline is determined. Incident reports will also be reviewed as part of daily standup and will include a review of any previous interventions and their effectiveness.

3. This system will be evaluated five days a week as part of daily stand up meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require significant change of condition monitoring as well as a review of skin issues throughout the month.

4. The Arbor Administrator, Executive Director and LN will be responsible for maintaining this system.

3. Resident 5 moved into the memory care facility in 01/2023 with diagnoses including Alzheimer's disease and abnormal wight loss.

During the acuity interview on 06/24/24, the resident was identified as having experienced weight loss.

Resident 5's weight record was reviewed during the survey and revealed the following:

The resident's "Weights and Vitals Summary", dated 01/09/24 through 06/18/24, were reviewed and interviews with staff were conducted during the survey.

* 01/09/24 - 164.8 pounds;

* 02/08/24 - 155.6 pounds;

* 05/07/24 - 163.5 pounds;

* 05/29/24 - 151.0 pounds; and

* 06/26/24 - 155.4 pounds, taken during the survey.

From 01/2024 to 02/2024, Resident 5 had lost 9.2 pounds or 5.58 % of his/her body weight, and between 05/07/24 and 05/29/24, the resident had lost 12.5 pounds or 7.64 % of his/her body weight which represented a significant change of condition.

There was no documented evidence the facility evaluated the resident's condition related to weight loss. On 06/25/24, Staff 2 (Regional RN) confirmed there was no RN assessment for the resident's significant weight loss in 02/2024 and there was one note stating the resident had weight loss in 05/2024, but there was no additional documentation which included findings, a description of the resident's status and a plan of care to address the weight loss.

On 06/26/124, the need to ensure the facility RN completed an assessment for the significant change of condition was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2. They acknowledged the findings.

2. Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia and was identified during the acuity interview as needing meal assistance.

The resident's progress notes dated 04/10/24 through 06/24/24 and previous six months of "Weights and Vitals Summary" were reviewed, observations were made, and interviews with staff were conducted during the survey.

The resident's weights were recorded as follows:

* 01/05/24 - 191 pounds (standing);

* 01/12/24 - 184.2 pounds (standing);

* 01/19/24 - 189 pounds (standing);

* 02/08/24 - 187.8 pounds (standing);

* 03/02/24 - 197.0 pounds (standing);

* 05/07/24 - 203.1 pounds (standing); and

* 06/17/24 - 184.6 pounds (standing).

Observations during the survey identified the resident had a pureed diet texture, the resident was dependent on caregivers for meal assistance. S/he ate less than 25% of breakfast and lunch from 06/24/24 through 06/26/24.

The resident's current weight could not be obtained due to the resident's current condition.

From 05/07/24 to 06/17/24 the resident lost 18.5 pounds or 9.10% of his/her body weight which constituted a severe weight loss which required an RN assessment.

During an interview on 06/26/24, Staff 2 (Regional RN) provided a "MC level of care and service plan" evaluation that she had been completed on 06/18/24. The evaluation read as follows:

* Weight status: loss;

* Goal: Will maintain current weight and/or increase weight to goal weight; and

* Weight loss will be monitored by LN [licensed nurse] and hospice and interventions adjusted as needed.

There was no further information regarding the residents current weight, goal weight, findings of a weight loss assessment and any interventions for the weight loss. Additionally, the service plan was not reflective of the resident's current eating status, weight loss or weight loss interventions.

The need to ensure an RN completed an assessment of the resident's severe weight loss which documented resident status, findings and interventions made as a result of the assessment was discussed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a timely assessment that documented findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 1, 3, and 5), who experienced significant changes of condition in weight. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 06/2022 with diagnoses including Alzheimer's dementia and anxiety, and was identified during the acuity interview as having experienced weight loss.

The resident's progress notes dated 03/24/24 to 06/24/24 and the "Weights and Vitals Summary" from 02/08/24 to 06/25/24 were reviewed, observations were made, and interviews with staff were conducted. The following was identified:

The resident's weight was recorded as follows:

* 02/08/24 - 136.2 pounds;

* 03/02/24 - 124 pounds;

* 05/07/24 - 125.4 pounds;

* 06/06/24 - 112.7 pounds;

* 06/17/24 - 114.8 pounds; and

* 06/25/24 - 120.6 pounds (taken during survey).

From 02/08/24 to 03/02/24 the resident lost 12.2 pounds or 8.9% of his/her body weight which constituted a severe weight loss for which a significant change of condition was required. From 05/07/24 to 06/06/24 the resident further lost 13 pounds or 10.3% of his/her body weight which constituted a severe weight loss for which a significant change of condition assessment was required.

During an interview at 1:15 pm on 06/26/24, Staff 2 (Regional RN) confirmed no RN assessment had been completed.

The resident was observed at two snack passes and for three meals. S/he consumed 100% of the snacks, 10% of one meal, and 100% of the other two meals. She/he was observed to require 40 minutes to over one hour to complete his/her meals. Staff were observed to assist him/her with feeding. S/he would attempt to feed him/herself using his/her fingers; however this was unsuccessful as his/her diet was pureed texture.

The need to ensure a timely RN assessment was completed which included resident status, findings, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 on 06/26/24. They acknowledged the findings.

1.  Resident 1, 3 and 5 have been assessed by RN addressing significant change of condition and service plans have been updated to include clear instructions to staff regarding resident's plan of care.

2.  RN has been provided training on change of condition, including significant change of condition, from NurseLearn, NurseLearn Mentor and Regional Nurse consultant. 24 hour report will be reviewed as part of daily standup and will include any residents who triggered for significant weight changes, as well as progress notes that have been written in the past 24 hours. This will also identify any other changes that have occurred and require follow up.    

3.  This system will be reviewed 5 days a week as part of daily stand up and RN will be notified of any significant changes of conditions so that assessment can be completed and interventions can be  implemented/updated as needed. Further evaluation of this system will occur as part of monthly CQI process which includes an audit of significant changes of condition and appropriate assessment.

4. Memory Care Administrator, Executive Director, and RN will be responsible for maintaining this system.

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 1 of 1 sampled resident (# 2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

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

Resident 2 moved into the memory care community in 02/2024 with diagnoses including vascular dementia and type II diabetes.

During the acuity interview on 06/24/24, Resident 2 was the only resident identified to receive insulin injections from staff.

a. Resident 2's MARs, dated 06/01/24 through 06/24/24, were reviewed and revealed insulin had been given by Staff 10 (MT) and Staff 19 (MT) on multiple occasions.

Delegation records for Resident 2 were reviewed on 06/26/24 and revealed the following:

* Staff 10 and Staff 19's delegation was completed on 04/24/24 and 04/26/24. The delegation records showed there was no documented evidence Staff 10 and 19's skills, abilities and willingness for the delegation tasks; and

* There was no rational, based on the competency of the unlicensed staff, for how frequently the unlicensed staff should be supervised and reevaluated.

b. The MAR showed a staff's initial of "DaMr" administered the resident's insulin on 06/07/24. Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) were asked the name of employee with initial of "DaMr" during the interview on 06/26/24. They were not able to provide the employee's name and was not able to provide the delegation documentation.

The need to ensure unlicensed staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1, Staff 2 and Staff 3 (RN/Health Care Director) on 06/26/24. They acknowledged the findings.

1. All staff responsible for administration of insulin to resident #3 have the appropriate delegations in place per Division 45 and Division 47. This includes; the frequency for reassessment, documentation of observation of task, frequency of supervision and reevaluation, and resident assessment. Memory Care Administrator confirmed resident #3 is the only resident requiring delegation.

2. To prevent recurrence the facility RN will review Division 47 and Division 45 and complete NurseLearn training with Mentor and Regional Nurse.  The RN will use facility CBC RN delegation form to document staff observation and competency, including current and next reassessment date for each staff member preforming the delegated task and each resident receiving delegated services.

3. This system will be reviewed every other month as part of the facility CQI program and will include an audit of all delegated services for continued compliance with Division 45 and Division 47.

4. Memory Care Administrator, Executive Director and RN will be responsible for maintaining this system.    

2.  Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia.

During the acuity interview on 06/24/24 and observations of Resident 1 during the survey, Resident 1 was noted to require two person assistance in transfer status from bed to wheelchair and relied on staff for incontinence care needs.

The surveyor observed on 06/25/24 at 12:42 pm, Staff 9 (CG) and Staff 12 (CG) and on 06/26/24 at 11:53 am Staff 6 (RCC) and Staff 12 provide incontinence care for Resident 1. During the observations, Staff 12 donned gloves without performing hand hygiene. Staff 12 then proceed to remove the resident's soiled brief, wipe feces, cleanse the resident's perineum area and applied moisturizer cream while wearing soiled gloves. Staff 12 failed to doff the soiled gloves, perform hand hygiene, and don clean gloves before applying cream and touching the resident's body, clean incontinent product, clothing and bed linens.

The above observation was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged appropriate infection control practices were not implemented.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 2 sampled residents (# 1) who received incontinent care and multiple unsampled residents who received dining services. Findings include, but are not limited to:

1. Three meal services and three snack services were observed from 06/24/24 to 06/26/24. The following was identified:

* Residents, many who were observed to eat with their hands, were not offered hand hygiene prior to meals or snacks;

* Direct care staff serving meals were not observed with a protective barrier between the food and their potentially contaminated clothing;

* Direct care staff were observed wearing single use gloves during dining services; however they did not perform hand hygiene prior to donning gloves and after disposing of the gloves;

* Staff were observed delivering meals, beverages, desserts, and snacks to residents' rooms without covering the food or beverage to protect from contamination;

* An unsampled resident was observed assisting a caregiver to set the dining room tables, touching cups, bowls, and silverware with his/her hands without first performing hand hygiene; and

* Silverware was set on the dining room tables several hours before meal service.

The need to ensure the facility maintained effective infection prevention and control protocols was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

1.  Direct Care Staff and Activity staff have been provided aprons, plate covers and plastic wrap. Additional training has been completed on infection control processes and dining service expectations including keeping food at appropriate temps, covering any food that leaves the kitchen/dining room, resident hand washing and appropriate glove use during dining services.  Training included not having residents set the dining room and not setting the dining room before the meal.  Training also included infection control practices related to proper infection control practices while providing incontinence care.

2. All staff will be training on infection control practices prior to working with residents. This training will also be reviewed as part of General orienation to reiterate the importance of infecttion control.

3.  This will be evaulated by all leadership staff as part of weekly walkthroughs and will further be evaluated quarterly as part of our CQI process.

4.  Memory Care Administrator and Executive Director will be responsible for maintaining this system.

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

Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia, atherosclerotic heart disease and hypothyroidism.

Review of Resident 1's current physician orders, MARs from 05/01/24 through 06/24/24 identified the following:

* The resident was prescribed Levothyroxine Sodium oral tablet 112 mcg, give one tablet by mouth in the morning (for hypothyroidism); and

* From 05/03/24 to 06/26/24 the resident was not administered the medication on 20 separate occasions because the medication was not available.

During an interview and observation of the medication cart on 06/26/24 at 11:20 am with Staff 3 (RN-Healthcare Director), it was confirmed the medication was not in the medication cart.

During an interview with Staff 4 (LPN - Assist Healthcare Director) on 06/26/24 it was reported " we are having pharmacy issues, [s/he] has VA [Veterans Administration], we faxed them but haven't received a response. When this happened before we contacted the POA [power of attorney] to authorize payment to use our pharmacy, which we did but then [s/he] ran out again. [S/he] is now on hospice and I have talked to them about the medication needing to be refilled. We are just having a hard time getting it."

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN), and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings. Prior to survey exit, Staff 2 confirmed the medication would be available the following day.

1.  Received medications for Resident #1.  Provided staff training regarding ordering, receiving and documentation and ensuring prompt attention when a new medication order arrives.

2.  When a medication is changed or a new order arrives, Medication Technician is to ensure medication is ordered and on hand.  If there is an issue with VA or a pharmacy, team will utilize our house pharmacy to obtain the medication until other issue is resolved.  If unable to obtain from either pharmacy, Med tech to notify LN and PCP and document in prog note.  The Clinical team will review progress notes on 24 hour report to identify any notes written that indicate medications are not available. Medication administration dashboard will also be reviewed to determine if a medication has not been given and this will be followed up on daily.

3.  This system will be reviewed 5 days a week during daily stand up by reviewing 24 hour summary.

4. Memory Care Administrator, Executive Director and LNs will be responsible for maintaining this system.

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

1. Resident 2 moved into the memory care community in 02/2024 with diagnoses including vascular dementia and type II diabetes.

Resident 2's 06/01/24 through 06/24/24 MAR were reviewed and revealed the following:

* Resident 2's MAR included to administer Glucose oral tablets "as needed for hypoglycemia." There were no resident-specific parameters including when to administer the PRN medication.

The need to ensure medications had resident-specific parameters for PRN medications and clear instructions to staff was reviewed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

2. Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia.

* Resident 1's 05/01/24 through 06/24/24 MARs included the following prescribed medications that lacked medication specific instructions on how the resident expressed pain to determine the level of pain s/he was experiencing and which PRN pain medication should be administered.;

* Tylenol 325 mg, give two tablets every six hours, as needed for fever greater than 100 degrees F or for mild pain; and

* Morphine Sulfate oral solution, give .25 ml by mouth every hour as needed for moderate to severe pain.

The MAR included a pain scale instructing unlicensed staff to give for mild pain 1-3, moderate pain 4-6 and severe pain 7-10.

Observations of the resident from 06/24/24 through 06/26/24 identified Resident 1 was unable to consistently make his/her needs known. When caregivers asked the resident if s/he was in pain s/he would sometimes say yes and other time would not answer the question. Other than saying yes the resident was not able to express the level or degree of pain.

The need to ensure medications had resident-specific parameters for PRN medications and clear instructions for unlicensed staff was reviewed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

1.  Medication and treatment orders reviewed for resident #1 and #3. Order instructions updated to include resident specific parameters for when to give the PRN, including a  description of how resident presents with hypoglycemia for resident #1 and how the resident expresses pain for resident #3

2.  Completed MAR/TAR audit for all residents to ensure resident specific parameters are in place for all PRN medications. As part of our triple check process for new orders or changes in orders, LN will verify all PRN orders contain parameters and clear instructions to staff on when to give.

3.  All orders, including PRNs will be reviewed by LN quarterly as part of our order recap process and then sent to the provider to also review and sign. This process will include the LN reviewing that all PRNs have clear parameters and instructions to staff as to when to give. Parameters will also be reviewed monthly as part of our CQI program.

4. Memory Care Administrator, Executive Director and LN will be responsible for maintaining this system.

2. Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia.

The resident's 06/01/24 to 06/24/24 MAR and current prescriber orders were reviewed. The following was identified:

* The resident had an order for diazepam 5mg, give 0.5 tablet by mouth every four hours as needed for anxiety/agitation/insomnia;

* There were no written, resident-specific parameters to instruct staff as to how the resident displayed anxiety, agitation, or insomnia;

* There were no resident specific non-pharmacological interventions; and

* Staff failed to document the reason for giving the medication and what interventions were attempted with ineffective results prior to administering the PRN on 06/16/24 and 06/23/24.

The need to ensure resident-specific parameters and documentation of non-pharmacological interventions to try and document as ineffective prior to administering PRN psychotropics was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

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

1. Resident 2 moved into the memory care facility in 02/2024 with diagnoses including vascular dementia, psychotic disturbance and anxiety.

Review of Resident 2's MAR, dated 06/01/24 through 06/24/24, and 05/18/24 through 06/23/24 progress notes revealed the following:

* The resident was prescribed hydroxyzine 25 mg for anxiety and Olanzapin 2.5 mg for agitation as needed;

* The MAR did not provide instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety behaviors for which staff could consider administering the medication; and

* Staff failed to consistently document non-drug interventions had been attempted with ineffective results prior to administering the medication on three occasions.

On 06/26/24, Resident 2's record was reviewed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN). Providing specific medical parameters including signs and symptoms for the administration of PRN psychotropic medications and to attempt non-pharmacological interventions prior to administering the PRN psychoactive medications was reviewed. They acknowledged the findings.

3. Resident 3 moved into the facility in 06/2022 with diagnoses including Alzheimer's dementia and anxiety.

The resident's 06/01/24 to 06/24/24 MAR and current prescriber orders were reviewed. The following was identified:

The resident had an order for diazepam, give 0.5 tablet by mouth every four hours as needed for anxiety/agitation/insomnia. There were no written, resident-specific parameters to instruct staff as to how the resident displayed anxiety, agitation, or insomnia. There were no instructions to staff to try non-pharmacological interventions and document as ineffective prior to administering the PRN.

The need to ensure resident-specific parameters and documentation of non-pharmacological interventions to try and document as ineffective prior to administering PRN psychotropics was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

1.  Reviewed residents 1-3 and updated MAR to include non-drug interventions and paramaters including signs and symptoms for the psychotropic prn medication.

2.  Completed MAR/TAR audit to ensure all PRN psychotropic medication have non-drug interventions and parameters.  Conducted training for all Med techs on the requirement for providing non-pharmacalogical interventions prior to administration and appropriate documentation. As part of our triple check system, LN will veryify that all psychotropic medications that are PRN have appropriate parameters and non-drug interventions that are to be attempted prior to use of medication, unless otherwise ordered by provider.

3.  All orders, including PRNs will be reviewed by LN quarterly as part of our order recap process and then sent to the provider to also review and sign. This process will include the LN reviewing that all PRNs have clear parameters and instructions to staff as to when to give and that any prn psychoactive medications have non-drug interventions and are only to be given if those are documented as not effective. Psycoactive PRNs will also be reviewed monthly as part of our CQI program to audit orders for parameters and non-drug interventions.

4. Memory Care Administrator, Executive Director and LN will be responsible for maintaining this system.

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, including sufficient staff to meet the fire safety evacuation standards. Findings include, but are not limited to:

The facility was licensed as a Memory Care with a capacity of 28 beds.

a. On 06/24/24 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. The facility acuity-based staffing tool (ABST) for all residents was reviewed during the survey.

During the acuity interview on 06/26/24 and subsequent resident record reviews, the following care needs were identified:

* The facility had a census of 17 residents;

* Three residents required two-person transfers;

* One resident required one-person assistance with all transfers;

* Six residents were identified as heavy care requiring full assistance with ADL's;

* Two residents were on hospice;

* Two residents needed one-on-one meal assistance; and

* Two residents had incidents of recent elopement.

The facility ABST was not accurately being used to determine the correct staffing minutes in multiple ADL areas for sampled Residents 1, 2 and 3 who required 1:1 meal assistance, two person ADL care needs, aggressive behaviors which resulted in multiple resident to resident altercations, and/or had multiple falls with injuries.

Refer to C 361

b. The facility's staffing plan, posted during the survey, showed the following:

* Day shift - 2 Caregivers and 1 Med Tech

* Evening shift - 2.5 Caregivers and 1 Med Tech; and

* Night shift - 1 Caregivers and 1 Med Tech.

Observations and interviews conducted between 06/24/24 and 06/26/24 showed the following:

* Multiple residents needed full meal assistance in their apartments or dining room, two-person transfers, toileting, and/or bathing;

* Observation of ADL care for Resident 1 on 06/26/24, the caregivers were discussing needing to request a third caregiver. In an interview regarding Resident 1's care needs requiring three caregivers, Staff 6 (RCC) stated, we can't that would leave no one on the floor with the other residents."

* During an interview on 06/25/24, Staff 12 (CG) reported "We need more people, we can't provide care timely. Like for [Resident 1] we need two people and there isn't anyone to help, especially during breaks when there is only two people on the floor. Sometimes we need three people to help transfer [Resident 1]. Three days per week we only have two caregivers and the Med Tech, it's not enough."

c. Review of the call light report from 05/15/24 through 06/26/24 identified 43 call response times were in excess of 30 minutes through nine hours. The call light report also identified 4 residents who had been identified during survey as heavy care requiring full assistance with ADL's, had multiple falls with injuries, were on hospice, and/or had a dementia diagnosis who experienced excessive call light response times.

The facility's failure to ensure staff adequate in number to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

1.  Comprehensive audit of all resident service plans completed.  ABST times and questions adjusted according to current resident needs.  Increased staffing to meet resident needs based off the ABST.  Training completed with all  direct care staff in regard to call light response times and expectation to answer promptly.

2.  ABST will be updated prior to move-in, upon move-in, 30-day review, quarterly review and when a change of condition occurs.  Staffing will be adjusted based off ABST whenever there is a change.  Review of call times during stand up, follow up with staff when there is non-compliance with expectation of prompt response.

3.  ABST is reviewed weekly and as needed based on new move-ins, 30-day, quarterly and when there is a change of condition.  Staffing adjusted accordingly.  Call times are reviewed during stand up meeting and monthly CQI meeting to identify trends and need for further training.

4.  Memory Care Administrator and Executive Director are responsible for maintaining this system.

Based on observation, interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that addressed all the following activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care for 3 of 3 sampled residents (#s 1, 2 and 3) whose ABST were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the memory care facility in 02/2024 with diagnoses including vascular dementia, psychotic disturbance and anxiety.

The resident's ABST, last updated 06/19/24, service plan available to staff dated 06/05/24, and Interim Service Plans from 05/24/24 to 06/08/24 were reviewed, interviews with staff were conducted revealed the following:

* The resident's ABST failed to capture the amount of staff time needed to provide care in the following areas; and

* Resident 2 had zero minutes added for assisting with leisure activities, non-drug interventions for behaviors and grooming such as nail care and brushing hair assistance on the ABST.

Observation of the resident, interviews with staff and review of the 06/05/24 service plan revealed staff provided leisure activities, non-drug interventions for behaviors and grooming assistance as the resident required.

The need to ensure all required ADLs on the ABST with the amount of staff time needed to provide care was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

2. Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia.

During the acuity interview on 06/24/24 staff reported the resident required two staff to transfer, required full ADL care including one-on-one meal assistance in his/her apartment, had multiple falls, a recent decline, and was on hospice.

Review of the facility's ABST for Resident 1 identified the facility failed to convert evaluated care needs into accurate staff hours used to generate the facility's staffing plan in the following areas:

* Time spent assisting with communication, assistive devices for hearing speech and vision;

* Time spent assisting with leisure activities;

* Time spent cueing or redirecting due to cognitive impairment or dementia;

* Time spent providing treatments for skin care, wound care or antibiotic treatment;

* Time spent supervising, cueing or supporting while eating;

* Time spent for bowel and bladder management; and

* Additional care and services for two person care needs.

The resident was identified as having a significant change of condition on 06/14/24 and the ABST was not updated to reflect the change.

The need to ensure all required ADLs on the ABST with the amount of staff time needed to provide care was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease, anxiety, and a history of falls.

The resident's ABST, last updated 06/20/24, service plan available to staff dated 06/11/24, and Interim Service Plans from 03/24/24 to 06/24/24 were reviewed, interviews with staff were conducted, and observations of the resident were made.

The resident's ABST failed to capture the amount of staff time needed to provide care in the following areas:

* Assisting with communication;

* Transferring in or out of bed or chair;

* Assisting with communication; and

* Supervising, cueing, or supporting while eating.

The need to ensure the ABST addressed the amount of staff time needed to provide care for the resident was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

1.  Comprehensive audit of all resident service plans completed.  ABST times and questions adjusted according to current resident needs.

2.  ABST will be updated prior to move-in, upon move-in, 30-day review, quarterly review and when a change of condition occurs.  Team have been trained to go into the ABST and hit save upon the review in order to show it has been updated when there are no changes.

3.  ABST is reviewed weekly and as needed based on new move-ins, 30-day, quarterly and when there is a change of condition.

4.  Memory Care Administrator and Executive Director are responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill records from 12/2023 through 05/2024 were reviewed with Staff 5 (Director Environmental) on 06/25/24 and the following was identified:

a. Fire drill records were being conducted in the assisted living which was a separate license from the attached memory care facility. The memory care facility lacked documentation of fire drills being conducted on alternating months which included the following required elements:

* Date and time of fire drill;

* Location of fire origin;

* Escape route used;

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

* Evacuation time period needed;

* Staff members on duty and participating;

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

b. Fire and life safety instruction for staff on alternating months lacked documentation of which staff were in attendance.

The requirements for providing and documenting a written record of fire drills, fire and life safety instruction and staff in attendance was discussed with Staff 5 on 06/25/24, Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

1.  Provided training to Maintenance Director on the requirement to document Fire Drills for Memory Care separate from Assisted Living and on the requirements for staff training on alternating months. A Memory Care specific fire drill has been completed.

2.  Computer program used for scheduling maintenance tasks has been updated to populate Memory Care fire drills separately than Assisted Living so that tasks will require separate documentation. Assisted Living and on alternating months ensure staff have received Fire and Life Safety training and have signed training documentation. Staff inservice schedule will be followed to ensure fire and life safety training is provided on alternating shifts and a sign in sheet will be used to document attendance.

3.  Fire drills and Inservice schedule will be reviewed monthly at CQI meetings to ensure schedule is being followed and all components are addressed.

4.  Memory Care Administrator, Executive Director and Maintenance Director are responsible for maintaining this system.

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

In an interview on 06/25/24, Staff 5 (Director Environmental) was asked how the facility provided fire safety upon admission and annual re-training on fire safety for residents. Staff 5 reported he thought "someone from marketing does this with the them, but she's on vacation now." Surveyor requested Staff 5 follow-up and see if the documentation could be provided. No further information was provided.

The need to ensure the residents were re-instructed upon move in and at least annually on safety procedures and the fire and life safety instruction was documented, was discussed with Staff 5 on 06/25/24 and Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

1. Fire and life safety training has been completed and documented for all current residents.

2. To prevent recurrance, move-in packet has been updated to include a form to document resident fire and life safety training within 24 hours of move-in. Environmental evaluation will be completed semi-annually and includes documentation of re-instruction on fire and life safety training, including specifics on what information is covered.

3. Fire drills and fire and life safety trainings for residents will be reviewed monthly as part of our CQI process to ensure compliance.

4. The Memory Care Administrator, Executive Director and Maintenance Director will be responsible for maintaining this system.

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

The interior of the building was toured at 9:05 am on 06/24/24. The following was identified:

* There was a pervasive, unpleasant odor in the facility hallways and the common room that did not dissipate during the survey;

* The interior and exterior of the kitchenette cabinets, drawers, and refrigerator had a buildup of food debris, splashes, spills, dust; and

* The carpet was stained in multiple areas in the hallways and common room.

The need to ensure the facility was maintained clean and free from unpleasant odors was discussed with Staff 1 (Interim ED/Regional Director of Operations) on 06/26/24. She acknowledged the findings.

1.  Carpet professionally cleaned and carpet squares replaced in all areas where stains were still present after professional cleaning.  Reviewed all resident apartments to determine sources of odor and providing training on handling soiled laundry and linen.  Additional staff training provided for incontinence care and removing incontinence trash from Memory care immediately.  Provided re-education on Memory Care kitchen sanitization and expectations.

2.  Twice weekly walkthough of Memory Care with a focus on environmental including odors, and ensuring community is clean and in good repair. Any areas identified as a concern will be corrected. Dining Services Manager to audit Memory Care kitchen monthly.  

3.  Twice weekly walkthroughs and monthly kitchen audits will be evaluated monthly at CQI meetings.

4.  Memory Care Administrator and Executive Director will be responsible for maintaining this system.

Concerns were identified and the facility was provided with technical assistance in the following areas:

(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Concerns were identified and the facility was provided with technical assistance in the following areas:

H 1517: OAR 411-004-0020(2)(d): Individual Privacy: Own Unit.

(d) Each individual has privacy in his or her own unit.

During the survey, concerns were identified in the following areas and the facility was provided with technical assistance:

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

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

Refer to C 150, C 200, C 231, C 295, C 360, C 361, C 420, C 422 and C 513.

Refer to C150, C200, C231, C295, C360, C361, C420, C422, C513 for POC

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 8, 11, 16, and 18) completed pre-service dementia care training that addressed required topics and that 3 of 4 long-term staff (#s 7, 12, and 17) completed a total of 16 hours of annual in-service training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 20 (Business Office Manager) at 12:20 pm on 06/26/24. The following was identified:

a. There was no documented evidence Staff 8 (MT), hired 05/08/24, Staff 11 (CG), hired 04/25/24, Staff 16 (CG), hired 04/03/24, and Staff 18 (CG), hired 03/25/24, completed all required dementia care pre-service orientation training topics, including:

*  Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms;

* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to identify and address pain, provide food and fluid, and use a person-centered approach;

* How to provide personal care to a resident with dementia; and

* The use of supportive devices with restraining qualities in memory care communities.

b. There was no documented evidence Staff 7 (CG), hired 04/16/21, Staff 12 (CG), hired 08/30/21, Staff 17 (CG), hired 07/13/21 completed 16 hours of annual in-service training.

The need to ensure staff completed all required pre-service orientation training and annual in-service training was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

1.  Audited all Memory Care team members to ensure they have appropriate training for pre-service and annual training and general orientation.

2.  Updated the correct courses in Relias to populate to ensure we meet regulatory requirements.  Monthly review of the staffing grid to ensure all staff have appropriate training.

3.  All staff trainings will be reviewed monthly during CQI Meeting.

4.  Memory Care Administrator, Executive Director and Business Office Manager are responsible for maintaining this system

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

Refer to C 252, C 260, C 270, C 280, C 282, C 303, C 310 and C 330.

Refer to C252, C260, C270, C280, C282, C303, C310 C330 for POC

Based on observation, interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 1 of 3 sampled residents (#1) whose service plan was reviewed. Findings include, but are not limited to:

Resident 1 moved into the memory care community in 12/2023 with diagnoses including vascular dementia, and was identified during the acuity interview as needing meal assistance.

Review of the previous six months of "Weights and Vitals Summary" indicated the resident had a severe weight loss on 06/17/24.

Resident 1's current service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident in the following areas:

* Eating status and assistance needed;

* Dietary needs including puree diet;

* Use of a divided plate, two handled cup with a lid and a cup with a lid and straw; and

* Weight loss and interventions.

The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Interim ED/Regional Director of Operations), Staff 2 (Regional RN) and Witness 1 (Consultant) on 06/26/24. They acknowledged the findings.

1.  Resident #1's service plan was reviewed and updated to include information and staff instructions related to nutrition and hydration status, preferences, and needs, including specific direction on meals including adaptive devices and level of assistance needed during meal time.

2. An audit will be done of all resident's nutritional plans to ensure accuracy and reflection of preferences and level of assistance needed. These nutritional plans, along with resident weight status will be reviewed with all service plan updates, including 30 day, quarterly and significant change of condition. All resident weights will be reviewed monthly and any changes identified will be assessed to determine the need for interventions.  

3.   Nutritional plans will be evaluated upon move-in, at 30-days, quarterly and with significant change of condition. All resident's weight status will be audited monthly as part of the CQI process.

4.  Memory Care Administrator and Executive Director will be responsible for maintaining this system.

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident was evaluated for activities addressing all required elements, develop an individualized activity plan based on their activity evaluation, and provide a selection of daily structured and unstructured activities for 3 of 3 sampled residents (#s 1, 2, and 3) whose evaluations and service plans were reviewed. Findings include, but are not limited to:

Observations of Residents 1, 2, and 3 were conducted from 06/24/24 to 06/26/24. Staff were not observed to provide a selection of daily structured and unstructured activities for Residents 1, 2, and 3.

The most recent quarterly evaluations and current service plans were reviewed for Residents 1, 2, and 3. The following was identified:

a. There was no documented evidence an activity evaluation had been completed that addressed all of the following:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

b. There was no documented evidence an individualized plan was developed for each resident.

The need to ensure activity evaluations were completed, individualized activity plans were developed, and a selection of daily structured and unstructured activities were provided for residents was discussed with Staff 1 (Interim ED/Regional Director of Operations) and Staff 2 (Regional RN) on 06/26/24. They acknowledged the findings.

1.  Conducted a comprehensive audit and updated every memory care resident's service plan with preferences, current abilities and specific direction given to Direct Care Staff on how to provide activities based on each resident's individualized plan.

2.  Memory Care Life Enrichment Director will review resident activities and abilities upon move-in, quarterly and upon change of condition and update service plan to include each residents individualized activity plan.  Based off resident need for direct care staff involvement with activities, ABST will be updated accordingly as well.

3.  At time of move-in, 30-day, quarterly, change of condition.  Monthly review during CQI .

4. Memory Care Administrator, Executive Director and Life Enrichment Director will be responsible for maintaining this system.