The findings of the re-licensure survey, conducted 05/17/22 through 05/18/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 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 05/18/22, conducted 10/26/22 through 10/27/22, 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 57 for Memory Care Communities.

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

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 second re-visit to the re-licensure survey of 05/18/22, conducted 03/23/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.  

Based on interview and record review, it was determined the facility failed to ensure unwitnessed falls were thoroughly investigated to rule out abuse/neglect and reported to the local SPD office, as appropriate, for 1 of 1 sampled resident (# 2) with incidents. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 04/2019 with diagnoses including dementia.

Review of the resident's clinical records, including progress notes, incident reports, investigations, and temporary service plans, dated 02/17/22 through 05/17/22, revealed the resident had an unwitnessed fall and sustained bruising and skin tears to the left shoulder and left upper arm on 05/10/22.

There was no documented evidence the unwitnessed fall with injury had been investigated to rule out abuse, and the facility did not report to the local SPD office.

The need to ensure resident incidents were thoroughly investigated and reported to the local SPD office when indicated was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RN Consultant) on 05/18/22. They acknowledged the findings. Verification the facility had reported the incident to the local SPD office was received on 05/18/22.

Resident #2 I.R. report regarding unwitnessed fall with injury has been investigated and abuse has been ruled out.  Incident was also reported to the State. I.R.s are reviewed daily at stand up with RCC , RN and Admin to rule out abuse and determine if the report needs reporting per regulation.   All staff will be in serviced on 6.9.22 on reporting abuse.  Administrator will be last signature on Incident Reports to ensure that they are thoroughly investigated and reported to SPD office when indicated.

RN will investigate all I.R.s and  documention in electronic medical record.

Investigations will be evaluated weekly for 6 weeks, bi-weekly for 6 six weeks and then monthly.   

Administrator will be responsible to monitor that the corrections are completed.  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 05/17/22 at 2:20 p.m., the facility's main kitchen was observed to need cleaning or repair in the following areas:

* Floors throughout the kitchen had black matter build-up and food debris in corners, around perimeter edges, under equipment and inside floor drains. Floors additionally had large scratches, gouges and large sections with scraped and missing paint;

* Shelving throughout the kitchen, including the refrigerator and freezer, and shelving in the dry storage, had food spills, white/gray accumulation, dust, and/or debris hanging from edges;

* Ceiling vents had an accumulation of lint and dust on the grates;

* Ceiling lights throughout the kitchen had dead insects and debris inside;

* Two floor fans had caked-on dust and cobwebs; and

* Doors frames and walls had splatters, dust/cobwebs, spills and/or chips.

On 05/17/22 the two kitchenettes were observed to need cleaning or repair in the following areas:

* Debris and spills were noted in drawers and cupboards;

* Counter edges had chips, gouges and missing pieces of laminate;

* Spills/splatters were on walls near the refrigerators;

* A fan on the floor had thick dust and cobwebs hanging from the front;

* Spills and debris were noted on shelves and in drawers of refrigerators; and

* Microwave was noted with spills and splatters along the inside of the door, sides, and top.

The need to ensure the kitchen and neighborhood kitchens were kept clean and in good repair was shown to and discussed with Staff 1 (Administrator) and Staff 6 (Dietary Manager) on 05/17/22. She acknowledged the findings.

Floors racks and all kitchenettes have been deep cleaned to address all sited issues.  Deep cleaning schedule put on list of duties for cooks and dietary aids.

Cleaning willl be reviewed with Administator during the weekly 1:1 meeting.

Administrator will walk through the kitchen weekly and audit for cleaning.    Results of the audit will be brought monthly for 3 months and reviewed quarterly in Q.A.P.I.

Dietary Manager is responsible to make sure corrections are completed.   

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

Resident 1 was admitted to the facility on 03/02/22. The resident's move-in evaluation was dated 03/02/22. The following elements were not addressed in the move-in evaluation:

* Customary routines: eating, bathing;

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* List of current diagnoses;

* Vital signs if indicated by diagnosis, health problems, or medications;

* Memory, orientation, confusion, and decision-making abilities;

* Presence of depression, thought disorders, or behavioral or mood problems;

* History of treatment and effective non-drug interventions;

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

* Ability to understand and be understood;

* ADLs including mobility, assistive devices, and dental status;

* Ability to use call system;

* Transportation;

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Nutrition habits, fluid preferences, and weight if indicated;

* Complex medication regimen;

* Recent losses;

* Unsuccessful prior placements;

* Elopement risk or history;

* Smoking, ability to smoke safely;

* Alcohol and drug use not prescribed by a physician; and

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

The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 05/18/22. They acknowledged the findings.

Resident #1 will have all missing information put into his chart.  A move in evaluation will be done prior to every move-in.  The initial move in screening assessment will be updated to include all required elements.  

Move-in evaluations will be reviewed by Administrator

RN will be responsible to see that move-in evaluations  are completed.   Administrator will bring results of audit to quarterly Q.A.P.I. meeting to make sure all assessments were done.  

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#6) who recently moved in. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in early September 2022. The resident's move-in evaluation was dated 08/17/22. The following elements were missing or not addressed in the move-in evaluation:

* Effective non-drug interventions for mental health issues;

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

* Pain: pharmaceutical interventions, including how a person expresses pain or discomfort;

* Skin condition;

* Nutrition habits;

* Emergency evacuation ability;

* Elopement risk or history; and

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

The need to ensure move-in evaluations addressed all required areas and information was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 10/26/22. They acknowledged the findings.

Resident #6 move-in evaluation has been reviewed to ensure all elements that were missing have been addressed on her service plan.  The move-in evaluation has been updated to include all required elements.  Move-in evaluations will be reviewed by the administrator.   Administrator will bring results of her own audits of move-in evaluations to quarterly QAPI meeting to review trends until the alleged deficient practice is resolved. RN will be responsible to see that move-in evaluations are complete with required components.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced a significant change of condition were assessed by the RN for 1 of 2 sampled residents (#4) with a significant change of condition. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's Disease.

Review of the resident's 02/14/22 through 05/17/22 weight records, progress notes, and RN assessments, observations of the resident, and interviews with staff revealed the following:

Resident 4's weight on 02/25/22 was 183 lbs. His/her weight on 04/05/22 was 198.2 pounds. This represented a 15.2 weight gain or 8.3 percent of the resident's body weight in one month, which was severe.

There was no documented evidence the RN had completed an assessment of the resident when s/he experienced a severe weight gain.

The resident's weight on 05/17/22 was 191 lbs. This represented a 7.2 lb or 3.6% weight loss.

The resident was observed to be fed by staff on multiple occasions during the survey.

In an interview with Staff 2 (RN), she acknowledged an assessment had not been completed. The RN indicated the facility had attributed the resident's weight gain to increased oral intake as the resident had transitioned from feeding him/herself to allowing staff assist during that time frame.

The need to ensure residents who experienced a significant change of condition were assessed by the RN was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (RN consultant) and Staff 4 (RCC). They acknowledged the findings.

Resident #4 significant wieght change was completed on 5.18.  Resident #4 was not put on weekly weights per hospice.  RN will monitor monthly wieght report.  If resident experiences a significant change of wieght an RN assessment will be completed.    

Wieghts will be reviewed during the RN 1:1 weekly meeting with Administrator.   any residents that have had a significant wieght change to Q.A.P.I. quarterly.

RN is responsible to see that the corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to ensure on-site health services were coordinated with outside health providers and that providers left written information in the facility which addressed the services being provided and any clinical information necessary for facility staff to provide supplemental care for 1 of 2 sampled residents (#4) who received services from outside providers. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's Disease.

Review of the resident's facility record and interviews with staff revealed the following:

During the acuity interview on 05/17/22, Resident 4 was identified to be receiving hospice services.

A progress note dated 04/19/22 indicated hospice services had been initiated.

During an interview with Staff 1 (Administrator), she stated the facility was unable to locate hospice provider written communications.

The need to ensure on-site health services were coordinated with outside health providers and that providers left written information in the facility which addressed the services being provided and any clinical information necessary for facility staff to provide supplemental care was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN consultant) and Staff 4 (RCC). They acknowledged the findings.

Hospice records have been obtained for #4 and put in chart.   All residents on Hospice will have a binder that all communications go into.   RN has communicated with Hospice team that this will be the new process going forward. Administrator and RN will review the Hospice binder during stand up daily.  The RN will audit outside resources/communications monthly to make sure outside care services are coordinated.   This process with be reviewed by RN and Admin quarterly at Q.A.P.I.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and/or provided clear instruction and parameters for administration of PRN medications for 2 of 4 sampled residents (#s 2 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 admitted to the facility in April 2019 with diagnoses to include diabetes.

Resident 2's 05/01/22 through 05/17/22 MAR was reviewed and revealed the following:

* Blood Glucose Monitoring (CBG) was ordered to be checked twice a day, before breakfast and dinner. On three occasions the MAR was blank where the CBG should have been documented.

* Basaglar Insulin 15 units subcutaneous injection was ordered to be administered daily with dinner. On three occasions the MAR was blank where the insulin administration should have been initialed as given.

* High protein snacks were ordered to be provided three times a day.  There were 27 occasions the MAR was blank where the snacks should have been initialed as given.

Staff 4 (RCC) reported staff had forgotten to go back and initial the MAR/DAR (Diabetic Administration Record) after checking Resident 2's CBG, administering insulin and after providing snacks.

The need to ensure MARs were accurate was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RN Consultant) on 05/18/22. They acknowledged the findings.

2. Resident 4 was admitted the facility in 05/2021 with diagnoses including Alzheimer's Disease.

Review of the resident's current physician orders and the 04/1/22 through 05/17/22 MAR revealed the following:

a. Resident 4 had multiple PRN bowel and pain medications which lacked parameters which instructed staff related to the sequence of administration.

b. There were multiple blanks on the MAR.  

The need to ensure the MAR was accurate and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant) and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

All Team Leads will have training on checking all parts of a resident's MAR DAR and TAR.  Resident #4  PRN medications for bowel and pain were updated with parameters and instruction for staff to the sequence of administration.

TLs will now be signing when poping medicatons and come back if there was a change in administration.  

A medication omission administration report will be done daily for 4 weeks by RN then weekly.  Trends will be brought to Q.A.P.I. meeting to be resolved.  

RN is responsible for tracking and making sure corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to maintain legible signatures of staff who administered medications and treatments, either on the MAR or on a separate signature page, filed with the MAR for 4 of 4 sampled residents (#s 2, 3, 4 and 5) whose MARs were reviewed.  Findings include, but are not limited to:

A review of Resident 2, 3, 4 and 5's 05/01/22 through 05/17/22 MARs revealed there were no documented signatures to identify which staff administered medications and treatments.

The need to ensure the facility maintained legible signatures of staff who administer medications and treatments, either on the MAR or on a separate signature page filed with the MAR, was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant), and Staff 4 (RCC) on 05/18/22.  They acknowledged the findings.

Paper signature sheets have been put into binder for Team Leads to sign at the beginning of every month.

We will be using paper sheets till our new system P.C.C.  can put signatures on the MAR.

This will be monitored monthly by the RN and the RN will be responsible to see that the corrections are completed.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were  attempted prior to the administration of PRN psychotropic medications and specific reasons for the use of the psychotropic medication for the resident were communicated to staff for 1 of  3 sampled residents (#4) who received as needed psychotropic medications. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's Disease.

Review of the resident's current physician orders, 04/04/01/22 through 05/17/22 MAR, and progress notes revealed the following:

A 04/18/22 physician order instructed staff to administer one 0.5 mg tablet of

lorazepam every six hours as needed for anxiety, agitation, or nausea. There was no documented evidence the facility provided information to staff as to how the resident expressed anxiety or agitation or what non-drug interventions to attempt prior to administration of the PRN psychotropic medication.

The medication was administered three times on 04/22/22 and once on 04/23/22. There was no documentation related to why the medication was administered or that non-pharmacological interventions were attempted prior to administration.

The need to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medications and the specific reasons for the use of the psychotropic medication for the resident were communicated to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant) and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Resident #4 lorazepam was updated in MAR to provide staff information as to what anxiety or agitation looks like for that resident.   Non-drug interventions were also added for staff to document what was tried before giving the PRN.

All PRN pain or psychotropic medication will be put into MAR with information on what each resident's pain, agitation, or anxiety looks like along with non-drug interventions for each resident.   

This will be evaluated monthly for 3 months and then reviewed  at quarterly with Q.A.P.I. for the next two meetings.

Resident Care Coordinator and Administrator will be responsible.  

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of PRN psychotropic medications for 2 of 2 sampled residents (#s 6 and 7) who received psychotropic medications. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in September 2022 with diagnoses including Alzheimer's Disease.

Review of the resident's current physician orders, 10/01/22 through 10/26/22 MAR, and progress notes revealed the following:

a. Resident 6 had a physician's order for Quetiapine 50 mg every four hours as needed for agitation. The resident received the PRN medication eleven times between 10/01/22 and 10/26/22. Ten of the eleven administrations lacked documentation that non-pharmacological interventions were tried and were ineffective before administering the medication.

b. Resident 6 had a physician's order for Lorazepam 0.5 mg twice a day as needed for anxiety. The resident received the PRN medication nineteen times between 10/10/22 and 10/26/22. Thirteen of the nineteen administrations lacked documentation that non-pharmacological interventions were tried and were ineffective before administering the medication.

2. Resident 7 was admitted to the facility in September 2020 with diagnoses including dementia.

Resident 7 had a physician's order for Lorazepam 0.5 mg every day as needed for agitation. The resident received the PRN medication three times between 10/01/22 and 10/26/22. Three of the three administrations lacked documentation that non-pharmacological interventions were tried and were ineffective before administering the medication.

During interviews on 10/26/22 with Staff 15 (MT) and on 10/27/22 with Staff 19 (MT), the electronic MAR was reviewed. Staff were unable to locate documented non-pharmacological interventions in the electronic system. Staff 15 stated that MT's had been instructed to enter a progress note following the administration of PRN psychotropic medications to document the interventions attempted before giving the medications.

The need to ensure documentation that non-pharmacological interventions were attempted and found ineffective prior to the administration of psychotropic medications was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (RCC) on 10/27/22. They acknowledged the findings.

Resident #6 and #7 have had their MARs updated to include non-pharmacological interventions documented prior to administration of PRN psychotropic medications.  All residents with PRN psychotropics have the same system in place and all residents MARs have been updated to include the non-pharmacological interventions.  Aministrator and RCC will review the MARs monthly for non-pharmacological interventions for three months the review quarterly at QAPI meeting until the alleged deficient  practice is resolved.  The administrator and RN are responsible to see that the corections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident service plan and evaluated on a quarterly basis for 1 of 1 sampled resident (#4) who had a side rail. Findings include, but are not limited to:  

Resident 4 was admitted to the facility in 05/2021 with diagnoses including Alzheimer's disease.

Review of the resident's facility record revealed a lack of documented evidence the use of the side rail had been included in the service plan and evaluated on a quarterly basis.

The need to ensure documentation of the use of supportive devices with restraining qualities was included in the resident service plan and evaluated on a quarterly basis was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant) and Staff 4 (RCC). They acknowledged the findings.

Resident #4 restraint/device assessment has been completed.  All restaints/devices will be reviewed quarterly by RN during the review of Service Plans.  Administrator will audit restraint/devices assessments monthly and bring results to Q.A.P.I. meeting for the next two meetings.   

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff  (#s 8, 12, 17 and 18) completed abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to:

A review of staff training records on 05/18/22 revealed the following:

There was no documented evidence Staff 8 (CG), Staff 12 (CG), Staff 17 (CG), or Staff 18 (MT), hired 01/21/22, 04/15/22, 01/31/22, and 09/13/21, respectively, had completed the required training in First Aid and abdominal thrust.

The need for staff to complete all required training within the appropriate time frame was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant), and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

All employee records have been audited to ensure all staff have received abdominal thrust and first aid training.  A training checklist to be used 30 days after hire has been implemented.     

Buisness office manager will give RCC a list of new employees for tracking and making sure 30 days after hire training is complete.   Aministrator will audit 25% of new hires to ensure training is complete.  This process will be brought to Q.A.P.I. by Administrator.   

Based on interview and record review, it was determined the facility failed to ensure fire and life safety documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill records were reviewed from 12/01/21 through 05/16/22.

The following deficiencies were identified:

* There was no documented evidence the facility was conducting fire and life safety instruction on alternating months from fire drills; and

* The evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, evidence alternate routes were used, and the number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) and Staff 5 (Maintenance Director) on 05/18/22. She acknowledged the findings.

Maintenance Director updated his schedule for fire drills and fire life and safety instructions for staff to be done alternating months.  Evacuation drill form has been updated to inculde information on the escape route used, problems encountered, evacuation time needed, evidence of alternative routes used and the number of occupants evacuated.   The process will be evaluated for 4 months then brought to the quarterly Q.A.P.I. meetings.

Maintenance Director is responsible to see that this process is completed.    

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

Refer to C252, C330, Z164 and Z165.

Refer to Plan of Correction for C252, C330, Z164, and Z165.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces did not contain drop-offs and were maintained in good repair. Findings include, but are not limited to:

Observations of the three secured courtyards on 05/17/22 showed the following:

* Concrete that had cracked, chipped, and separated created uneven surfaces; and

* Multiple drop-offs of two to four inches were noted along pathway edges.

The need to ensure pathways in the resident courtyard did not have potential tripping hazards was discussed with Staff 1 (Administrator) on 05/17/22. She acknowledged the findings.

Maintenance Director has filled drop-offs in the courtyards with soil.  Landscaping company was contacted and asked not to use the edger in courtyards.    Bark has been delivered to fill in the areas.  All outdoor areas are at risk for being potential trip hazards.  This area will get evaluated weekly by Administrator and Director of Maintenance to look out for trip hazards.  Admininstrator will go over out door rounds at Q.A.P.I.

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

Observations of the facility on 05/17/22 showed the following areas in need of cleaning or repair:

* Walls throughout the facility had large, long black streaks and scrapes. The walls had spills, dings, and chipped paint;

* On entrance into the facility two doll babies, being held by a resident, had large amounts of brown substance on the lower legs and clothing;  

* Window sills throughout the facility had food debris, dust, dead insects, and pieces of tissues. The sills in the front sitting area had large chips with missing paint; and

* The common area bathroom near room 25 did not have a call light cord in place for residents to gain assistance when using the restroom.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 05/17/22. She acknowledged the findings.

Walls will be repaired by Maintenance Director.  Housekeeping will be conducted by Maintenance Director to ensure window sills are free from food debris, dust, dead insects, and pieces of tissues.  The sills in front sitting areas have been repainted.  A call light cord has been installed in common area bathroom.  Building rounds will be done weekly by Maintenance Director and Administrator.  Results of these rounds will be brought to Q.A.P.I. for the next two meetings.  

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 231, C 240, C 252, C 372, C 420, C 510 and C 513.

Refer to Plan of Correction for C 231, C 240, C 252, C 372, C 420, C 510, and C 513.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 8 and 17) completed all required pre-service orientation prior to performing any job duties; 3 of 3 newly hired staff (#s 8, 12 and 17) completed all required pre-service dementia training before providing care and services independently; 4 of 4 staff (#s 8, 12, 17 and 18) demonstrated competency in all assigned job duties within 30 days of hire; and 2 of 2 long-term staff (#s 4 and 13) completed 16 hours of annual training. Findings include, but are not limited to:

Staff training records were reviewed on 05/18/22.

1. There was no documented evidence Staff 8 (CG), hired 01/21/22, and Staff 17 (CG), hired 01/31/22, completed one or more of the required pre-service orientation topics:

* Resident rights and values of community-based care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures; and

* Written job description.

2. There was no documented evidence Staff 8, Staff 12 (CG), hired 04/15/22, and Staff 17 completed one or more of the required pre-service dementia topics:

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

* Techniques for understanding, communicating, and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

* Environmental factors that are important to a resident's well-being;

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

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

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

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

3. There was no documented evidence Staff 8, Staff 12, Staff 17, and Staff 18 (MT), hired 09/13/21, demonstrated competency in all assigned job duties within 30 days of hire. The facility was instructed Staff 18 could not be scheduled to perform medication administration until there was documented evidence she had demonstrated competency in those job duties.

4. There was no documented evidence Staff 4 (RCC), hired 04/26/16, and Staff 13 (MT), hired 08/03/18, completed the required 10 hours of annual training related to provision of care in community-based care or the required six hours related to dementia care.

The need to ensure staff completed all required training within the specified time frames was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant), and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Staff #8, #12, #17, #18 all have documented evidence of demonstrated competence in all assigned job duties.  Staff #18 has demonstrated competenency in preforming medication administration.  Staff #4, #13, have completed the requied ten hours of annual training related to provision of care in community based care or the six hours related to dementia care.  RCC has created a staff tracking system that tracks when training is due.  Business office manager will audit monthly.  Aministrator will audit 10% of employees  monthly to make sure training is completed to Q.A.P.I. next two meetings.

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 280, C 290, C 310, C 320, C 330 and C 340.

Refer to Plan Of Correction for c 280, C 290, C 310, C 320, C 330 and C 340.  

Based on 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 C252 and C330.

Refer to C252 and C330.

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

Resident 3 and 4's current service plans were reviewed during survey. Both of the service plans lacked information and staff instructions related to individualized nutrition and hydration preferences and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant) and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

An individualized nutrition and hydration plan has been developed for residents #3 and #4.  All residents service plan have been reviewed to ensure they contain staff instructions related to individualized nutrition and hydration preferences and needs.  RN will audit 20% of Care Plans monthly to ensure nutrition and hydration plans are develped.   Results of audits will be brought to Q.A.P.I. for the next two meetings.   

Based on interview and record review, it was determined the facility failed to evaluate residents for activities and to develop individualized activity plans from the evaluation for 4 of 4 sampled residents (#s 2, 3, 4 and 5) whose service plans were reviewed, and failed to offer a selection of daily structured and non-structured meaningful activities which promoted or helped sustain the physical and emotional well-being of residents. Findings include, but are not limited to:

A review of the service plan for Residents 2, 3, 4 and 5, and an interview with Staff 1 (Administrator) on 05/18/22 revealed the following:

1. The facility had not completed activity evaluations which addressed the following:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

2. There was no documented evidence individualized activity plans, which addressed what, when, how, and how often staff should offer and assist the resident with activities, were developed and documented.

3. Observations made on 05/17/22 and 05/18/22 revealed the facility was not providing a selection of daily scheduled or unscheduled activities to promote or help sustain the physical and emotional well-being of residents.

The need to ensure the facility completed an activity evaluation addressing the required elements, developed an individualized activity plan based on the evaluation for each resident, and provided meaningful activities for residents every day was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RN Consultant), and Staff 4 (RCC) on 05/18/22. They acknowledged the findings.

Activity evaluations have been completed for Residents #2, #3, #4, and #5.   Activities program has been reviewed to ensure meaningful activities are being offered daily.  Additionally, activity evaluations have been completed for all residents.   The process will be the Activity Director will complete the activity evaluation upon move in.   Administrator will audit each move-in to ensure activity evaluation has been completed for the next six months.  Results will be brought to Q.A.P.I. for the next 2 meetings.   

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 6, 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Residents 6, 7 and 8's service plans offered information relating to the resident's past interests and some current interests; however, the facility had not thoroughly evaluated the following:

* 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.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with individualized activities.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Administrator) on 10/27/22. She acknowledged the findings.

Residents #6 and #7 service plans have been updated to include the following: current interests, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to paricipate, and identification of activities for behavioral interventions.  

Resident #8 no longer resides at the facility. Residents #6 and #7 service plans have been updated with detailed information on what, when, how and how often staff should offer and asist them with specific individualized activities.

All service plans have been reviewed to assure individualized activity plans are specific to each resident.

Activity director will complete individualized activity service plan upon move-in, quarterly, and with change of condition.  Administrator will audit activity service plans monthly for the next 6 months and review at QAPI for next two meetings.  Administrator is responsible to see that the activity plan corrections are completed and monitored.    

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others, and had not coordinated outside consultation for these behaviors for 2 of 2 sampled residents (#s 6 and 8) who had documented behaviors. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 06/2020 with diagnoses including cerebrovascular accident and dementia with behavioral disturbance.

In an interview on 10/26/22 with Staff 2 (RN) and Staff 4 (RCC), Resident 8 was identified as having frequently refused care, and "occasionally yelled and hit at staff". Reportedly, it was often necessary to wait and re-approach the resident when rendering assistance.

Resident 8's service plan, dated 10/10/22 provided the following information to staff: "Sometimes it requires 3 people for peri care. [He/she] will become stiff and combative. This is a difficult task."

Resident 8's records lacked an individualized behavioral plan, which implemented effective interventions and assisted staff in minimizing the negative impact of the behaviors. The facility had not coordinated outside consultation, to obtain behavioral support services for the resident.

On 10/27/22 the need to develop and implement an individualized service plan for behaviors that negatively impacted the resident or others, was discussed with Staff 1 (Administrator) and staff 2 (RN). They acknowledged the findings.

2.  Resident 6 was admitted to the facility in September 2022 with diagnoses including Alzheimer's disease.

Resident 6's progress notes documented multiple incidents of problematic behaviors including resident to resident altercations, elopement attempts, resistance to care, striking staff, disrobing in public, pacing, difficulty sleeping and eating in the dining room.

The resident's current service plan, last updated 10/06/22, included a description of the behaviors displayed by the resident. The interventions included the following:

* Cues, reminders, or redirection for elopement risk, a sign posted to remind visitors to be sure no one follows them out of the building;

* Day and night time two-hour safety checks, attempt to distract when going into other resident's rooms, if resistant or combative please give PRN medications; and

* Provide distraction. Resident "loves to fold laundry, ...courtyard areas and walks in the halls."

During interviews on 10/26/22 and 10/27/22, direct care staff confirmed Resident 6 displayed the behaviors listed above and staff would attempt to re-direct the resident when s/he was displaying unsafe behaviors. Staff had attempted providing alternate seating arrangements for the resident at meal time in an effort to reduce stimulation and noise during meals. Staff stated attempts to re-direct the resident and use of PRN medications were mostly ineffective.

In an interview on 10/26/22, Resident 6's behaviors were discussed with Staff 1 (Administrator) and Staff 2 (RN). Facility staff had discussed some other interventions that were attempted but these interventions had not been documented on the service plan or Interim Service Plans (ISP's). The facility had not attempted to get outside consultation to provide behavior support services and help determine interventions for the behaviors.

The need to include an individualized behavior plan for residents with behavioral symptoms, ensure staff were provided clear direction on interventions to provide and initiate and coordinate outside consultation for problematic behaviors was discussed with Staff 1 and Staff 2 on 10/27/22. They acknowledged the findings.

Resident #8 no longer resides at the facility.

Resident #6 service plan has been revised to include an individualized behavior plan, incorporating behavioral symptoms, insuring staff are provided clear direction on interventions to provide, initiate and coordinate outside consultation for problamatic behaviors.

The memory care community will initiate and coordinate outside consultation for residents with behavior symtoms with negatively impact themselves or others.  If resident is a danger to themselves or others they will be transferred to acute care when indicated or if a behavior is unmanagable at the facility.  The RCC will audit behavior services plans and interventions monthly to assure all residents have individualized behavior plans for 3 months and then to QAPI quarterly until substantial compliance is obtained.   Administrator is responsible to see that behavior plans are used and individualized for each resident and the corrections are completed and monitored.