The findings of the re-licensure survey conducted 12/06/22 through 12/09/22 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 12/09/22, conducted 07/24/23 through 07/26/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey, conducted on 10/25/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 12/09/22, conducted 03/14/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

During the re-licensure survey, conducted 12/06/22 through 12/09/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in the report.

Refer to plans of correction for the following citations:  C154, C200, C231, C252, C260, C270, C280, C310, C325, C330, C360, C361, C370, C372, C374, C420, C422, C613, C622, and C640     

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

During interviews on 12/06/22 through 12/08/22, sampled residents, non-sampled residents and a witness reported the following related to unresolved complaints and the facility's complaint process:

* Extended wait times for care and long call light response times;

* Meal service: meals were often late, weekly menus were not available, menus were frequently not followed and alternates were not available;

* The facility's activity bus was no longer available;

* Housekeeping services were not provided as scheduled;

* Residents were not aware of the facility's concern or grievance process;

* Complaint/Grievance forms were not always available; and

* The facility was not responding to or not providing follow-up to reported concerns.

During an interview on 12/08/22, Staff 1 (ED), Staff 4 (District Director of Operations) and Staff 20 (District Director of Clinical Operations), stated the facility had various systems in place for residents and families to report complaints, including a concern hot line number which was posted in the facility's lobby, and those concerns were responded to within 72 hours. Staff 4 provided an electronic record which showed a monthly intake log. The record did not provide documented evidence to show how the facility responded to and/or resolved resident complaints.

The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1, Staff 4 and Staff 20 on 12/08/22. They acknowledged the findings.

1.District Director of Operations conducted a Town Hall meeting with residents on 1/16/2023 and a written grievance procedure was provided to residents on 1/19/2023.

2.Associates will be educated on reporting concerns voiced by residents to management.  Community management staff will be educated on the community grievance log and response to resident concerns in writing by 2/1/2023.

3.Executive Director will review grievances submitted every 30 days to assure concerns have been addressed and resolved.

4.The Executive Director or designee is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure 3 of 3 sampled residents (#s 3, 6 and 7) and a non-sampled resident were treated with dignity and respect related to ADL needs and a safe and homelike environment. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 08/2021 with diagnoses including stroke.

Review of the resident's service plan, dated 09/30/22, and interviews with care staff between 12/06/22 and 12/09/22 indicated the resident required 1-2 staff assistance with all ADL care. The resident could express the need to use the restroom and call for assistance appropriately when s/he needed to use the restroom. The resident required 1-2 staff assistance for transfers, utilized a wheelchair for mobility and required extensive assistance to get to the bathroom and complete toileting tasks. The resident was alert and oriented, could direct his/her own care and had moments with increased confusion.

Interviews with Resident 6 between 12/06/22 and 12/08/22 revealed:

* The resident stated call light response times could be slow at times. S/he needed help for all transfers from the recliner, bed, wheelchair, toilet, etc. The resident further indicated s/he needed assistance with clothing and hygiene as well due to limited use of his/her left side. When the resident needed to use the restroom s/he would press the pendant for help, but if it took too long s/he would sometimes attempt to transfer himself/herself. The resident indicated s/he had fallen in the past and injured himself/herself after waiting too long for staff, tried not to self transfer unless it was a dire situation. Usually, the wait was around 20 minutes maybe 30 minutes with some faster, the longest she had waited was about an hour. The resident was able to point out a large clock on the wall and stated s/he had a watch as well.

* The resident indicated s/he did not want to get anyone in trouble or himself/herself but had concerns. The resident stated s/he has had several occurrences when s/he was not able to make it to the bathroom because of the wait time and soiled her pants. The resident indicated s/he would quite often need his/her pants changed due to these accidents. The resident further indicated a staff member recently told the resident they did not want the resident to fall so asked him/her to please not try to get up on their own, "just go in your chair" if you have to. The resident stated s/he "laughed it off," s/he had no intention of going to the bathroom in his/her chair on purpose, "that's not what I'm going to do." The resident stated s/he just wanted to use the bathroom when s/he needed to use the bathroom. The resident declined to share any specific staff names.

In interview on 12/07/22, Witness 1 (Family Member) stated there had been almost daily occurrences when the resident required a clothing change because s/he could not make it to the bathroom in time, "like today." The resident was able to use the toilet with minimal accidents if assisted timely. Witness 1 confirmed they had reported the concerns to facility staff. The resident was not able to get up on his/her own without a high risk for a fall.

Observations of the morning meal and care of Resident 6 on 12/07/22, showed Staff 11 (CG) was delivering the third floor breakfast meals from approximately 9:10 am to 10:15 am. No other caregiving staff was observed on the floor during this time period. At 10:20 am the caregiver was directed by Staff 13 (MT) that the resident's light was on and s/he had been waiting for a "long time," and to check on the resident. Staff 11 entered the resident's room and assisted the resident to transfer to the wheelchair and then to the bathroom. The resident and his/her visitor, Witness 1, stated it had been about 30 minutes since the light was first turned on. The resident was unable to make it to the restroom in time and now required a clothing change as well as the cover on his/her chair changed.

In interviews on 12/07/22, Staff 10 and 11 (CGs) indicated the resident was able to call for assistance and let them know when s/he needed to use the restroom. The staff stated they checked in on the residents as they could and would answer the call lights as fast as they could get to them. The staff both indicated the resident could not safely transfer on his/her own.

The need to ensure a resident was treated with dignity and respect related to their toileting needs was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. They acknowledged the findings.  

2. Resident 7 was admitted to the facility in 04/2021 with diagnoses including chronic pain and anxiety.

The resident's service plan, dated 10/25/22, and interviews with care staff between 12/07/22 and 12/09/22 indicated the resident was independent for the majority of his/her ADL care. The resident used a wheelchair to maneuver around the facility but could transfer on his/her own. The resident required assistance from staff for any incontinent episodes to get cleaned up. The resident was alert and oriented, able to express his/her needs and direct his/her care.

In interviews on 12/07/22, Resident 7 indicated the following:

* The resident stated s/he was primarily independent with his/her care. The resident could transfer, dress and toilet himself/herself without staff assistance. The resident stated s/he has had a couple instances in the last few weeks, when s/he needed help cleaning up after a toileting accident. The resident further stated s/he had to wait an extended period, over 30 minutes, before a staff member even answered the light and then the staff that answered refused to help him/her clean up. The resident indicated s/he had to call again more than once until s/he finally got the help s/he needed to get cleaned up, the staff were "more concerned with getting the light shut off than helping" the resident. The resident felt like s/he did not matter and was a nuisance. The resident felt terrible about the mess, but it wasn't done on purpose and s/he wanted to get cleaned up and needed help.

* The resident stated s/he had two incidents with Resident 2 over the last few months. The resident indicated s/he did not trust or feel particularly safe near Resident 2. One incident occurred after Resident 7 closed the door on Resident 2 while outside, Resident 2 was not locked outside but became angry. Resident 7 stated Resident 2 began screaming, yelling and calling him/her vulgar names. Resident 7 stated it really frightened and upset him/her. Resident 7 did not feel his/her concerns were taken seriously or that anything was done in response to the incident when s/he reported it to Staff 1 (ED).

* The resident additionally indicated s/he and the other resident were "called out," at a subsequent resident meeting as if they "were children who needed to get along". Resident 7 hoped for more support and not to be embarrassed in front of others over an upsetting incident.

* The second incident involved the elevator and Resident 2 trying to force his/her way into the elevator with Resident 7 while s/he partially blocked the door. Resident 7 indicated two other staff intervened which allowed him/her to travel down in the elevator alone and Resident 2 went down separately. Resident 7 did not report the elevator incident to Staff 1 directly. Resident 7 indicated there had been no further incidents with Resident 2.

In interview on 12/08/22, Staff 1 indicated she was aware of both incidents at the time they occurred. Resident 7 reported the incident in the dining room and Staff 6 (Maintenance) reported the incident at the elevator to her. There were no investigations of either incident documented. Staff 1 stated she was not aware of nor did she perceive that Resident 7 was upset or afraid at the time of the incidents.

In interview on 12/09/22, Staff 10 and Staff 22 (CGs) indicated the resident was alert and oriented, could direct his/her own care and required minimal assistance for ADLs. The staff further indicated the resident would require assistance with any incontinent episode or toileting accidents. Staff 10 stated the resident would absolutely require staff assistance for hygiene and clean up if there was a toileting accident. Staff 10 was aware of at least one episode in the last few weeks, but s/he was not the one who responded to the light so had no additional information. Staff 11 stated s/he would check back in with the resident if there was an accident or issue but gave him/her an opportunity to take care of it on his/her own first.

Observations of the resident on 12/07/22 and 12/08/22 showed the resident up and around the facility in his/her wheelchair. The resident was not observed to have any issues with Resident 2 or others around him/her.

The need to ensure a resident was treated with dignity and respect related to their toileting needs and resident altercations was discussed with Staff 1, Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. They acknowledged the findings.  

3. Resident 3 was admitted to the facility in 03/2021 with diagnoses including multiple sclerosis. During the entrance conference, staff reported the resident had a recent stroke and hip fracture, had been hospitalized, the fracture surgically repaired and was now bedbound.

Resident 3's record and interviews with staff indicated, prior to the hospital stay, the resident was independent for most ADL's including transfers, mobility and toileting. Upon return to the facility, was unable to bear weight, requiring multiple staff for transfers in and out of bed.

A temporary service plan, dated 11/16/22, instructed staff to use a "bear hug" transfer technique and another temporary service plan, dated 11/17/22, instructed staff to use "1-2 person assist pivot transfers."

A review of the progress notes, dated 11/19/22, stated the resident was "screaming in room, stating [s/he] wants to get out of bed to sit on the toilet to have a bowel movement ...wants to do it on the toilet instead of the bed..." Hospice was contacted related to the resident's distress and advised facility staff to administer a muscle relaxer.

In an interview on 12/07/22 at 11:00 am, the Resident 3 stated s/he felt upset staff were not able to get him/her out of bed to use the bathroom. The resident stated that care staff reported they were not able to safely lift and transfer him/her out of bed and into the wheelchair or sit in his/her recliner.

In an interview on 12/07/22, Staff 10 (CG) explained "we know how to do it, we just haven't been told we can."

The most recent service plan, dated 11/22/22, provided the following information: "[resident] is dependent with toileting, incontinent of bowel and bladder. Staff to wipe, cleanse skin, apply protective skin cream, change clothes and linens as needed ..."

The resident's status and care needs were discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 12/08/22. Staff 2 acknowledged the facility had not been able to transfer the resident out of bed per the resident's preference and request. Staff 2 stated the resident was no longer able to be transferred out of bed and the facility did not utilize mechanical lifts. The surveyor informed Staff 1 and Staff 2 that because they had accepted Resident 3 back to the facility following the hospitalization, the facility was responsible to meet the resident's care needs and preferences, and failure to do so was a violation of the resident's right to be treated with dignity and respect. Staff 1 and 2 acknowledged the findings.

1.Resident received copies of the Bill of Rights and the Grievance Procedure on 1/19/2023

2.Associates will be provided education on Resident Rights by 2/1/2023.  

3.Residents will continue to receive a copy of resident rights upon move in.  Associates will continue to be provided education on resident rights upon hire.  Residents' rights concerns will be addressed daily as part of stand up meeting and will be investigated as they arise by Executive Director.  Executive Director will host quarterly Town Hall meeting to address resident concerns.

4.Executive Director or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause, falls and resident to resident altercations were promptly investigated to rule out abuse and neglect and reported to the local SPD office as required for 3 of 5 sampled residents (#s 5, 6 and 7) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment and stroke.   

The resident's service plan dated 10/06/22 and interviews with care staff between 12/06/22 and 12/08/22 indicated the resident required 1-2 staff assistance with ADL care. The resident could transfer and walk on his/her own and had a history of frequent falls. The resident did not consistently recognize limitations and safety concerns.  

Review of incident investigations, physician communications and progress notes from 09/01/22 through 12/06/22 showed the following:

* Progress notes dated 11/05/22 indicated the resident experienced two falls. One fall was non-injury and one fall resulted in a skin tear. No investigation could be located for either fall.

* Five additional fall investigations had no documentation the administrator had reviewed the incidents.

The facility was asked to report the fall with injury to the local SPD office and confirmation of the report was received prior to exit.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reviewed by the administrator was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. The staff acknowledged the findings.

2. Resident 6 was admitted to the facility in 08/2021 with diagnoses including stroke.  

During the acuity interview on 12/06/22 the resident was identified as having an injury of unknown cause.

The resident's service plan dated 09/30/22 and interviews with care staff between 12/06/22 and 12/09/22 indicated the resident required 1-2 staff assistance with all ADL care. The resident required 1-2 staff assistance for transfers and utilized a wheelchair for mobility.  

Review of incident investigations, physician communications and progress notes from 07/20/22 through 12/06/22 showed the following:

* A progress note dated 08/19/22 indicated the resident had a skin tear. There was no additional information noted about the skin tear.

No investigation was completed regarding the skin tear.  

* An investigation dated 11/27/22 indicated the resident sustained a cut to the lower leg that required stitches. The investigation indicated blood was noticed while wheeling the resident to the bathroom. The investigation did not contain any other specifics to the event and there was no documented administrator review.

In interviews between 12/06/22 and 12/07/22, Resident 6 indicated his/her leg was injured during a transfer. The staff member was not familiar with him/her, pulled the resident up from behind, "which does not work," and "it immediately hurt." Something on the wheel or footrest was inside the resident's leg. The resident stated s/he "screamed" to be put back down and then there was "quite a lot of blood." The resident stated s/he had about seven stitches in place and they continued to be in place as directed by the doctor.

The facility was asked to report the 08/19/22 skin tear which lacked investigation and the incomplete investigation of the 11/27/22 injury to the resident's leg to the local SPD office and confirmation of the reports was received prior to exit.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reviewed by the administrator was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. The staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 04/2021 with diagnoses including anxiety and chronic pain.  

During the acuity interview on 12/06/22, Resident 7 was identified as being involved in resident to resident altercations with another resident.

The resident's service plan dated 10/25/22 and interview with care staff between 12/07/22 and 12/09/22 indicated s/he was independent for the majority of his/her ADL care. Resident 7 used a wheelchair to maneuver around the facility but could transfer on his/her own. The resident would require assistance from staff for incontinence episodes. Resident 7 was able to express his/her needs and direct his/her care.

Review of incident investigations 09/07/22 through 12/07/22 and progress notes showed the following:

* There were no incident investigations related to resident to resident altercations.

* There were no progress notes related to any resident to resident altercations.

In an interview on 12/07/22, Resident 7 reported there were two altercations with Resident 2 that caused the resident to be fearful and s/he did not feel safe around the other resident. Resident 7 indicated staff were aware of the incidents.  

In interview on 12/08/22, Staff 1 indicated she was aware of both incidents at the time they occurred. Resident 7 reported the incident in the dining room and Staff 6 (Maintenance Manager) reported the incident at the elevator to her. There were no investigations of either incident documented. Staff 1 stated she did not perceive that Resident 7 was upset or afraid.

The facility was asked to report both of the resident to resident altercations which lacked investigation, to the local SPD office and confirmation of the reports was received prior to exit.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reviewed by the administrator was discussed with Staff 1, Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. The staff acknowledged the findings.

1.Incidents for Resident 5, 6 & 7 were reported to APS prior to surveyors exiting the community.

2.Staff will receive training on abuse & neglect reporting by 2/1/2023.  Community Nurses will receive additional education on investigation and self-reporting procedures.  Incidents will be discussed at our daily stand up meeting to ensure investigation is completed timely.  Any incidents without known cause, or otherwise meet reporting criteria will be reported to Adult Protective Services.  Incidents from the past 30 days will be reviewed to assure any incident meeting abuse or neglect reporting criteria are reported to Adult Protective Services.

3.Incidents will be reviewed during routine clinical meeting to monitor effective follow-up, investigation, and/or assure APS reporting has occurred.  Executive Director will regularly review incident reports to determine effective investigation and follow-up information.

4.The Executive Director or designee is responsible for this plan of correction.

2. Resident 6 was admitted to the facility in 08/2021 with diagnoses including stroke, leg fracture and arm fracture.

Observation of the resident, interview with staff, the resident and a family member and review of the resident's 07/20/22 through 12/06/22 progress notes, physician communications, evaluations and temporary service plans were completed.

On 07/23/22 the resident experienced a fall which resulted in two fractures and a hospital admission. The resident returned to the facility on 08/12/22. The evaluation completed on 08/12/22 was not reflective of the resident's current care needs, abilities or the recent fractures and repair.

Subsequent evaluations completed in 09/2022 and 10/2022 also did not reflect the resident's current care needs and abilities.

The need to ensure resident evaluations were completed, at least quarterly, and reflective of the resident's current care needs was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident evaluations contained sufficient and/or accurate information and were reflective of resident care needs for 2 of 6 sampled residents (#s 3 and 6) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including multiple sclerosis. In 11/2022, Resident 3 was diagnosed with a stroke and hip fracture following a fall.

Observations of the resident, interviews with direct care staff and a review of Resident 3's evaluation, dated 11/16/22, revealed the evaluation contained inaccurate or incomplete information in the following areas:

* Mobility, transfer and ambulation needs;

* Toileting status and needs;

* Assistance needed with dressing and hygiene tasks; and

* Wound care to incision site.

The need to ensure resident evaluations contained sufficient and/or accurate information was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 12/08/22. They acknowledged the findings.

1.The evaluation for Resident 6 has been updated to reflect current needs.  Resident 3 no longer lives in the community.    

2.Resident records will be reviewed to ensure that evaluations are complete and current.  Community Nurses will receive additional education on the resident evaluation process.

3.Residents will be evaluated before move in, quarterly and upon change of condition.  Executive Director or designee will conduct random audits on 5 resident records weekly for the next 60 days to ensure presence and accuracy of evaluation.

4.The Executive Director or designee is responsible for this plan of correction.

2. Resident 5 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment and paralysis.

Observations of the resident, interviews with staff and review of the service plan dated 10/06/22 showed the service plan was not reflective of the resident's current care needs, was not consistently followed and/or did not provide clear direction to staff in the following areas:

* Shower assistance and shower bench:

* Adaptive shoe horn device;

* Falls, slides out of bed and safety interventions;

* Catheter care, night bag and day bag/leg bag use;

* Staff assistance levels for ADL care, 1 vs 2 staff;

* Food textures and cut up foods for meals;

* Mattress pad use; and

* Refusals of care, confusion, exiting the facility and unsafe decision making.

The need to ensure resident service plans were reflective of current care needs, were consistently followed by staff and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 08/2021 with diagnoses including stroke.

Observations of the resident, interviews with staff and review of the service plan dated 12/13/21 (from service plan binder) and 09/30/22 (printed from the computer), showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff  and/or did not provide clear direction to staff in the following areas:

* Falls, fracture history and safety interventions:

* Transfer pole use, stability and maintenance;

* Transfer procedure, assistance level of 1 vs 2 staff for transfers and gait belt use;

* Unable to stand for extended periods, hand weakness and leg buckling;

* Incontinent care, toileting needs and toileting frequency;

* Elevating legs and edema;

* Sleeping in bed vs sleeping in recliner and assistance needed;

* Special brief use for night time and additional type for daytime use;

* Leg wound with stitches; and

* Dressing, hygiene and shower assistance needs.

The need to ensure resident service plans were reflective of current care needs, were consistently followed by staff and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. They acknowledged the findings.

4. Resident 7 was admitted to the facility in 04/2021 with diagnoses including muscle spasms and chronic pain.

Observations of the resident, interviews with staff and review of the service plan dated 03/19/22 (from service plan binder) and 10/25/22 (printed from computer), showed the service plan was not reflective of the resident's current care needs, was not consistently followed and/or did not provide clear direction to staff in the following areas:

* Shower assistance:

* Behaviors, outbursts and anxiety;

* Resident to resident altercations; and

* Staff assistance with toileting accidents.

The need to ensure resident service plans were reflective of current care needs, were consistently followed by staff and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were person centered, updated at least quarterly, reflective of residents' needs and provided clear direction to staff and were followed for 5 of 7 sampled residents (#s 2, 3, 5, 6 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 03/2018 with diagnoses including sepsis, diabetes, hypertension and osteomyelitis.

The service plan and temporary service plans were reviewed and the resident and staff were interviewed. The following areas were not person centered, reflective of the resident's needs or did not provide clear caregiving instruction:

* Preference of body part relating to blood draws for capillary blood glucose (CBG) readings;

* Customary eating routine and where s/he preferred to eat meals;

* Customary sleeping routine;

* Interventions relating to behaviors and alcohol consumption;

* Fall history and person centered interventions; and

* Interventions to help staff reduce verbal altercations with other residents.

The service plan available to staff, dated 08/04/22, had not been updated as needed or quarterly.

The need to ensure service plans were updated quarterly, were person centered, accurate and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 12/09/22. They acknowledged the findings.   

5. Resident 3 was admitted to the facility in 03/2021 and experienced a stroke and hip fracture in 11/2022.

Observations of the resident, interviews with direct care staff and review of the service plans, dated 11/16/22 and 11/22/22, showed the service plans were not reflective of the resident's current care needs, were not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Transfer procedure: including assistance level needed, how and when to transfer the resident out of bed for toileting;

* Meal assistance: including how and when to provide assistance, use of nectar thickened liquids;

* Weight monitoring procedure;

* Pain management: including pharmacological and non-pharmacological interventions;

* Nail care;

* Oral care; and

* Housekeeping services.

The need to ensure resident service plans were reflective of current care needs, were consistently followed by staff and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 12/08/22. They acknowledged the findings.

1.The service plans for Residents 2, 5, 6 and 7 were reviewed and updated to reflect current status. Resident 3 no longer lives in the community.

2.Resident service plans will be reviewed to confirm that each is reflective of current status.   As part of the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. Clinical team and/or operations team will utilize a service plan calendar to ensure timely completion.  Community Resident Care Coordinator received training on 1/18/2023 regarding the need for a copy of the current service plan be available for reference by caregivers.  

3.RCC or designee will audit caregiver service plan binder weekly for 30 days to assure current service plan is available.  The Executive Director and/or designee will randomly audit  5 resident service plans weekly for 60 days to assure ongoing compliance.  

4.The Executive Director  and/ or designee is responsible for this plan of correction

3. Resident 5 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment and paralysis.  

Interviews with staff and review of the resident's 10/06/22 service plan, 09/02/22 through 12/04/22 temporary service plans, progress notes, incident investigations and physician communications were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Catheter bag changes for day/night and blood in the urine;

* Skin tear;

* Behaviors and refusal of care;

* Weight changes:

* Falls with and without injury;

* ER visits and UTI; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 08/2021 with diagnoses including stroke.   

Observations of the resident, interviews with staff and review of the service plan dated 12/13/21 (from service plan binder) and 09/30/22 (printed from the computer), 07/20/22 through 12/06/22 temporary service plans, progress notes, incident investigations and physician communications were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Skin tear and stitches;

* Falls with and without injury; and

* Hospital and ER visits.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. They acknowledged the findings.

5. Resident 7 was admitted to the facility in 04/2021 with diagnoses including chronic pain and anxiety.   

Observations of the resident, interviews with staff and review of the service plan dated 03/19/22 (from service plan binder) and 10/25/22 (printed from computer), 09/01/22 through 12/08/22 temporary service plans, progress notes and incident investigations were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Resident to resident altercations; and

* Anxiety and fear reported by the resident.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident specific instructions or interventions were developed and the condition was monitored to resolution at least weekly for 5 of 6 sampled residents (#s 2, 3, 5, 6 and 7) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 03/2018. Progress notes dated 09/01/22 through 12/05/22, the service plan and temporary service plans were reviewed and revealed the following:

A progress note dated 09/15/22 stated, "Resident is on alert for behaviors. No sign of aggressiveness, foul language, or agitation." The alert charting was closed on 09/29/22.

Additional documentation was requested from Staff 1 (ED) on 12/08/22 at 12:17 pm. On 12/08/22 at 1:37 pm, Staff 1 confirmed she did not know what happened on 09/15/22 and that there was no additional information of what occurred that day.  

The need to ensure changes of condition were evaluated and included resident specific instructions or interventions was discussed with Staff 1 and Staff 2 (Health and Wellness Director) on 12/08/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility 03/2021 and experienced a stroke and hip fracture in 11/2022.

The resident's clinical records including service plans, temporary service plans and progress notes from 11/16/22 to 12/06/22, revealed the following:

a. On 11/16/22, upon return from hospitalization for surgical repair of a hip fracture, Resident 3 required treatment and monitoring of a surgical incision .

In an interview on 12/07/22, Staff 2 (Health and Wellness Director) stated the facility procedure was for a facility nurse to review notes from outside providers. Resident 3 had Hospice services that were providing the wound care to his/her incision and the outside provider notes mentioned the wound care being provided. However, multiple provider notes did not have documented evidence they had been reviewed by facility staff. In addition, there was no other documented evidence the facility nurse had evaluated the resident's skin condition or monitored the incision, at least weekly, until resolved.

b. Resident 3 experienced a stroke in 11/2022 resulting in left extremity weakness and swallowing difficulty. Observations of the resident during meals revealed s/he required nectar thickened liquids and had difficulty managing holding a cup and utensils. Resident 3 was unable to use his/her left hand to feed him/herself. Caregivers were needed to provide meal assistance for eating and drinking.

The 11/22/22 service plan instructed staff to "be alert to weight loss", however, the records lacked evidence the resident was monitored, consistent with his/her evaluated needs and there was no information on weight monitoring.

The need to monitor changes of condition, determine interventions and evaluate their effectiveness was discussed with Staff 1 (ED) and Staff 2 on 12/08/22. They acknowledged the findings.  

1.Records for Resident 2, 5, 6 and 7 were reviewed and updated accordingly.

2.Resident records for those with a known pattern of falls, behaviors, skin issues or significant weight change will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record.  Associates will be educated on proper reporting of changes in condition and related documentation by 2/1/2023.   Med Tech associates and Community Nurse will be educated on change of condition documentation to reflect weekly monitoring until resolved.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, documentation is reflected in the resident record and updates are made to the service plan as appropriate.  

3.The Executive Director and/or designee will randomly audit 5 resident records weekly for 60 days to assure ongoing compliance.

4.The Executive Director, nursing team and/or designee is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely, documented findings, resident status and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 3 and 5) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment and stroke.

Weight records, dated 06/15/22 through 11/08/22 and progress notes dated 09/02/22 through 12/04/22, indicated the resident experienced a 9.8 pound weight gain from 11/2022 to 11/2022. This constituted a 5.07% significant weight gain in one month.

A current weight for December was not provided prior to exit.

Progress notes and physician communications dated 09/02/22 through 12/04/22 indicated the resident experienced multiple falls with and without injury, emergency room visits for catheter blockages and received treatment for UTIs.

Multiple observations of the resident between 12/06/22 and 12/08/22  showed the resident was independent with his/her meal once it was delivered. The resident normally ate in the dining room but currently received room delivery.

The resident ate 75-100% of the meals observed. The resident had snacks and fluids available in his/her apartment as well as the items delivered to his/her apartment at meal time. The resident was able to request additional items and maneuver around the facility independently.

In interviews between 12/06/22 and 12/08/22, Staff 10 and 11 (CGs) indicated the resident's intake was very good and s/he was able to eat without assistance. The resident required some assistance with ADLs but consumed food and fluids on his/her own once delivered.

Interview with Staff 2 (Health and Wellness Director) on 12/08/22 indicated an assessment was completed on 12/06/22. She could not say why she waited so long other than just ran out of time. Staff 2 stated the resident ate very well and had only minor edema. Staff 2 understood the need for timely completion of an assessment and to include interventions as a result of the assessment. Staff 2 believed the resident was currently stable.

The facility failed to ensure an RN assessment was completed for the weight gain in 11/2022 which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 and Staff 3 (District Director of Operations) on 12/08/22. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2021 and returned to the facility in 11/2022 with diagnoses of a stroke and hip fracture with surgical repair.

Upon return to the facility, Resident 3 was admitted to hospice services and required extensive assistance with all ADL's. The resident was observed during the survey to be non-ambulatory and required meal assistance to complete meals. The fracture, stroke and resulting decline in mobility and ADL functioning constituted a significant change in condition.

A review of the resident's clinical record, including progress notes from 11/16/22 through 12/06/22 showed an "RN note for change of condition assessment" dated 11/22/22. The RN assessment note failed to address the resident's evaluated needs related to the stroke.

The need for an RN assessments to include findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 12/08/22. They acknowledged the findings.

1.A change of condition assessment for Resident 5 was completed by the RN.  Resident 3 no longer lives in the community.

2.Resident records for those with a known pattern of significant weight changes or receiving hospice services will be reviewed to assure proper evaluation, preventative measures as appropriate and documentation is reflected in the resident record.  Associates will be educated on proper reporting of changes in condition and related documentation by 2/1/2023.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, documentation is reflected in the resident record and updates are made to the service plan as appropriate.  

3.The Executive Director and/or designee will randomly audit 5 resident records weekly for 60 days to assure ongoing compliance.

4.The Executive Director and Registered Nurse will be responsible for this plan of correction.

2. Resident 11 was admitted to the facility in 06/2015 with diagnoses including hypertension and osteoporosis.

Review of Resident 11's physician's orders and MARs dated from 05/01/23 through 07/24/23 revealed the following:

a. The resident had a physician's order directing staff to take his/her blood pressure and pulse every Tuesday for monitoring. The parameter directed staff to notify the prescriber if the "top number is above 140 or the bottom number is more than 90 or less than 60."

On 07/11/23 the recorded blood pressure reading was 152/70, which per the signed orders, needed to be reported to the physician. On 07/25/23 at 9:29 am, Staff 23 (ED) confirmed there was no documented evidence staff notified the prescriber.

Staff coded the resident was "absent from home," on the MARs and the blood pressures were not obtained on the following dates:

* 05/09/23;

* 05/16/23;

* 06/13/23; and

* 07/18/23.

The physician's order did not specify a time for staff to take the blood pressure and the resident received all of his/her medications on the above mentioned days between the hours of 6:00 am through 5:00 pm. On 07/25/23 at 2:16 pm, Staff 23 confirmed the blood pressures were not taken on the above dates.

b. The following medications were not administered per physician's orders:

* Aspirin (for heart health) on 05/27/23;

* Calcarb (supplement used for bone loss) from 05/27/23 through 06/08/23; and

* Multivitamin (supplement) from 06/19/23 through 06/23/23.

On 07/25/23 at 3:47 pm, Staff 23 (ED) verified the medications were not carried out as prescribed.

The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 23, Staff 24 (Health and Wellness Director), and 25 (Regional RN) on 07/25/23 at 2:16 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 3 sampled residents (#8 and 11) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 01/2020 with diagnoses including dementia and iron deficiency anemia.

Review of Resident 8's current facility records and MARs from 07/01/23 through 07/24/23 revealed the following:

Resident 8's current facility records included a legally recognized prescribing practitioner order dated 06/28/23 to "give [Resident 8] full glass of water with each med pass and ensure [s/he] is provided sufficient fluids throughout the day. Labs showing dehydration." However, Resident 8's MAR did not indicate water had been administered with each med pass.

In an interview on 07/24/23 at 1:15 pm, Staff 28 (MT) confirmed Resident 8 was given medications crushed with applesauce during the medication pass.

The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 23 (ED), Staff 24 (Health and Wellness Director), and 25 (Regional RN) on 07/25/23 at 1:55 pm. They acknowledged the findings. No further information was provided.

Sampled resident #8

1. Order was entered into emar day of finding;  order implemented for resident to receive 8oz of water at every medication pass.

2. 90 day physician orders have been reviewed, compared to the MAR, and sent to residents primary care physician to sign.  This is done quarterly. We have a triple check process  for all orders completed daily.

3.  The clinical team is reviewing new orders daily during clinical meeting.

4.  Health and Wellness Director, Executive Director and Resident Care Coordinator is responsible for this plan of correction.

Sampled resident #11

1. HWD added scheduled time in emar for blood pressure to be taken.

2.  HWD added an additional prompt in emar for medication technician to document whether physician needs to be notified based off of prameters from doctors orders. Re-education for our medication technicians is scheduled for 8/25/23 to review order processing, vital signs, parameter notification.  90 day physician orders have been reviewed, compared to the MAR, and sent to residents primary care physician to sign.  This will be done quarterly.  We have a triple check process for all all orders completed daily.

3.  HWD, RCC, ED will review emar dashboard daily during clinical meeting.

4.  HWD, ED, RCC will be responsible daily to ensure compliance.

4. Resident 5 was admitted to the facility in 05/2022 with diagnoses including mild cognitive impairment and hemiplegia.

Review of the resident's 09/02/22 through 12/04/22 progress notes, physician communications, and the 11/01/22 through 12/06/22 MARs showed the following:

* Caregivers were to change the catheter urine bag to the daytime leg bag in the morning and the night time bag at bedtime each day.

The MARs showed the bag was signed by the medication technicians as changed each day.

Observation of the resident from 12/06/22 through 12/09/22 showed the large night time bag was in place with no change to the smaller leg bag. The resident was frequently seen wearing his/her catheter bag hanging from his jeans pocket.

In an interview with Staff 7 (RCC) on 12/08/22, she stated while working as a medication technician, she signs that the bag change was completed because it was a reminder for care staff and confirmed she reminded them to do it. Staff 7 indicated she had no idea if the bag was actually changed.

In interviews with three care staff it was determined the bag change was a caregiver task not the medication technician. The staff indicated they did not record any information on the MAR as they were caregivers. The staff further indicated they did not always help the resident change the bag so they were unsure when it was completed.

The need to ensure treatments completed were signed by the person completing them on the MAR was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) on 12/08/22. The staff acknowledged the findings.

3. Resident 2 was admitted in 03/2018 with diagnoses including sepsis, diabetes, hypertension and osteomyelitis.

The 11/01/22 through 12/06/22 MARs and physician's orders were reviewed and identified the following inaccuracies:

* There were two PRN pain medications, Tylenol and Norco, with no parameters to direct unlicensed staff on which one to administer first;

* On 11/17/22 and 11/24/22 the staff member who administrated routine insulin (for diabetes) was not the same person who signed the MAR; and

* A transcription error for Melatonin (for insomnia) gave direction to staff for a scheduled dose and a PRN dose. The PRN dose was not on the current physician's order.  

The need to ensure MARs included resident specific parameters, were initialed by the same staff member who administered the medication and were accurate was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 12/09/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and instructions for PRN medications and were initialed by the individual who administered the medications for 4 of 5 sampled residents (#s 2, 3, 4, and 5) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including diabetes.

Review of Resident 4's MAR dated 11/01/22 through 12/05/22 revealed the MAR lacked resident specific parameters and instructions for five PRN bowel medications for constipation.

During an interview on 12/08/22, Staff 7 (RCC) confirmed the MAR did not provide resident specific parameters or instructions related to when staff should administer each medication.

The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 4 (District Director of Operations) on 12/08/22. They acknowledged the findings.

2. Resident 3 was admitted to hospice services following a hip fracture and stroke in 11/2022.  

A review of Resident 3's MARs, dated 11/01/22 through 12/06/22, revealed the MAR lacked resident specific parameters and instructions to staff on when to administer four different PRN medications for pain.

During an interview on 12/08/22, Staff 2 (Health and Wellness Director) confirmed the MAR did not include resident specific parameters or instructions for staff on when to administer each medication.

The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 2 on 12/08/22. They acknowledged the findings.

1.The MAR for Resident 2, 4 and 5 have been reviewed to assure resident specific parameters and instructions for PRN medications were present.  Resident 3 no longer lives in the community.

2.Community Nurses will receive training on assuring parameters and clarification are in place with as needed orders to eliminate judgement by the unlicensed staff.  The MARs for the remaining residents will be reviewed to assure proper parameters and clarifications are present and assure accurate documentation in coordination with current physician orders.  Medication Technicians will be educated on following physician orders, MAR documentation and transcription by 2/1/2023.  Transcription will be reviewed by Community Nurses in conjunction with the routine clinical meeting.

3.The Executive Director, Community Nurse and/or designee will randomly audit 5 resident records weekly for 60 days to assure ongoing compliance.  

4.The Executive Director will be responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self administer medications had an evaluation completed at least quarterly to determine their ability to self administer medications for 1 of 2 sampled residents (#6) reviewed for self administration. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 08/2021 with diagnoses including stroke.

During record review of Resident 6, it was determined the resident self-administered his/her own medications.

The resident's 07/20/22 through 12/06/22 progress notes, evaluations, physicians orders and the 11/01/22 through 12/06/22 MAR were reviewed.

The last self administration evaluation was completed on 08/24/21. Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (District Director of Operations) confirmed there was no more recent evaluation of the resident's ability to self administer his/her medications.

The need to ensure residents who self administered their medications were evaluated at least quarterly was discussed with Staff 1, Staff 2 and Staff 3 on 12/08/22. The staff acknowledged the findings.

1.Resident 6 has been evaluated for the ability to self-administer medications.  

2.An audit of residents who self-administer medications will be completed by 2/1/2023 to assure proper orders and self-administration evaluations are on file.  Self-medication reviews will be completed as part of service planning & evaluation process.

3.The Executive Director and/or designee will conduct random audits of 5 resident records weekly for 60 days to assure ongoing compliance.   

4.The Executive Director and Community Nurses are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self administer medications had an evaluation completed at least quarterly to determine their ability to self administer medications for 1 of 1 sampled resident (#11) reviewed for self administration. This is a repeat citation. Findings include, but are not limited to:

Resident 11 was admitted to the facility in 06/2015 with diagnoses including food in esophagus and was identified as having swallowing issues.  

The resident's medical chart was reviewed and revealed the resident self administered the following medications:

* Estrace cream (for the prevention of urinary tract infections);

* Serevent Diskus Aerosol (for throat irritation);

* Cortisporin cream (for ear wax build-up); and

* Nitroglycerin (for chest pain or esophageal spasms).

A quarterly self-administration of medications evaluation was requested. On 07/24/23 at 2:19 pm, Staff 24 (Health and Wellness Director) confirmed there was no documentation one had been completed for the resident.

The need to ensure residents who self administered their medications were evaluated at least quarterly was discussed with Staff 23 (ED), Staff 24 and Staff 25 (Regional RN) on 07/25/23 at 2:16 pm. They acknowledged the findings.

Sampled resident #11

1. Self med evaluations will be updated quarterly with residents scheduled care plan update.  #11 resident self medication evaluation was completed the same day it was identified; prior to survey exit.

2.  A self medication audit was done on all our residents who self administer to ensure the self medication evaluations are present.  All of our resdients are scheduled quarterly going forward with their self medication evaluations as well as their quarterly evaluations and care conferences.

3.  This will be reviewed daily; clinical whiteboard identifies all residents that are self med (full and or partial) with the date due for their next self medication evaluation.

4.  HWD, ED, and RCC will work together to ensure all self medication evaluations are completed quarterly.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled residents (#3) who received psychotropic medications. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2021 with diagnoses including major depressive disorder and anxiety.

The resident's 11/01/22 through 12/06/22 MARs and physician orders were reviewed and the following was noted:

Resident 3 was prescribed Lorazepam PRN for anxiety and it was administered to the resident on nine occasions between 11/24/22 and 12/06/22.

The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications and the MAR lacked information on non-pharmacological interventions to attempt.

During an interview on 12/08/22, Staff 2 (Health and Wellness Director) confirmed the MAR system did not have non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 on 12/08/22. They acknowledged the findings.

1.Resident 3 no longer lives in the community.

2.Remaining resident records with orders for as needed psychotropic medication will be reviewed to assure presence of resident specific behaviors and non-pharmacological interventions.  Medication Technicians will be educated on documentation of non-pharmacological interventions attempted prior to administering as needed phsychotropic medication before 2/1/2023.  MAR documentation will be reviewed in conjunction with the routine clinical meeting.  

3.Executive Director, Community Nurse and/or designee will conduct random eMAR audits weekly for 60 days to assure ongoing compliance.

4.The Executive Director is responsible for this plan of correction.   

Based on observation, interview and record review, it was determined the facility failed to ensure sufficient numbers of direct care staff to meet the 24 hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

At the time of survey, the facility was home to 68 residents, located on three separate floors three floors. During the acuity interview on 12/06/22, the facility identified there were three residents with high ADL care needs and one resident who required two direct care staff for transfers.

The facility's posted staffing plan, confirmed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 12/08/22, reflected the following:

* Day shift 2 MTs and 3 CGs;

* Evening shift 2 MTs and 2 CGs; and

* Night shift 1 MT and 1 CG.

Observations, record review and interviews with sampled residents, non-sampled residents, facility staff and family members conducted during the survey, revealed the following:

* In interview on 12/07/22, Resident 7 stated the facility needed to take a look at how the staff were being assigned and how many were in the building. The response times to call lights could take up to an hour, sometimes more. The resident indicated s/he had called for assistance on two occasions in the last few weeks after a toileting accident. The staff were slow to respond and the staff that did respond refused to help him/her clean up and s/he had to call again. The resident stated the staff was "more concerned with getting the light shut off than helping" him/her.

* In interviews on 12/06/22 and 12/07/22, Resident 6 stated call light responses could be slow, with the longest wait time being about an hour. The resident stated there were times the long wait resulted in the resident soiling his/her pants. The resident was fearful of transferring himself/herself as s/he had fallen in the past when attempting to self transfer.   

* In an interview on 12/07/22, a non-sampled resident stated s/he did not need the staff often for his/her own needs, but knew they were busy and could be slow to respond to the lights. The resident stated s/he found it difficult to locate staff in the evening. S/he had attempted on more than one occasion to assist a neighbor who had turned on their light and then began to yell out for assistance when nobody responded. This could go on for up to an hour before staff responded or could be located, the non sampled resident indicated s/he had looked floor to floor to try to find help as well.

* In interview on 12/06/22, Resident 4 stated "sometimes it takes too long and by the time they come it's too late to get to the bathroom."

* Four sampled residents and three non-sampled residents reported concerns related to the facility's meal service including concerns that meals frequently arrived late in both the dining room and with room trays.

* One non-sampled resident reported concerns related to staff working too many shifts in a row and making mistakes when administering medications.

* In interview on 12/07/22, Witness 1 (Family Member) stated s/he visited Resident 6 several times a week. Witness 1 indicated it was often difficult to locate staff, especially in the evening and on the weekend. Witness 1 stated as an example that s/he was at the facility to visit the resident on 12/04/22, and the residents's call light wasn't answered for approximately an hour. Witness 1 could not locate staff so she assisted the resident on her own at around 1:00/1:30 pm. A review of the call light response log for Sunday, 12/04/22 near 1:00 pm, showed a response time of 84 minutes and 17 seconds.

* In interviews on 12/07/22, Staff 13 (MT) indicated there were two medication technicians split between the three floors. She stated medication technicians usually just passed medications and caregivers provided most of the assistance for the residents' ADL needs such as transfers.

* In interviews on 12/07/22, Staff 10 (CG) and Staff 11 (CG), stated the medication technicians usually only passed medications but would occasionally answer call lights if they were asked to. The caregivers stated at times the call light wait times could be long. They did their best to answer the lights quickly and assist residents. The staff further indicated things like cleaning or trash pick up might not get done right away. The caregivers stated there were five residents who required two caregivers to provide ADL assistance at least some of the time due to physical abilities or behaviors.

Observations of the third floor on 12/07/22, showed Staff 11 (CG) on meal delivery from approximately 9:10 am to 10:15 am. No other direct care staff were observed on the floor during this time period. At 10:20 am Staff 11 ran out of milk for cereal and headed to the kitchen to retrieve more, when Staff 13 (MT) directed Staff 11 to check on Resident 6 as the resident had been waiting a "long time." Staff 11 entered the resident's room and assisted the resident to the restroom. The resident and Witness 1 (Family Member) stated it had been about 30 minutes since the call light was first turned on, the resident could not wait any longer for the bathroom and now required a clothing change.

The survey team reviewed the facility's electronic record for call light response logs for one non-sampled resident and Residents 4, 5, 6 and 7, from 11/07/22 through 12/07/22, and Resident 3's call light response log was reviewed for 11/16/22 through 11/26/22. The response logs revealed:

* On 56 occasions the call light took 20-30 minutes to be answered; and

* On 72 occasions the call light took greater than 30 minutes to be answered.

The need to ensure sufficient staffing to meet the scheduled and unscheduled needs of the residents, as well as the extended call light log times were discussed with Staff 1 and Staff 20 (District Director of Clinical Operations) on 12/08/22. They acknowledged the findings.

1. community looked at tasks provided by caregivers that is not direct resident care and moved to appropriate departments such as moving in room meal delivery from care staff to the dining department on 1/16/2023

2. resident acuity was reviewed with RCC and RN to identify and correct any inaccuracies which would affect acuity based staffing model

3. call light response times will be reviewed a minimum of 3 times weekly for the next 60 days to monitor progress of reducing response time

4. Executive Director or designee is responsible for this plan of correction

Based on interview and record review, it was determined the facility failed to ensure the ABST (Acuity Based Staffing Tool) was updated to determine appropriate staffing levels to address activities of daily living and other tasks related to care for 6 of 7 sampled residents (#s 2, 3, 5, 6 and 7). Findings include, but are not limited to:

During an interview on 12/08/22, Staff 1 (ED) Staff 4 (District Director of Operations) and Staff 20 (District Director of Clinical Operations) stated the facility's ABST system determined staffing needs with information electronically transferred from the resident's service plans and was continuously updated, electronically, on a daily basis.

Observations, interviews, and review of clinical records including service plans for Residents 2, 3, 5, 6, and 7 revealed the service plans were not updated to reflect the residents care needs in order to ensure the facility's ABST tool was accurately updated to determine the needed staffing levels.

The need to ensure the ABST tool was updated to determine appropriate staffing levels to address activities of daily living and other tasks related to care was discussed with Staff 1, Staff 4, and Staff 20 on 12/08/22. They acknowledged the findings.

1.The service plans for Residents 2, 5, 6 and 7 were reviewed and updated to reflect current status. Resident 3 no longer lives in the community.

2.Resident service plans will be reviewed to confirm that each is reflective of current status, thus transferring to the community acuity based staffing tool.   As part of the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. Clinical team and/or operations team will utilize a service plan calendar to ensure timely completion.  

3.The Executive Director and/or designee will randomly audit  5 resident service plans weekly for 60 days to assure ongoing compliance.  

4.The Executive Director  and/ or designee is responsible for this plan of correction

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

During a review of the facility's ABST, it was determined the tool failed to include all of the 22 required ADL components to include:

* Transfer in and out of bed or a chair; and

* Assisting with leisure activities.

The ABST tool was reviewed and discussed with Staff 23 (ED). No additional documentation was received.

1. As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff according to our Brookdale acuity based staffing tool.

2.  Our home office team will continue to establish proper communication with DHS regarding the ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or above staffing levels currently identified in our tool.

3.This will be evaluated by the HWD/RCC to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met.

4.  The Executive Director is responsible to ensure that our staffing levels are appropritate as defined by our staffing tool.

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

The facility's ABST was reviewed on 10/25/23.

There was no documented evidence all 22 required ADLs were addressed separately on the acuity-based staffing tool the facility was using.

During an interview on 10/25/23 at 10:45 am, Staff 23 (ED) confirmed all required ADLs were not addressed separately on the facility's acuity-based staffing tool.

The need to have all required ADLs listed separately on the ABST was discussed with Staff 23 on 10/25/23. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure documentation that 4 of 4 newly hired staff (#s 13, 14, 15 and 16) completed required pre-service orientation training prior to assuming their job duties, and 2 of 2 long-term staff (#s 17 and 18) completed infectious disease prevention training by 07/01/22. Findings include, but are not limited to:

Staff training records were reviewed with Staff  20 (District Director of Clinical Operations) on 12/07/22. The following were identified:

* Staff 13 (MT), Staff 14 (CG), Staff 15 (MT), and Staff 16 (CG), hired on 10/24/22, 08/12/22, 08/18/22 and 07/29/22 respectively, did not complete all required pre-service orientation topics prior to beginning job duties; and

* Staff 17 (MT) and Staff 18 (Dishwasher), hired on 08/01/14 and 12/19/18 respectively, did not complete required infectious disease prevention training by 07/01/22.

The need to ensure documentation of completion of pre-service orientation and infectious disease training was completed timely was discussed with Staff 1 (ED) and Staff 20 on 12/08/22. They acknowledged the findings.

1.Business Office Manager is in the process of assuring Staff #13, 14, 15, 16 have completed pre-service orientation topics and Staff #17 & 18 have completed required infectious disease training.

2.Business Office Manager will conduct an audit by 2/1/2023 of current employee files for documentation of training in pre-service topics and infection control training.  Any associate missing this training will be scheduled for completion by 2/7/2023.

3.Business Office Manager has revised the orientation process to include assuring completion of infection control training prior to being scheduled for on the floor orientation. The Executive Director or designee will review new hire training files for completion for the next 60 days and then conduct random audits thereafter as part of ongong quality assurance.

4.The Executive Director and Business Office Manager are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to verify and document that 4 of 4 newly hired direct-care staff (#s 13, 14, 15 and 16) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to:

Staff training records reviewed on 12/07/22 with Staff 20 (District Director of Clinical Operations) revealed the following:

Staff 13 (MT), Staff 14 (CG), Staff 15 (MT), and Staff 16 (CG), hired on 10/24/22, 08/12/22, 08/18/22 and 07/29/22 respectively, lacked evidence of completing the required training or demonstrating competency in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting changes of condition;

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

* Other duties as applicable.

The need to ensure documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 20 on 12/08/22. They acknowledged the findings.

1.Resident Care Coordinator is in the process of completing return demonstration documentation for Staff #13, 14, 15 & 16 which will be completed by 2/1/2023.

2.Business Office Manager will conduct an audit by 2/1/2023 of current associate files to determine if skill competency documentation is present as required. All associates found to be missing competency documentation will be retrained with return demonstration observation by 2/7/2023.  New hire staff will receive training with return demonstration by Health & Wellness Director, Resident Care Coordinator or designee. Staff will not be scheduled for independent work until competency training has been completed.

3.Business Office Manager will monitor competencies for compliance and will communicate with clinical leadership when staff are able to be scheduled for independent work after validation that all required competency trainings have been completed.  Executive Director or designee will review new employee training files for completion for the next 60 days and then will conduct random audits thereafter as part of ongoing quality assurance.

4.The Executive Director and Business Office Manager are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long-term direct care staff (#s 17, 19, 20 and 21) completed the minimum required 6 hours of annual dementia in-service training in all required topics. Findings include, but are not limited to:

Staff training records reviewed with Staff 20 (District Director of Clinical Operations) on 12/07/22 revealed the following:

Staff 17 (MT), Staff 19 (MT), Staff 20 (CG), and Staff 21 (CG) hired on 08/01/14, 11/05/18, 03/21/19, and 08/01/14 respectively, lacked documented evidence of completing the required 6 hours of annual dementia in-service training.

The need to ensure all required in-service training hours were completed annually was discussed with Staff 1 (ED) and Staff 20 on 12/08/22. They acknowledged the findings.

1.An annual inservice calendar was put in place to assure scheduling of 12 hours of annual inservicing for direct care staff to include 6 hours specific to dementia training topics.

2.Business Office Manager and Resident Care Coordinator will be provided education as it relates to requirements in rule.  Business Office Manager will conduct an audit of training files to determine staff in need of annual training hours.  Staff will be scheduled to complete all needed inservice hours by 2/7/2023.  The Business Office Coordinator will routinely monitor completion of on-line training courses as well as track inservice hours provided during all associate meetings.

3.Executive Director and/or designee to audit inservice hours weekly for 30 days to assure staff completion of assigned tasks, then reduce to audits twice monthly for 60 days.  Training records will be reviewed monthly on an ongoing basis.

4.The Executive Director and Business Office Manager are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to document all required components on fire drill records. Findings include, but are not limited to:

Six months of fire drill records dated 06/30/22 through 12/06/22 were reviewed on 12/07/22. The following deficiencies were identified:

The fire drill records did not document:

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

The requirements for providing and documenting fire drills were discussed with Staff 1 (ED) and Staff 6 (Maintenance Manager) on 12/07/22 and 12/08/22. They acknowledged the findings.

1.A Fire Drill was conducted on 12/31/2022 and is scheduled every month.  

2.Maintenance Director will be provided education on conducting drills according to schedule and documentation of required components. Fire and Safety drill documentation will include problems encountered, evacution time period needed and number of occupants evacuated.  These drills will be conducted by Maintenance Director or designee.

3.The Executive Director will review fire and safety drill documentation monthly to monitor for compliance with the required elements and schedule.

4.The Executive Director and Maintenance Supervisor are responsible for this plan of correction.  

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

Fire drill records from 06/2022 through 11/2022 were reviewed. The facility lacked documentation that residents were being instructed on fire and life safety procedures within 24 hours of admission and annually.  

The need to document instruction to residents in fire and life safety procedures within 24 hours of move-in and annually thereafter was discussed with Staff 1 (ED) and Staff 6 (Maintenance Manager) on 12/07/22 and 12/08/22. They acknowledged the findings.

1.The Executive Director or designee will provide fire and life safety instruction to residents during Town Hall meeting scheduled for January 25, 2023. Residents will be provided with a map showing evacuation route. This map will be posted on the back of the resident's door and resident will sign to showcase understanding.

2.Maintenance Director will be provided training regarding the need to provide education on fire and life safety procedures within 24 hours of resident move in and annually.

3.Maintenance Director or designee will review that maps remain posted inside resident doors during routine facility walk throughs.

4.The Executive Director and Maintenance Director are responsible for this plan of correction.   

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

Refer to C 325 and C 361

See C 325 and C 361

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

Refer to C361.

Based on observation and interview, it was determined the facility failed to keep all interior and exterior materials, surfaces and all equipment necessary for the health, safety and comfort of the resident clean and in good repair. Findings include, but are not limited to:

The interior and exterior of the building was toured on 12/06/2022 at 1:13 pm. The following areas needed cleaning or repair:

* Multiple resident room doors and facility doors had black scuff marks, dings, scrapes and scratches;

* Missing windowsills in residents' laundry rooms on first and third floors;

* Gouges in handrails outside of 104, 114, 120 and 208;

* Multiple handrail guards with missing wood dowels;

* Handrails throughout the facility had rough areas and on the first floor;

* The elevator frame on the first, second and third floors had chipped paint and scuff marks;

* Entrance and exit doors in kitchen had chipped paint and black scuff marks;

* Persistent odor in hallway near rooms 113 through 116;

* Dining room pillars with debris, gouges and in disrepair;

* Overhead light fixtures in dining room had an accumulation of dead insects;

* Vents outside of 105 and 220 had dirt, dust and debris;

* Outdoor entrance near room 115 had buildup of cobwebs, dead insects and leaves;

* Two out of three outdoor vents near a patio had green matter;

* A cement ramp from the sidewalk to the smoking area was crumbling and was in disrepair;

* Multiple dining room chairs with rips, worn areas and in disrepair;

* Multiple dining room tables with scratches and scuffs;

* Dirt, dust and debris behind the dryers on second and third floor laundry rooms;

* Dried brownish-red matter on handrails outside of room 222;

* Dark reddish matter on handrail near 317;

* A dresser by 327 had scuffs and chips; and

* Walls throughout facility had dried matter and stains.

On 12/07/22, the building's interior and exterior were toured with Staff 1 (ED) and Staff 6 (Maintenance Manager). They acknowledged the findings.

1.The community experienced a flood and multiple areas of the community are currently being repaired.  Areas mentioned in survey that are not contained within the flood repair zone will be addressed by the compliance date.  

2.Associates will be educated on reporting common area cleaning and repair requests by 2/1/2023.  Work orders will be reviewed weekdays during routine stand-up meeting.

3.Routine communty walk-throughs will be conducted by the Executive Director or designee weekly for 1 month then monthly thereafter in conjunction with Safety Committee meeting reviews to assist in maintaining gereral building compliance.

4.The Executive Director, Maintenance Director and/or designee are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure the stove in the activity room, located on the second floor had a keyed, remote switch or safety device to ensure staff control and that each resident or unit must be provided a mailbox that meets US Postal Service requirements. Findings include, but are not limited to:

The interior environment was toured on 12/06/22 and 12/07/22 and revealed the following:

1. The stove in the activity room located on the second floor was able to be turned on without the use of a key, remote switch or other safety device.  

During an interview with Staff 1 (ED) on 12/06/22, it was reported that there was no keyed, remote switch or safety device to ensure staff control. She took immediate action and had stove unplugged.

2. The mailbox face for residents on the third floor was in disrepair, allowing all third floor mailboxes to be exposed and opened when pulled.

The need to ensure the stove in the second floor activity room had a functioning keyed, remote switch or other safety device was discussed with Staff 1 on 12/06/22. The need to provide a mailbox to each resident or unit that meets US Postal Service requirements was discussed with Staff 1 and Staff 6 (Maintenance Manager) on 12/07/22. They acknowledged the above findings.

1.An order has been placed for equipment to make the mailbox repairs.  Regional Maintenance Tech reviewed common are stove on 1/20/2023 to determine appropriate locking mechanism.

2.Associates will be educated on reporting repair needs with the resident mailbox and the need and use of the safety device installed in common area stove.  Work orders will be reviewed weekdays during routine stand-up meeting.

3.Routine communty walk-throughs will be conducted by the Executive Director or designee weekly for 1 month then monthly thereafter in conjunction with Safety Committee meeting reviews to assist in maintaining gereral building compliance.

4.The Executive Director, Maintenance Director and/or designee are responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

During an environmental walk-through on 12/06/22, the outdoor fireplace exhaust vent temperature was 206.0 degrees F when measured by the surveyor at 2:10 pm. The exhaust vent was located adjacent to the outdoor patio where residents were observed to pass through and the height of the vent was measured at four feet and seven inches.

The location of the outside fireplace exhaust vent was subject to incidental contact by residents.

The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1 (ED) and Staff 6 (Maintenance Manager) on 12/07/22. They acknowledged the findings.

1.The fireplace has been disabled until a solution can be found to assure incidental contact with the fireplace element above 120 degress does not occur.

2.Associates will be educated on regulation related to heating elements and temperatures.

3.Routine exterior walks will be conducted by the Executive Director or designee weekly for 1 month then monthly thereafter in conjunction with Safety Committee meeting reviews to assist in maintaining gereral building compliance.

4.The Executive Director, Maintenance Director and/or designee are responsible for this plan of correction.