The findings of the re-licensure survey, conducted 10/16/23 through 10/20/23, 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, 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 survey to the re-licensure survey on 10/20/23, conducted 06/10/24 through 06/12/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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 second re-visit to the re-licensure survey of 10/20/23, conducted 09/10/24 through 09/11/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third re-visit to the re-licensure survey of 10/20/23, conducted 12/09/24 through 12/11/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the fourth re-visit to the re-licensure survey of 10/20/23, conducted 04/21/25 through 04/22/25, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and available for inspection. Findings include, but are not limited to:

A tour of the facility conducted on 09/10/24 identified the Ombudsman Notification Poster was not posted in a location routinely accessible to residents.

The need to ensure all required postings were in an accessible and conspicuous location for residents was discussed with Staff 26 (ED). on 09/11/24. She acknowledged the findings.

1.) Ombudsmen poster placed in resident cooridor by RCC office.

2.) Daily rounds are being conducted to ensure Ombudsmen poster stays in desired location.

3.) Daily

4.) Executive Director, LPN

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that promoted privacy, respect, and dignity in a homelike environment. Findings include, but are not limited to:

The community was toured on 09/10/24 through 09/11/24.

The facility was comprised of four cottages. Two cottages with 10 units and two cottages with 12 units. Of the 44 units, 40 were double occupancy.

The double occupancy units were observed and noted to be without a privacy curtain or screen of any kind.  

The lack of privacy for residents residing in shared apartments was reviewed with Staff 26 (ED) and Witness 2 (RN Consultant) on 09/11/24. They acknowledged the lack of privacy.

1.) 40 double occupancy units inventoried, quotes for ceiling track and curtains submitted for all double occupancy rooms.

2.) Education on resident rights provided to all staff. Plan for double occupancy rooms to have partitions placed, beginning in cottage A, then B, then C, then D.  Ensuring all double occupany rooms will recive curtains for privacy

3.) Daily, weekly

4.) Executive Director, Administrator

Based on observation, interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse or neglect, document all required areas of an investigation, and/or report to the local SPD office if abuse or neglect could not be ruled out, for 5 of 5 sampled residents (#s 1, 2, 4, 6 and 7) reviewed for incidents or injuries of unknown cause. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2018 with diagnoses including dementia.

During survey interviews with staff, review of the resident's 07/23/23 service plan, 07/18/23 through 10/16/23 temporary service plans and charting notes, physician communications, and incident investigations were reviewed, and the following was identified:

* 07/25/23 bruise to top of right hand; and

* 08/14/23 bruising to both wrists and the back of both hands.

There was no documented evidence the investigations of the occurrences included all the required components, were reviewed by the Administrator, and did not identify how abuse or neglect was ruled out. The occurrences were not reported to the local SPD office if abuse and/or neglect could not be ruled out.

At the request of the survey team, all incidents above were reported to SPD before the survey team exited the facility on 10/20/23.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation including if abuse and neglect could be ruled out and if not, the injuries were reported to the local SPD office was discussed with Staff 1 (ED), Staff 5 (RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

2. Resident 2 moved into the MCC in 10/2023 with diagnoses including dementia and history of falls. Resident 2 required a walker for mobility.

Observations of the resident, interviews with staff, and review of the resident's temporary service plans, facility "charting notes", and incident investigations were completed.

Observations of the resident from 10/17/23 to 10/19/23 revealed the resident required cueing assistance with transfers and step by step direction for bathroom use.

Clinical records reviewed from 10/11/23 to 10/16/23 noted the following:

* On 10/16/23 staff documented on facility "charting notes" that the resident had skin injuries and suspected fall. It was further noted that the resident had an abrasion to forehead, bruise and abrasion to bridge of nose, and skin tear on left arm that was approximately 3.0 x 5.0 x 4.5 cm. Staff documented on a 10/16/23 incident report that the resident did not remember what happened when staff found the injuries. Staff further documented "NA" to all questions in the investigation.

There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the skin injuries or suspected fall was not the result of abuse, and the facility lacked documentation of required investigative components including individuals present, a description of the event, follow-up action and Administrator's review.

The need to investigate unknown injuries or an incident of suspected abuse or neglect, and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 2 (RCC), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/18/23 and 10/19/23. They acknowledged the findings. The surveyor requested Staff 5, Staff 6 and Staff 7 to report the incident to the local SPD office. Confirmation that the incident was reported to the local SPD was received prior to the survey team exiting from facility.

3. Resident 7 moved into the MCC in 10/2022 with diagnoses including Wernicke's dementia. Resident 7 required a wheelchair for mobility.

Observations of the resident, interviews with staff, and review of the resident's 07/25/23 service plan, temporary service plans, facility "charting notes", and incident investigations were completed.

a. Clinical records reviewed from 07/20/23 to 10/18/23 noted the following:

On 07/22/23 staff documented on a facility charting notes that "the aggressive resident entered this residents [resident's] room and began hitting [him/her] ...[his/her] left shoulder hurts."; and

* Staff documented on a 07/22/23 incident report that staff heard Resident 7 screaming for help. Staff ran into the resident's room and observed another resident "attacking" the resident. The document showed staff left blanks to all questions in the investigation.

There was no documented evidence the incident had been thoroughly investigated to rule out the possibility of abuse and there was no documented evidence the incident was reported to the local SPD.

On 10/19/23, the surveyor requested Staff 2 (RCC), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) report the incident to SPD. Confirmation that the incident was reported to local SPD was received prior to the survey team exiting from facility.

The need to investigate incidents of suspected abuse and neglect, and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 5, Staff 6 and Staff 7 on 10/19/23 and 10/20/23. They acknowledged the findings.

b. During the acuity interview on 10/16/23 the resident was identified as a smoker and required staff supervision during smoking.

Clinical records reviewed from 07/20/23 to 10/18/23 noted the following:

* On 07/22/23 staff documented on a facility "charting notes" that the resident had an open area on left foot. The resident went out to smoke and "cigarette dropped on my slipper and I didn't notice it until my slipper was smoking."

* The resident's 07/25/23 service plan showed the resident smoked cigarettes and staff were responsible for the task; and

* Staff documented on the 07/22/23 incident report "Resident notified CG [caregiving staff] ...another resident accidentally burned [his/her] foot while smoking."

There was no documented evidence the incident had been thoroughly investigated to rule out the possibility of neglect due to the lack of supervision while Resident 7 was smoking and there was no documented evidence the incident was reported to the local SPD.

On 10/19/23, the surveyor requested Staff 2 (RCC), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) to report the incident to SPD. Confirmation that the incident was reported to the local SPD was received prior to the survey team exiting from facility.

The need to investigate incidents of suspected neglect and to report the incidents when the facility's investigation was unable to rule out neglect was discussed with Staff 5, Staff 6 and Staff 7 on 10/19/23 and 10/20/23. They acknowledged the findings.

4. Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure.

Observations of the resident, interviews with staff, and the resident's current service plan dated 09/10/23, interim service plans, charting notes, and incident reports were reviewed and identified the following:

* 07/07/23 - unwitnessed fall with injury;

* 07/28/23 - unwitnessed fall without injury;

* 08/10/23 - unwitnessed fall with injury;

* 08/17/23 - unwitnessed fall without injury;

* 08/25/23 - unwitnessed fall without injury; and

* 10/15/23 - bruise on top of the resident's left arm.

There was no documented evidence the facility promptly investigated the incidents to rule out abuse and/or neglect, or reported incidents to the local SPD office if abuse and/or neglect could not be ruled out, and that the Administrator had reviewed the incidents.

The facility was asked to self-report the incidents to the local SPD office and confirmation was provided on 10/19/23.

The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.  

5. Resident 4 moved to the facility in 10/2022 with diagnoses including Wernicke's dementia and acute encephalopathy.

Observations of the resident, interviews with staff, and review of the resident's 07/25/23 service plan, temporary service plans, facility charting notes, and incident investigations were completed.

a. An incident report dated 08/14/23 revealed Resident 4 had been involved in a resident to resident altercation. The incident report stated Resident 4 was rocking back and forth in a chair in the dining room. A resident sitting across from Resident 4 requested s/he stop rocking. Resident 4 stated s/he "didn't have to". The other resident grabbed his/her cup and threw it across the table at Resident 4's face.

There was no documented evidence the facility promptly investigated the incident to rule out abuse and/or neglect, or reported incident to the local SPD office if abuse and/or neglect could not be ruled out, and that the Administrator had reviewed the incident.

During an interview on 10/17/23 with Staff 2 (RCC) it was confirmed the incident had not been reported to the local SPD office. This surveyor requested Staff 2 report the incident to the local SPD office. Documentation was provided to the survey team to confirm it had been reported to the local SPD office on 10/17/23 at 4:30 pm.

The need to ensure resident incidents were reported to the local SPD office was discussed with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

b. Staff noted the following incident in a facility charting note dated 09/21/23: Resident 4 was sitting next to another resident on the couch and s/he was rubbing Resident 4's hand and talking with him/her when the other resident bent forward and kissed Resident 4 on the lips. Resident 4 "did not seem bothered by it" and closed his/her eyes and went to sleep. The other resident was told s/he cannot kiss others and stated "no problem" in response.

There was no documented evidence the facility promptly investigated the incident to rule out abuse and/or neglect, or reported incident to the local SPD office if abuse and/or neglect could not be ruled out and that the Administrator had reviewed the incident.

An interview with Staff 2 on 10/17/23 at 12:40 pm revealed there was no documented evidence the incident had been investigated to rule out whether or not abuse and neglect had occurred and confirmed the incident had not been reported to the local SPD office. The surveyor requested Staff 2 report the incident to the local SPD office. Documentation was provided to the survey team to confirm it had been reported to the local SPD office on 10/17/23 at 4:30 pm.

The need to ensure resident incidents were promptly investigated and reported to the local SPD office when the facility failed to protect residents from harm was discussed with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

1. All identified incidents for resident 1, 2, 4, 6, 7 during the state survey were faxed to APS prior to the survey team leaving.

2. All incident reports are to be reviewed by the administrator. The consultant team is reviewing incident reports and providing feedback. Staff will be trained on how to identify incidents, how to document incident observations and how to communicate incidents to RCC/Nurse/Administrator. All care staff to take the online OCP course Elder Abuse Prevention, Investigation, and Reporting by Nov 30. The clinical team will review incident reports and investigations during daily clinical meeting and report to APS as appropriate.

3. Daily, weekly, monthly.

4. RCC, nurse, administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident altercations and elopement incidents were immediately reported to the local SPD or AAA office as suspected abuse and promptly investigated; and the facility failed to ensure injuries of unknown cause were immediately reported to the local SPD or AAA office as suspected abuse unless an immediate investigation reasonably concluded and documented the physical injury was not the result of abuse for 2 of 3 sampled residents (#s 8 and 10) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the memory care community in 10/2021 with diagnoses including dementia.

The resident's service plan, dated 04/19/24, incident investigation reports, progress notes from 02/18/24 through 06/05/24, observations of the resident, and interviews with care staff during the survey indicated the resident was dependent on staff for ADL care and required staff assistance of toileting care.

The resident's clinical record revealed the following:

* 04/27/24 - "found small quarter sized bruise on [his/her] right bicep, color was purple."

On 06/12/24 at 12:43 pm, Staff 2 (RCC) confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested Staff 1 report the incident to the local SPD office.

In a 06/12/24 interview with Staff 5 (Health Services Director/RN) and Staff 25 (Acting ED), they reported when staff identified skin issues, the skin issues would be reported to the facility nurse who would follow up on the skin injuries. They confirmed there was no incident report or other document confirming the facility conducted an immediate investigation into the injury to conclude the injury was not the result of abuse or neglect to Resident 8.

On 06/12/24 at 2:41 pm, confirmation that the report had been sent to the local APD office was provided prior to survey exit.

The need to ensure investigations into physical injuries of unknown cause were documented, to include the injuries were not the result of abuse or neglect, was discussed with Staff 2, Staff 5, and Staff 25 on 06/12/24. They acknowledged the findings.

2. Resident 10 was admitted to the facility in 05/2024 with diagnoses including Alzheimer's disease.

A review of the resident's 05/01/24 initial service plan, progress notes dated 05/01/24 through 06/10/24, incident reports, and interim service plans (ISPs) were completed, and interviews were conducted. The following was identified:

* 06/02/24 - Resident displayed "behaviors and agitation" after seeing two other residents sitting together watching TV: s/he was ". . . loudly yelling at care staff and slamming cupboard doors."

* 06/03/24 - The resident had a verbal altercation with another resident which involved yelling, name-calling, and clenched fists, with no physical contact.

* 06/06/24 - The resident was actively exit-seeking and ". . . attempting to push through staff when they come [sic] through the door . . ." Staff noted s/he also tried ". . . to figure out how [staff member] get [sic] out through the back and standing back by that door . . ."

* 06/07/24 - The resident got through the doors of the locked unit and was in the front lobby on two occasions.

* 06/08/24 - The resident followed a visitor out the door, ". . . pushed activitys [sic] directors [sic] face and pushed her out of the way . . .," and ". . . made it to the front lobby." S/he then went out of the building. Staff documented a MT was outside watching the resident, and the manager called 911. The resident was eventually calmed down by staff and returned to the unit.

There was no documented evidence these incidents were immediately reported to the local SPD as suspected abuse or promptly investigated.

In an interview on 06/11/24, Staff 2 (RCC) stated that on 06/03/24, when Resident 10 and another resident were yelling at each other, she separated the two and nothing further happened. She reported she did not think of the incident as a resident-to-resident altercation because there was no additional interaction between the two residents.

On 06/12/24, the facility was asked to report the resident-to-resident altercation to the local SPD office because they failed to rule out abuse at the time of the incident. Confirmation of the report was received prior to survey exit.

The need to immediately report all suspected abuse to the local SPD office and to promptly investigate all resident incidents was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consultant RN) on 06/12/24. They acknowledged the findings.

1.) All identified incidents for resident 8 and 10 during state survey were faxed to APS prior to the survey team leaving and confirmed by survey team.

2.)  All incident reports are to be reviewed by the administrator.  The consultant team is reviewing incident reports and providing feedback.  Continued staff education on how to identify incidents, how to document incident observations and how/who to communicate incidents to RCC/Nurse/Adminstrator.  All care staff have taken the online OCP course Elder Abuse Prevention on November 30th,2023. Educate staff on Northstar Abuse Reporting and Incident Reporting policy and procedures\.  The clinical team will review incident reports and investigations during daily clinical meeting and report to APS as needed.

3.)  Daily, weekly, monthly

4.) RCC, LPN, RN, Executive Director, Assistant Executive Director   

Based on observation, interview, and record review, it was determined the facility failed to immediately investigate an un-witnessed fall and an injury of unknown cause to reasonably conclude and document the incidents were not the result of neglect or abuse, and failed to report the incidents to the local SPD or AAA for 2 of 2 sampled residents (#s 12 and 13) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 moved into the memory care community in 03/2021 with diagnoses including dementia.

The resident's service plan, dated 08/20/24, incident investigation reports, progress notes from 08/13/24 through 09/09/24, observations of the resident, and interviews with care staff during the survey indicated the resident required assistance from staff for ADL care.

On 08/31/24 Resident 12 was noted to have a ..."skin tear (1.5 cm) from unknown origin on (R) ring finger...Res[ident] states that [s/he] does not know how the change to skin happened..."

There was no documented evidence this injury was immediately reported to the local SPD as suspected abuse or promptly investigated.

On 09/10/24 at 3:45 pm, Staff 35 (RN Health Services Director) confirmed the physical injury had not been investigated nor reported to the local unit. The surveyor requested Staff 35 report the incident to the local SPD office.

Confirmation that the report had been sent to the local APD office was provided prior to survey exit.

The need to ensure investigations of physical injuries of unknown cause were documented, to include the injuries were not the result of abuse or neglect, was discussed with Staff 26 (Executive Director), Staff 35 (RN Health Services Director), and Staff 36 (LPN Assistant Health Services Director) on 09/10/24 and 09/11/24. They acknowledged the findings.

2. Resident 13 was admitted to the facility in 06/2024 with diagnoses including Alzheimer's disease.

The resident's service plan, dated 08/06/24, incident investigation reports, progress notes from 09/03/24 through 09/10/24, observations of the resident, and interviews with care staff during the survey indicated the resident required assistance from staff for ADL care.

On 09/03/24 Resident 13 was noted to be found on the floor after care staff "...heard a thud..."

There was no documented evidence this incident was immediately reported to the local SPD as suspected abuse or promptly investigated.

On 09/10/24 at 3:45 pm, Staff 35 (RN Health Services Director) confirmed the un-witnessed fall had not been investigated nor reported to the local unit. The surveyor requested Staff 35 report the incident to the local SPD office.

Confirmation that the report had been sent to the local SPD office was provided prior to survey exit.

The need to ensure investigations of unwitnessed falls were documented, to include the falls were not the result of abuse or neglect, was discussed with Staff 26 (Executive Director), Staff 35 (RN Health Services Director), and Staff 36 (LPN Assistant Health Services Director) on 09/10/24 and 09/11/24. They acknowledged the findings.

1.) All indentified incidients for resident 12 and resident 13 found during state survey were faxed to APS prior to the survey team leaving and confirmed by the survey team.

2.) All incident reports are to be reviewed by the administrator.  The consultant team is reviewing incident reports and providing feedback.  Continued staff education on how to identify incidents, how to document incident observations and how/who to communicate incidents to RCC/Nurse team/ Executive Director. Incident report with additional information introduced to staff and community for use. All Staff have taken the online OCP course Elder Abuse Reporting upon hire or previously.  Staff educated on Northstar Abuse Reporting and Incident Reporting policy and procedures.  The clinical team will review incident reports and investigations during daily clinical meeting and report to APS as needed.

3.) Daily, Weekly, Monthly

4.) RCC, LPN, RN, Executive Director

Based on interview and record review, it was determined the facility failed to investigate an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out for 1 of 1 sampled resident (#15) and to document all required areas of an investigation including administrator review for 1 of 2 sampled residents (#17) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. During the survey, Resident 18 was residing in the memory care community and had a diagnosis of dementia.

During the acuity interview on 12/09/24, the resident was identified as having bruises on the abdominal area.

An 11/15/24 charting note showed the resident had bruising on the lower right side of the abdomen, measuring 12 x 8 cm, dark in color with some green discoloration. Additionally, the lower left abdominal area had an 8 x 6 cm dark bruise.

There was no documented evidence that the facility conducted an investigation to determine the cause of the skin injury. The incident was not reported to the local SPD office. The surveyor requested Staff 26 (ED) and Witness 1 (Consultant RN) report the incident to the local SPD office. A copy of confirmation that the report was sent to the SPD office was provided prior to exit.

The need to ensure injuries of unknown cause were immediately investigated by the facility, and if abuse was not able to be reasonably ruled out, the injury was reported to the local SPD office, was discussed with Staff 26 and Witness 1 on 12/11/24 at 9:09 am. They acknowledged the findings.

2. Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia.

During the acuity interview on 12/09/24, the resident was identified as having unwitnessed falls and resident-to-resident altercations.

Resident 17's medical records and facility investigations were reviewed.

The resident's service planned interventions for aggression was a scheduled and PRN behavior medication and for staff to use "warmth, bathing, or a meal/snack." Resident 17's service plan identified him/her as being a high fall risk and having a "recent fall." The fall interventions were for the resident to use "proper footwear" and ensure a "well lit and clutter free area to ambulate."

The following investigations were reviewed:

* 11/24/24: Resident-to-resident altercation;

* 11/29/24: Resident-to-resident altercation;

* 12/02/24: Unwitnessed fall at 9:30 am resulting in head and spine pain;

* 12/02/24: Unwitnessed fall at 9:10 pm, after which Resident 17 reported pain; and

* 12/07/24: Unwitnessed fall resulting in the resident hitting his/her head.

There was no documented evidence the investigations had been reviewed by the Administrator.

The need to ensure all investigations of suspected abuse had documented evidence of the Administrator's review was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.

1. Resident 15 report was sent to APS prior to survey leaving to community.  Administrator has reviewed and signed all investigations.

2. The Administrator will review, discuss, and sign incident reports during clinical meetings. The Administrator and nurses will review any new progress notes and other documentation daily during clinical meetings to ensure any potential incidents have been identified, investigated, and reported.  The Administrator, nurses, and resident care coordinator will complete daily walking rounds through all four resident cottages to observe resident care, talk with care staff, and inquire about any care concerns or observations including potential incidents. This communicates to all care staff, the leadership team's engagement and gives the staff an opportunity to approach with any questions or concerns if they are not sure about a situation. The leadership team will also be able to proactively observe staff-resident interactions. The consultant will review root cause analysis with the administrator, nurses, and resident care coordinator including education on five whys.

3. Daily, Weekly, Monthly,

4. Resident Care Coordinator, Nurses, Administrator

Based on interview and record review, it was determined the facility failed to immediately investigate incidents of abuse or suspected abuse relating injuries of unknown cause to rule out abuse or suspected abuse and report to the local SPD office if abuse could not be ruled out and report resident to resident altercations to the local office for 1 of 1 sampled resident (# 9). This is a repeat citation. Findings include, but are not limited to:

Resident 9 moved into the memory care community in 05/2022 with diagnoses including Lewy Body dementia and Alzheimer's disease.  

The resident's facility records including progress notes, dated from 01/22/25 through 04/21/25, the 01/22/25 service plan, and Interim Service Plans, dated from 01/29/25 through 04/20/25, were reviewed.

There was no documented evidence the following incidents were reported to the local SPD office or that the facility had immediately investigated the issue in order to rule out abuse or possible abuse:

* 04/17/25: Resident to resident altercation; and

* 04/20/25: Skin tear on left elbow.    

A copy of the confirmations that the facility reported the above incidents to the local SPD office was provided on 04/22/25.

The need to ensure the facility immediately investigated incidents of abuse, suspected abuse, or an injury of unknown cause to rule out possible abuse or report to the local SPD office if abuse could not be ruled out was reviewed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant) on 04/22/25 at 4:36 pm.

1. Resident #9 no longer resides in the community. The events listed in the survey have been reported as required, documentation of the reports was provided on 4/22/25.

2.Community employees have completed the Oregon Care Partners training titled "Elder Abuse Prevention and Investigation." The direct, call reporting line has been posted in each medication room for ease of use by staff when management is not in the building, to ensure timely reporting. All incidents are reviewed during community stand-up and clinical meetings the following business day. All incident investigations are completed by the community administrator with support from the IDT to ensure proper interventions, investigations, and reporting per the rule.

3.Monitoring will be completed using the Electronic Health Record system. The system logs and tracks each event and aids in appropriate and timely documentation. The community Administrator will review and monitor each report for proper investigation and reporting (if needed) prior to completion.

4.The Administrator will be responsible for assuring that Incident reports are monitored, investigated and reported to meet the regulation.    

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests. Findings include, but are not limited to:

At the time of the survey, the facility was home to 62 residents, consisted of four cottages (A, B, C and D), who resided in the Memory Care Community.

During the survey, 10/16/23 through 10/20/23, there was a lack of scheduled activities that occurred in the facility.

An activity calendar for the facility was requested on 10/16/23 during the entrance conference and Staff 2 (RCC) provided the activity calendar during the survey.

Review of the monthly activity calendar for October 2023 showed the following:

* 10:00 am - Morning meeting; and

* 3:00 pm - Group activity.

There were only two activities scheduled daily. Throughout the survey from 10/17/23 to 10/20/23, the two scheduled activities were not observed to take place during the survey. Residents were observed sitting in common areas for long periods of time, sleeping, while a television played continuously, walked the halls, or remained in their rooms unengaged in individual and/or group activities.

On 10/19/23 and 10/20/23, failure to provide an activity program based on individual needs and group interests was reviewed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations). They acknowledged the findings.

1. The community is actively recruiting for an activities director. The marketing director is currently acting as the activity director designee and is creating the monthly calendar. A designated caregiver is ensuring activities are being done per the calendar and ensuring 1:1 activities are happening.

2. The activity calendar is being developed to have scheduled activities through the day and swing shift.

Caregivers are being trained on how to perform both scheduled and spontanous actvites and are responsible for at least 50% of the individualized activities.

3. Daily, Monthly, Quarterly.

4. Marketing Director, Designated Caregiver, Administrator.

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 (# 2) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 moved into the memory care facility in 10/2023 with diagnoses including Alzheimer's disease.

The resident's new move-in evaluation was reviewed and the following elements were not addressed:

* Physical health status including visits to health practitioner(s) ER, hospital or NF in the past year;

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

* Cognition, including decision making ability;

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

* Communication and sensory including ability to understand and be understood;

* Independent activity of daily living including housework and laundry and transportation;

* Pain including non-pharmaceutical interventions and how a person expressed pain or discomfort;

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

* Indicators of nursing needs including potential for delegated nursing tasks;

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior to placements; and

* Environmental factors that impact the resident's behavior including noise, lighting, room temperature.

The need to ensure the move-in evaluation included all required elements was discussed with Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/18/23 at 11:00 am. They acknowledged the findings.

1. An up-to-date evaluation will be completed on Resident 2. All evaluations are being reviewed and an evaluation checklist is being provided by the consultant.

2. Education will be provided by the RN consultant to the health services team on how to conduct and document an evaluation to ensure all required evaluation items are included. The RCC is taking the OHCA course Role of the RCC. All evaluations will be reviewed for completeness.

3. Prior to move-in, 30-days and quarterly.

4. RCC, Nurse, Administrator

3. Resident 2 moved into the memory care facility in 10/2023 with diagnoses including Alzheimer's disease.

There was no service plan for the resident. During an interview on 10/17/23 at 1:18 pm, Staff 20 (CG) confirmed there was no service plan for the resident.

The need to ensure service plans were available to staff to follow was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on  10/18/23 and 10/20/23. They acknowledged the findings.

4. Resident 3 moved into the memory care facility in 08/2020 with diagnoses including dementia.

a. Resident 3's service plan, updated 11/03/22, temporary service plans and facility charting notes dated 07/19/23 through 10/13/23 were reviewed. Interviews with care staff were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Dressing assistance;

* Grooming assistance;

* Shaving including frequency of services;

* Oral care assistance;

* Bathing;

* Ambulation including the use of wheelchair versus walker;

* Transfer assistance;

* Toileting assistance;

* Hospice service including when to contact and who to contact; and

* Radio on all times.

b. The most recent service plan, dated 11/03/22, was accessible to staff. There was no documented evidence the facility completed quarterly service plans for Resident 3.

The need to ensure service plans were reflective of the resident's care needs, provided clear caregiving instructions, and were updated quarterly as required was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/18/23 and 10/20/23. They acknowledged the findings.

5. Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure.

Observations of the resident, interviews with staff, and a review of the resident's current service plan dated 09/10/23, interim service plans, and charting notes dated 07/21/23 to 10/15/23 showed the service plan was not reflective of the resident's status and did not provide clear direction to staff in the following areas:

* Two-person assistance and gait belt use with toileting, incontinence care, and transfers;

* One-to-one meal assistance;

* Significant weight loss;

* Use of a wheelchair and assistance needed; and

* Interventions to minimize falls.

The need to ensure service plans were reflective of residents' status and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs, were available to staff, were reviewed quarterly as required, and provided clear instruction to staff for 5 of 6 sampled residents (#s 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2022 with diagnoses including Wernicke's dementia, UTI (resolved), acute kidney injury (resolved) and acute encephalopathy.

Interviews with care staff and observations of Resident 4 during the survey revealed s/he was dependent on staff for cueing for all ADL's and had a history of falls.  

Resident 4's current service plan, dated 07/25/23, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas:

* Activities;

* Fall interventions; and

* Pain management and how pain was exhibited.

The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 03/2022 with diagnoses including Parkinson's disease and dementia without behavioral disturbance.

Interviews with care staff and observations of Resident 5 during the survey revealed s/he received a mechanical soft diet and thickened liquids.

Resident 5's current service plan dated, 10/02/23, failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas:

*Activities; and

*Thickened liquids.

The need to ensure service plans were reflective of the resident's current care needs and provided clear direction to staff was discussed with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

1. Service plans for resident 2, 3, 4, 5, & 6 will be updated to include all missing elements identified during survey. Consultant is providing instruction on service plan development with the team. A checklist is being provided by the consultant with all the required service planning elements.

2. Education will be provided by RN consultant to those responsible for completing the service plan. RCC taking the OHCA course Role of the RCC. A review of upcoming service plans will be done weekly during a clinical meeting.

3. Weekly, Monthly, Quarterly.

4. RCC, Nurse, Administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs; included a written description of who should provide the services and what, when, how, and how often the services should be provided; and/or were implemented for 3 of 4 sampled residents (#s 8, 9, and 11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the memory care community in 10/2021 with diagnoses including dementia.

The resident's 04/19/24 service plan, and 02/05/24 through 05/10/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 06/10/24 and 06/11/24.

Resident 8's service plan was not reflective, did not provide clear direction to staff, including what, when, how, and how often services should be provided, and was not implemented in the following areas:

* Fall interventions;

* Use of a wheelchair;

* Daily routine;

* Oral health care including use of denture;

* Use of a gait belt with transfer;

* As needed health shakes;

* Daily walking exercise; and

* Scheduled toileting.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff, including what, when, how, and how often services should be provided, was discussed with Staff 2 (RCC) and Staff 25 (Acting ED) on 06/12/24. The findings were acknowledged.

2. Resident 9 moved into the memory care community in 05/2022 with diagnoses including Lewy Body dementia.

The resident's 04/17/24 service plan and 03/20/24 through 05/23/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 06/10/24 and 06/11/24.

Resident 9's service plan was not reflective and did not provide clear direction to staff, including what, when, how, and how often services should be provided, in the following areas:

* Daily routine including shower time preferences; and

* High protein snacks.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff, including what, when, how, and how often services should be provided was discussed with Staff 2 (RCC) and Staff 25 (Acting ED) on 06/12/24. The findings were acknowledged.

3. Resident 11 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease with behavioral disturbance.

Review of the resident's 05/01/24 service plan revealed it was not reflective of the resident's current status and needs and/or did not provide clear direction regarding the delivery of services in the following areas:

* Dressing preferences;

* Visual and auditory hallucinations;

* Food preferences;

* Meal assistance needed;

* Behaviors;

* One-on-one activities for staff to attempt;

* Fall interventions; and

* Level of assistance needed with ADLs.

The need for service plans to accurately reflect residents' current needs and provide clear direction to staff was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consultant RN) on 06/12/24. They acknowledged the findings.

1.)  Service plans for resident 8, 9, and 11 will be updated to include missing elements identified during survey.  Consultant is continuing to provide instruction on service plan development with the team.  A checklist has been provided by the consultant with all the required service planning elements.

2.)  Education will continue to be provided by RN consultant to team members responisble for completing the service plan.  A review of upcoming service plans will be done weekly during a daily clinical meeting.

3.)  Weekly, Monthly, Quarterly

4.)  RCC, LPN, RN, Executive Director, Assistant Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, included a written description of how often the services should be provided, and were readily available to staff and provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 12, 13, and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 moved into the memory care community in 03/2021 with diagnoses including dementia.

The resident's 08/20/24 service plan, and 08/28/24 through 09/03/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 09/10/24 and 09/11/24.

The current service plan, dated 08/20/24, was not available to staff.

Resident 12's service plan was not reflective, did not provide clear direction to staff, including what, when, how, and how often services should be provided, in the following areas:

* Fall interventions;

* Hospice services;

* Bathing or showering frequency;

* Health shakes; and

* Weight loss.

The need to ensure staff had access to service plans and service plans were reflective of the identified needs of the resident and provided clear direction including what, when, how, and how often services should be provided, was discussed with Staff 26 (ED), Staff 35 (RN Health Services Director), Staff 36 (LPN Assistant Health Services Director), and Witness 2 (Consultant RN) on 09/10/24 and 09/11/24. The findings were acknowledged.

2. Resident 13 moved into the memory care community in 06/2024 with diagnoses including Alzheimer's dementia.

The resident's 08/06/24 service plan and 09/03/24 through 09/10/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 09/10/24 and 09/11/24.

The current service plan, dated 08/20/24, was not available to staff.

Resident 13's service plan was not reflective and did not provide clear direction to staff, including what, when, how, and how often services should be provided, in the following areas:

* Anxiety;

* Walking to exhaustion;

* Bathing or showering frequency; and

* Chronic back pain.

The need to ensure staff had access to service plans and service plans were reflective of the identified needs of the resident and provided clear direction to staff, including what, when, how, and how often services should be provided was discussed with Staff 26 (ED), Staff 35 (RN Health Services Director), Staff 36 (LPN Assistant Health Services Director), and Witness 2 (Consultant RN)on 09/10/24 and 09/11/24. The findings were acknowledged.

3. Resident 14 was admitted to the facility in 04/2023 with diagnoses including dementia.

The resident's 08/08/24 service plan and 08/02/24 through 08/28/24 temporary service plans were reviewed, observations were made, and interviews with caregivers were conducted on 09/10/24 and 09/11/24.

The current service plan, dated 08/08/24, was not available to staff.

Resident 14's service plan was not reflective and did not provide clear direction to staff, including what, when, how, and how often services should be provided, in the following areas:

* Assistive devices;

* Specific fluid restriction directions; and

* Bathing or showering frequency.

The need to ensure staff had access to service plans and service plans were reflective of the identified needs of the resident and provided clear direction to staff, including what, when, how, and how often services should be provided, was discussed with Staff 26 (ED), Staff 35 (RN Health Services Director), Staff 36 (LPN Assistant Health Services Director), and Witness 2 (Consultant RN) on 09/10/24 and 09/11/24. The findings were acknowledged.

1.) Service plans all printed and placed in appropriate binders in cottages prior to the survey team exiting community.  Service plan for resident 12, 13, 14 were updated to include missing elements identified during survey. All service plans have been updated with shower days.

2.) Education will be continued to be provided by RN consultant to team members responssible for completing the service plan. A schedule will be developed for quarterly review. All service plans will be updated prior to move-in, 30-days, quarterly, and with any significant change in condition.

3.) Weekly, Monthly, Quarterly

4.) Executive Director, LPN

2. Resident 15 was admitted to the facility in 05/2023 with diagnoses including schizophrenia and dementia.  

Observations were made of the resident's care on 12/09/24 through 12/10/24, interviews with the facility staff were conducted, and the current service plan, dated 08/19/24, was reviewed.

a. Resident 15's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Hospice services;

* Refusals of shower;

* Refusals of mouth care and personal hygiene;

* Unsteady gait;

* Increased assistance in toileting use; and

* Weight loss.

b. The service plan had not been updated quarterly as required.

The need to ensure the service plan was updated quarterly, reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24 at 9:09 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services, changes and entries made to the service plan were dated and initialed, were implemented, and completed quarterly for 3 of 3 sampled residents (#s 15, 16, and 17) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 16 was admitted to the facility in 10/2024 with diagnoses including depression with psychotic features, generalized anxiety, left-side affected stroke, and vascular dementia.  

Observations were made of the resident's care on 12/10/24, interviews with the resident and facility staff were conducted, and the current service plan, dated 11/07/24, was reviewed.

Resident 16's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* How a person expresses pain, anxiety or discomfort;

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

* How a person expresses memory loss;

* Instructions on signs and symptoms of complications to report while on anti-depressant and anti-anxiety therapies;

* Instructions on fall prevention;

* Skin integrity and instructions on to whom to report skin impairments;

* Instructions for signs and symptoms of complications to report while monitoring surgical incisions;

* Instructions to staff on providing care to the resident with left-sided weakness secondary to a history of stroke;

* Incorrect reference to resident requiring wheelchair for assistance with mobility;

* Recent losses;

* Smoking;

* Alcohol and drug use;

* Instructions on signs and symptoms for potential allergic reaction to Bupropion;

* Instructions on signs and symptoms of post-fall injury to report; and

* Instructions on signs and symptoms of dehydration to report.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24. They acknowledged the findings.

3. Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia.

The resident's service plan, dated 08/10/24, and Interim Service Plans were reviewed, staff were interviewed, and the resident was observed.

The service plan did not provide clear direction to staff regarding the delivery of services, and/or was not implemented in the following areas:

* Activities;

* Presence of a roommate;

* PRN medications for behaviors;

* Behavior interventions including family contact information for staff to utilize;

* Dressing;

* Falls;

* Bathing;

* Toileting assistance needed including incontinent products used;

* Escorts needed for appointments outside of the community;

* Mobility device;

* Key use;

* Pain interventions;

* The use of chocolate desserts to help redirect escalating behaviors towards other residents;

* Preference to have sheets on his/her bed; and

* Monthly weights.

Additionally, the service plan had not been updated quarterly and updates were not dated or initialed.

The need to ensure the resident's service plan was reflective of their current care needs and provided clear directions to staff regarding the delivery of services, changes and entries made to the service plan were dated and initialed, were implemented, and completed quarterly was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.  

1. The service plans for residents 16, 15, 17 were updated to include missing elements identified during survey.  Services plan updates have been dated.

2. A service plan schedule has been implemented. All resident service plans will be reviewed and updated as needed. Consultant will review a select number of service plans for completeness and accuracy during scheduled visits. The Admnistrator and nurses will complete the NurseLearn course "Individualized Care/Service Plans."

3. Weekly, Quarterly

4. Administrator, Scheduler, LPN, RCC

2. Resident 20 moved into the memory care community in 09/2021 with diagnoses including Alzheimer's disease and hypertension.

Observations of the resident, interviews with facility staff, and the 04/16/25 service plan and Interim Service Plans, from 01/24/25 through 04/13/25, reviewed during the survey, revealed Resident 20's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services in the following areas:

* Use of a floor mat while in bed;

* Use of a soft brace to the arm while in bed;

* Conflicted information related to shower status;

* Activity status including preferences;

* Hospice services status;

* Repositioning every two hours;

* Skin status on legs;

* Use of a cushion while in wheelchair; and

* Use of anti-depression medication.

On 04/22/25 approximately at 2:10 pm, the need to ensure service plans were reflective of resident needs and preferences and provided clear direction to staff was discussed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant). They acknowledged the findings.

3. Resident 4 moved into the memory care community in 10/2022 with diagnoses including Wernicke encephalopathy.

Observations of the resident, interviews with facility staff, and the 02/06/25 service plan and Interim Service Plans, dated from 01/10/25 through 04/20/25, were reviewed during the survey and revealed Resident 4's service plan was not reflective of his/her status and did not provide clear direction regarding the delivery of services in the following areas:  

* Would put self in shower;

* Attending Bible study in the facility every Sunday;

* What genre of music the resident enjoys;

* Fall interventions;

* How the resident communicates unmet needs, including pain and need for connection; and

* Resident 4's routine of being up and walking throughout the day and night and then mostly sleeping for the following 24 hours.

The need to ensure service plans were reflective and provided resident specific instruction was discussed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant) on 04/22/25 at 5:19 pm. They acknowledged the findings.  

4. Resident 9 moved into the Memory Care Community in 05/2022 with diagnoses including Lewy Body dementia and Alzheimer's disease.  

Observations of the resident, interviews with facility staff, and the 01/22/25 service plan and Interim Service Plans, dated from 01/29/25 through 04/20/25, were reviewed during the survey and revealed Resident 9's service plan was not reflective of his/her current status, did not provide clear direction regarding the delivery of services, and/or was not implemented in the following areas:  

* How often the resident was assisted to the restroom;

* Meal assistance including ability to feed self and the need for cueing/redirection;

* Ability to communicate;

* Interventions for re-directing behaviors;

* ADLs including shaving and brushing his/her teeth;

* Skin issues; and

* The use of glasses.

The need to ensure service plans were reflective and provided resident specific instruction was discussed with Staff 43, (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant) on 04/22/25 at 5:19 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction regarding the delivery of services, and/or were implemented for 4 of 4 sampled residents (#s 4, 9, 19, and 20,) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 19 moved into the memory care community in 04/2023 with diagnosis including cognitive dysfunction, leukoencephalopathy  (a rare brain infection), and dysphasia.

The current service plan dated 04/21/25 and Interim Service Plans were reviewed, observations were made, and interviews with facility staff were conducted. The following was identified:

The resident's service plan lacked resident specific instruction, was not reflective of the resident's current status, and/or was not implemented in the following areas:

* Significance of the baby doll the resident had with him/her;

* Frequency and time of safety checks;

* Lack of footwear used and instruction relating to non-slip socks;

* Current diet order;

* Clear instruction to staff regarding nutrition and hydration;

* Catheter care that included clear direction to staff;

* Recent hospitalizations;

* Recent falls and fall interventions;

* Toileting assistance that included number of staff, frequency, and resident specific instruction;

* Incontinent assistance and brief changes that included number of staff, frequency, and resident specific instruction;

* Transfer status that included number of staff and instruction;

* Pain interventions including use of ice pack for shoulder;

* Change in ability to use his/her right arm after a fall;

* Shower instruction that included number of staff and resident specific instruction; and

* Diagnosis of leukoencephalopathy and how it impacted ADL care.

The need to ensure service plans were reflective, provided resident specific instruction, and was implemented was reviewed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant) on 04/22/25 at 2:24 pm. They acknowledged the findings.

1. Resident #9 no longer resides in the community. For residents 4, 19, and 20, the community has reviewed and updated the service plans to be sure that they are person-centered and meet the resident's needs in a way that supports dignity, privacy, choice, individuality and independence.

2. Each resident will have an evaluation completed with a person-centered service plan initiated upon move- in, and at least quarterly or with a significant change thereafter. Training has been provided to appropriate staff on how to complete the person- centered service plan to include personalization, resident choice/routine and staff direction on how to meet those needs. The service plans will be available in the Electronic Health Record (EHR) and on the floor in each community for staff access.

3. Random service plan audits will be conducted monthly for three months to assure they are person-centered, appropriate and reflect the resident's status and needs and will include staff direction to meet those needs.

4. The Administrator will be responsible for assuring that service plans are monitored on-going to meet the regulation.   

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the facility RN and service plans updated, failed to monitor and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift and made part of the resident's record with weekly progress noted through resolution for 1 of 6 sampled residents (#6) who experienced severe weight loss, multiple falls with injuries and pain. Findings include, but are not limited to:

Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure.

Review of the resident's record, including weight records dated between 04/21/23 and 10/16/23, the most recent service plan and evaluation, interim service plans, 10/01/23 through 10/16/23 MAR, incident reports, and charting notes dated between 07/21/23 and 10/16/23, interviews and observations with staff and the resident were conducted between 10/17/23 and 10/20/23.

a. Weight records from 04/2023 through 10/2023 indicated the resident weighed:

* 04/21/23: 156.4 lbs.;

* 08/03/23: 153 lbs.;

* 09/03/23: 144.8 lbs.; and

* 10/16/23: 134.2 lbs.

The resident lost 8.2 lbs. between 08/03/23 and 09/03/23, which was a 5.3% loss of his/her total body weight. This represented a significant weight loss in 31 days and constituted a significant change of condition.

The resident experienced a 22.2 lb. weight loss from 04/21/23 to 10/16/23 which was a 14.1% severe weight loss in six months and constituted a significant change of condition.

There was no documented evidence the facility RN was notified of the resident's weight loss; actions or interventions were determined, communicated to staff on all shifts, and implemented; or interventions were monitored for effectiveness.

On 10/18/23, the surveyor requested Resident 6's weight. Staff 16 (CG) reported the resident's weight was 137.2 lbs.

Meal observations on 10/18/23 and 10/19/23 revealed Resident 6 was unable to feed  him/herself, required one to one meal assistance from staff, and ate approximately 25% of his/her meals.

Multiple interviews with staff throughout the survey indicated the resident began to decline approximately "a couple of months ago" and required full assistance with meals.

During an interview on 10/18/23 with Staff 5 (Health Services Director, RN) and Staff 6 (Regional RN) it was confirmed there was no documented evidence an RN had assessed the weight loss or decline in the resident's ability to feed him/herself.

The facility failed to evaluate Resident 6's severe weight loss, determine what actions or interventions were needed, communicate the actions or interventions to staff, and refer the weight loss to the RN for further assessment. The resident continued to lose weight.

b. Resident 6's current service plan dated 09/10/23 indicated the resident had a history of falls and had experienced multiple falls since the last evaluation.

On 5/11/23 the resident sustained a fracture to his/her right foot from a fall. The service plan directed staff to ensure the resident wore nonskid socks. The service plan noted the resident had vision impairments, was mostly non-verbal, and required one staff partial assist with transfers with use of rollator walker.

Observations of the resident from 10/17/23 to 10/19/23 noted the resident required two-person assistance with a gait belt for transfers, full assistance with meals, used a wheelchair with staff assistance, and was unable to ambulate.

The resident's charting notes, and incident reports dated 07/07/23 through 08/04/23 identified the following:

* 07/07/23 2:00 pm - Care Staff were in the med room and heard a "thud sound". The resident was found in the living room sitting on the floor. As care staff moved the resident to the couch the resident said, "stop I hurt." It was noted the resident randomly said, "I hurt" during the ten minutes of having his/her vitals taken."

* 07/28/23 5:37 pm - Care staff found the resident sitting on floor in front of his/her wheelchair.

* 08/01/23 1:32 pm - Care staff heard a "thud" the resident was found in the living room laying down on the floor. The resident would not allow care staff to touch him/her. The resident was sent to the emergency department.

* On 08/04/23 an RN charting note documented the resident has had 14 falls since physical therapy was discontinued on 03/22/23. Thirteen falls were non-injury and one injury fall resulted in a fractured right foot on 05/11/23.

There were no interventions or actions put in place to prevent further falls.

The resident's charting notes, and incident reports dated 08/10/23 through 10/16/23 identified the following:

* 08/10/23 1:30 pm - Care Staff heard a "thud" and the resident was found in the living room, laying on his/her back. Resident 6 was sent to the emergency department.

* 08/13/23 5:38 am - Care Staff documented the resident had an assisted fall to the floor with injuries. Staff noted that during a transfer from the wheelchair to the toilet the resident's legs gave out and was assisted to the floor. The resident sustained an abrasion to the top left back area and had an open area to his/her elbow.

* 08/17/23 7:28 pm - Care Staff documented a resident was heard yelling that Resident 6 had fallen and was on the floor. Care Staff observed Resident 6 on the floor, in a seated position.

* 08/23/23 9:52 pm - Care Staff noted the resident was trying to sit back down in his/her wheelchair, and while staff was helping another resident, Resident 6 missed his/her wheelchair. The "resident had complained of pain in his/her bottom", "no signs or symptoms of bruising or redness."

* 08/25/23 6:34 pm - Care staff found the resident sitting on floor against the couch.

* 10/03/23 - Care Staff documented the resident was sent out to the hospital to be evaluated for a possible left ankle fracture.  

* 10/11/23 - Care Staff noted the resident was removed from alert for return from hospital. "Hospital said [s/he] was fine did not break or hurt anything." "[Resident 6's]  mobility is back at base line."

The resident experienced an additional five falls between 08/10/23 through 10/16/23, had multiple emergency department visits due to the falls, physical injuries, and pain.

The facility failed to thoroughly evaluate each fall to identify and document factors that might have contributed to the resident's falls. Although actions and interventions were noted in incident reports and progress notes, there was no documented evidence they were communicated to staff on all shifts and monitored for effectiveness. This placed Resident 6 at further risk of repeated falls and injuries.

c. Resident 6's charting notes reviewed from 07/21/23 through 10/16/23 identified the following:

* 07/21/23 - Care Staff documented when toileting the resident, a "mass like bump" was observed on the resident's "upper stomach." Staff noted, "[Resident 6] did show signs of pain when touching it. Staff notified the LPN, and she stated it was a bug bite.

* 07/22/23 - The LN documented, "[Resident 6] has a history of having this type of lump appearing and resolving" and notified the PCP for further instructions.

* 08/07/23 - Care Staff documented the PCP responded to the fax about [Resident 6] having a lump on abdominal area...Feels like a possible hernia but is not causing [him/her] any pain...Monitor for now."

* 10/11/23 - Care Staff documented the "resident had very strong foul smell when [s/he] urinates. No complaints of pain or discomfort when [s/he] is toileting."

During an interview on 10/19/23, Staff 16 reported the resident still had the mass on his/her stomach. A visible raised area was observed on the resident's abdomen and was noticeable below his/her clothing.

On 10/19/23, the observation and documentation related to the resident's abdominal mass was discussed with Staff 5 and Staff 6. Staff 5 was unaware of the resident's condition.

There was no documented evidence the facility identified resident specific interventions regarding the changes of condition, communicated the interventions to all staff, and monitored the resident according to his/her evaluated needs.

The need to ensure changes of condition were identified, reported to the RN if determined to be a significant change of condition, interventions determined, documented, and communicated to staff with monitoring occurring per the resident's evaluated needs was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.  

1. RN completed significant change of condition for resident 6. Clinical meetings are being scheduled as well as full documentation review to identify changes of condition.  A 24-hour book is being used with ISPs. Weekly weights will be reviewed by the RN and assessments completed weekly. RN to assess fall interventions and ADLs and implement ISPs and update service plan as appropriate.  

2. Clinical meetings for review of change fo condition multiple times per week. ISPs and alert charting will be reviewed in the clinical meeting. Education will be provided to care staff about the difference between significant change and short-term change of condition and how to communicate to nursing. Training will be provided by the consultant to the nursing team on how to recognize, respond, monitor, and document changes in condition. A white board will be utilized to track  change of condition and will be updated daily and as needed.

3. Daily, Monthly, Quarterly.

4. RCC, Nurses, Administrator

Based on observation, interview, and record review, it was determined the facility failed to evaluate changes of condition; failed to determine and document what actions or interventions were needed for the resident; failed to communicate determined actions or interventions with staff on each shift; failed to ensure the actions or interventions were resident-specific and made part of the resident record; and/or failed to monitor the changes through resolution, with at least weekly documentation of progress, for 3 of 4 sampled residents (#s 8, 10, and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the MCC in 10/2021 with diagnoses including dementia.

Review of the resident's record, including the most recent service plan, interim service plans, incident reports, and charting notes dated between 02/05/24 and 06/05/24, interviews with staff, and observations of the resident were conducted on 06/10/24 and 06/11/24. The following was revealed:

There was no documented evidence resident-specific actions or interventions were determined for the following short-term changes of condition, that the determined actions or interventions were communicated to staff on all shifts, that the resident was monitored consistent with his/her evaluated needs and service plan, and/or that weekly progress was noted through resolution:

* 04/27/24 - Bruise on the right upper arm;

* 05/29/24 - Found on floor with "bruising and redness above left eyebrow and on left cheek."; and

* 06/03/24 - Found on floor.

The need to ensure resident-specific actions or interventions were determined and documented, communicated to staff on each shift, and the conditions were monitored consistent with the resident's evaluated needs, with progress noted at least weekly until resolved was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), and Staff 25 (Acting ED) on 06/12/24. They acknowledged the findings.

2. Resident 10 was admitted to the facility in 05/2024 with diagnoses including Alzheimer's disease.

During the acuity interview on 06/10/24, Staff 2 (RCC), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 1 (Consultant RN) reported Resident 10 may become aggressive if s/he was approached for an interview and would notice if s/he were observed in an obvious manner. Based on this information, the resident was not interviewed during the survey.

The resident's 05/01/24 initial service plan, progress notes dated 05/01/24 through 06/10/24, incident reports, and interim service plans (ISPs) were reviewed, and interviews were conducted. The resident experienced the following:

* 05/14/24 - Exit-seeking behavior;

* 06/03/24 - Resident-to-resident altercation; and

* 06/06/24 - Exit-seeking behavior.

The resident was put on alert charting for these short-term changes of condition. However, there was no documented evidence that the changes were evaluated; that resident-specific actions or interventions were determined, documented, communicated to staff on all shifts, and made part of the resident's record; or that the resident was monitored consistent with his/her evaluated needs and service plan.

The need to evaluate changes of condition, determine and implement resident-specific interventions, and monitor the resident consistent with his/her evaluated needs and service plan was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consulting RN) on 06/12/24. They acknowledged the findings.

3. Resident 11 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease with behavioral disturbance.

The resident's 05/01/24 service plan, progress notes dated 03/04/24 through 06/07/24, incident reports, and interim service plans (ISPs) were reviewed, and interviews were conducted. The resident experienced the following:

* 05/25/24 - fall with arm pain; and

* 05/31/24 - aggressive behavior toward staff.

The resident was put on alert charting for these short-term changes of condition. However, there was no documented evidence the changes were evaluated; that resident-specific actions or interventions were determined, documented, communicated to staff on all shifts, and made part of the resident's record; or that the resident was monitored consistent with his/her evaluated needs and service plan.

The need to evaluate changes of condition, determine and implement resident-specific interventions, and monitor the resident consistent with his/her evaluated needs and service plan was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consulting RN) on 06/12/24. They acknowledged the findings.

1.)  Resident 8 service plan will contain resident specific actions and interventions, consistent with the residents need and progress noted at least weekly.  Resident 10 service plan evaluated for change of conditionand monitoring.  Resident 11 service plan evaluated for change of condition, evidence the changes were evaluated.  

2.)  Daily clinical meetings for review of change of condition will occur.  ISPs and alert charting will be reviewed during the daily clinical meeting.  Eduation to care staff on short-term change of conditions and how to communicate to LPN and RN.  White board will be updated to keep track of change of condition and will be updated as needed.

3.)  Daily, Monthly, Quarterly

4.)  RCC, LPN, RN, Executive Director, Assistant Executive Director

Based on observation, interview, and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs and service planned interventions for 1 of 2 sampled residents (# 13) reviewed for falls. This is a repeat citation. Findings include, but are not limited to:

Resident 13 was admitted to the facility in 06/2024 with diagnoses of dementia and was evaluated to be at risk for falls.

Resident 13 was observed during the survey to ambulate with the use of a four-wheeled walker.

Resident 13's current service plan indicated the resident was a fall risk and provided interventions to reduce falls.

Resident 13's clinical record revealed the resident was found on the floor on 09/03/24.

There was no documented evidence Resident 13's fall interventions were evaluated and monitored for effectiveness.

The need to monitor interventions related to the falls experienced by Resident 13 was reviewed with Staff 26 (ED),  Staff 35 (RN Health Services Director) and Staff 36 on (LPN Assistant Health Services Director) on 09/10/24 and 09/11/24. They acknowledged the findings.

1.) Resident 13 intermittent service plan updated for FWW walker and fall risk and interventions to communicate resident changes to care staff. .

2.) Daily clinical meetings with clinical meeting process for review of change of condition.  ISPs and alert charting will be reviewed during the daily clinical meeting.  Education with staff regarding short-term change of conditions and how to communicate with nursing team.

3.) Daily, Monthly, Quarterly

4.) LPN, RN

2. Resident 15 was admitted to the facility in 05/2023 with diagnoses of dementia.

During the acuity interview on 12/09/24, the resident was identified as having recent weight loss and as a result, the resident was enrolled in hospice services.

Resident 15 was observed during the survey to walk and eat independently without any issues.

The resident's service plan, dated 08/18/24, and a Temporary Service Plan, dated 11/21/24, did not indicate the resident's weight loss status.

Resident 15's weight record was reviewed during the survey and revealed the following:

* 08/07/24: 147.5 pounds:

* 11/08/24: 143.5 pounds; and

* 12/10/24: 141.0 pounds (during the survey).

The weight records showed the resident lost 2.5 pounds, or 1.7 % of his/her body weight from 11/2024 to 12/2024 in a month. It was not a significant change of condition. There was no documented evidence the facility determine what resident-specific action or intervention was needed for the resident, communicated the determined action or interventions to staff and documented weekly progress note until the condition resolved.

The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24 at 9:09 am. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document weekly progress until the condition resolved for 3 of 3 sampled residents (#s 15, 16 and 17) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 16 was admitted to the facility in 10/2024 with diagnoses including depression with psychotic features, generalized anxiety, left-side affected stroke, and vascular dementia.  

Clinical records, including the current service plan and progress notes, dated from 11/10/24 through 12/09/24, were reviewed, and interviews with facility staff and the resident were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

11/27/24: new orders for hydrocodone-acetaminophen 5-325 mg, oxycodone-acetaminophen 5-325 mg, and morphine ER 15 mg;

11/28/24: " ...continued to have edema" in the genital area;

11/28/24: "Pain was reported with movement due to surgical incisions.";

12/03/24: unwitnessed fall;

12/04/24: "Resident c/o [complained of] severe pain coming from hernia" in the genital area during primary care provider visit ...; and

12/04/24: returned from ER with a diagnosis of "swelling" in the right area of genital region.

The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24. They acknowledged the findings.

3. Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia.

The resident's service plan, dated 08/10/24, Interim Service Plans, progress notes, dated 11/09/24 through 12/09/24, and 12/01/24 through 12/09/24 MAR were reviewed. Staff were interviewed and the resident was observed. The following changes of condition were identified:

* 11/24/24: Resident to resident altercation;

* 11/29/24: Resident to resident altercation;

* 12/02/24: Unwitnessed fall at 9:30 am;

* 12/02/24: Unwitnessed fall at 9:10 pm; and

* 12/07/24: Unwitnessed fall.

There was no documented evidence Resident 17's changes of condition had resident specific actions or interventions determined, the actions or interventions were communicated to staff on each shift, or progress was noted weekly through resolution.

On 12/09/24 at approximately 5:00 pm, Staff 37 (RN Health Services Director) verified Resident 17 would cease behaviors towards other residents if offered "chocolate cake" or ice cream. He reported ice cream was available on the unit "at all times". When looking through the kitchenette on 12/09/24, Staff 37 verified the desserts were not available to staff at that time.

The chocolate dessert intervention was not documented in the resident's record and had not been made available to staff.

The need to ensure the facility determined what resident-specific actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and progress was noted through resolution was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.

1. Resident 16's 90-day medication orders were sent to PCP for review and signature. ATSP is in place for pain and swelling of scrotum; TSP in place for fall intervention; resident added to weekly skin rounds for scrotal swelling. Resident 15 - the RN and LPN completed a root cause analysis on weight loss prior to hospice and interventions were implemented. Resident 17 - interventions for resident to resident concerns implemented and nursing assessment in place; TSP in place for chocolate dessert intervention.  Interventions for both falls to be communicated to staff via TSP based on root cause analysis. Weekly audit of progress notes and other documentation completed by consultant and administrator to review change of condition response.

2. Clinical meetings are scheduled Monday-Friday, and will include the Administrator, LPN, RN, and RCC/ staffing coordinator. The Administrator, RN, and LPN will complete the NurseLearn Module 1 by alleged date of compliance. Every other Wednesday beginning, at 6AM and 6 PM shift change, a staff meeting will be held with a standing agenda of abuse and neglect reporting, investigation, and documentation. The LPN will apply to and complete the NurseLearn Enhanced Program starting January 3, 2025 with the support from the Administrator to block time off each week for program requirements.

3. Daily, Weekly, Monthly

4. Administrator, Nurses, RCC, Staffing Coordinator

Based on observation, interview and record review, it was determined the facility failed to ensure the RN conducted an assessment when residents experienced a significant change of condition, failed to develop interventions based on the results of the assessment, and failed to update the service plan for 1 of 2 sampled residents (#6) who experienced significant changes of condition. Resident 6 experienced severe weight loss, multiple falls with injuries, and pain. Findings include, but are not limited to:

Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure.

a. A review of Resident 6's weight records showed the resident had experienced a severe weight loss between 04/21/23 (156.4 lbs.) and 10/16/23 (134.2) of 22.2 pounds or 14.1% severe weight loss in six months and constituted a significant change of condition, and between 08/03/23 (153 lbs.) and 09/03/23 (144.8 lbs.) the resident lost 8.2 lbs which was a 5.3% loss of his/her body weight. This represented a significant weight loss in 31 days and constituted a significant change of condition.

There was no documented evidence the facility RN had completed a significant change of condition assessment for the weight loss, which included documented findings, resident status interventions made as a result of an assessment or had updated the service plan as appropriate. The resident continued to lose weight.

Refer to C 270, example a.

b. A review of Resident 6's charting notes and incident reports dated 07/07/23 through 10/16/23 identified the resident experienced eight falls between 07/07/23 through 10/16/23, multiple emergency department visits due to the falls, physical injuries, and pain.

Interviews with staff throughout the survey indicated the resident had a significant decline in transfers, mobility, toileting, and eating independently.

Observations of the resident from 10/17/23 to 10/19/23 noted the resident required two-person assistance with a gait belt for transfers, full assistance with meals, used a wheelchair with staff assistance and was unable to ambulate.

There was no documented evidence the facility RN had completed a significant change of condition assessment for the resident's overall functional decline, repeated falls with injuries, and pain which included documented findings, resident status, interventions made as a result of an assessment or had updated the service plan as appropriate. This placed Resident 6 at further risk of repeated falls and injuries.

Refer to C 270, example b.

On 10/20/23, the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations). They acknowledged the findings.

1. RN completed significant change of condition for resident 6 and interventions put in place regarding significant weight change, falls, and decline in ADLs. Weekly and monthly weight monitoring is in place. The RN is documenting progress weekly and is evaluating the effectiveness of interventions implemented for significant change of condition. Care staff will be trained in notifying RN of significant change of condition.

2. Clinical meetings for review of change of condition. The consultant will provide training to the RN on how to recognize, respond, monitor and document significant change of condition. Weight monitoring and tracking will be done weekly/monthly and the white board will be updated during the clinical meeting. Education will be provided to care staff on the differences between a significant change and short-term change of condition and how to communicate this to the RN.

3. Daily, weekly.

4. RN, Administrator

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 2 of 2 sampled residents (#s 1 and 7) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

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

1. Resident 1 was admitted to the facility in 09/2018 with diagnoses including diabetes and dementia.

A facility acuity interview conducted 10/16/23 revealed Resident 1 was administered insulin injections by non-licensed staff. The non-licensed staff were delegated by Staff 23 (Agency RN) who was hired specifically for delegation.

Resident 1's MARs from 10/01/23 through 10/16/23 and delegation records were reviewed and revealed the following:

Resident 1's MARs noted insulin had been given by Staff 18 (MT) and Staff 22 (MT) on multiple occasions.

On 10/18/23 documentation of the delegations for Resident 1 were requested.

At 3:15 pm on 10/18/23, Staff 6 (Regional RN) provided delegation documentation as Staff 23 was no longer in the facility. Staff 6 stated when she initially asked Staff 23 for the documentation, Staff 23 stated it hadn't been done. Later that day, Staff 23 provided Staff 6 with the delegation documentation. Staff 6 talked with two of the MTs whose delegations were included. Both Staff 18 and Staff 22 stated to Staff 6 they had not seen the delegation form, and it was not their signatures on the form. Staff 6 said she was not sure about the other delegations, and they were being investigated.

At the time of the survey the facility contracted with an LPN to administer insulin until the facility RN could complete delegations.

The need to ensure staff who administered insulin injections were delegated and re-evaluated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings

2. Resident 7 moved into the facility in 10/2022 with diagnoses including type II diabetes and Wernicke's dementia.

During the acuity interview on 10/16/23, Resident 7 was identified to be administered insulin injections by non-licensed staff.

Review of the 10/01/23 to 10/19/23 insulin administration records and delegation records showed the following:

* Staff 3 (Staffing Coordinator), Staff 11 (MT) and Staff 24 (MT), documented on the MAR they administered Resident 7's insulin injection on multiple occasions; and

* There was no documented evidence of delegation for Staff 3, 11 and 24.

On 10/19/20 at 1:20 pm, Staff 6 (Regional RN) confirmed Staff 3, 11 and 24 administered insulin injection to the resident and there was no documented evidence Staff 3, 11 and 24 were delegated for the resident's insulin administration task.

On 10/20/20, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations). They acknowledged the findings. During the survey, Staff 6 stated Staff 24 was no longer working in the facility and contracted with an LPN who would administer insulin to all residents who required insulin administration until the facility RN could complete delegations.

1. Currently any delegatable procedures are being done by the LPN or RN. The RN is working on completing the diabetic assessments. The RN will evaluate all med techs for competence and complete all delegation paperwork.

2. The RN consultant will provide RN delegation forms and training to the community RN on RN delegation. The RN delegation binder will be re-organized and will have the necessary resources for the med tech.

3. Weekly, Monthly.

4. RN and Administrator.

Based on observation, interview and record review, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment and to comply with a qualified designated Infection Control Specialist and completed specialized training in infection prevention and control protocols within three months of being designated. Findings include, but are not limited to:

1. Resident 2 was observed eating lunch from 12:10 pm until 12:45 pm on 10/17/23 and breakfast from 8:20 am to 9:14 am on 10/18/23. S/he used his/her fingers to pick up all food, including meat, vegetables and scrambled eggs. The resident was observed frequently putting his/her fingers in his/her mouth as well as wiping his/her hands on his/her pants. Care staff observed in the dining room at the time of breakfast and lunch did not wash the resident's hands prior to meal services and following the meal.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/18/23 and 10/20/23. The findings were acknowledged.

2. Upon entrance to the facility on 10/16/23, the facility's designated Infection Control Specialist and documentation of completed specialized training in infection prevention was requested. No information was provided.

During the survey on 10/18/23, Staff 2 (RCC) reported Staff 4 (Environmental Services Director) was the facility's designated Infection Control Specialist.

On 10/19/23 at 8:20 am, survey team received the documentation of the facility's designated Infection Control Specialist completed specialized training in infection prevention. The documentation showed the training was completed on 10/18/23.

On 10/20/23 at 9:30 am, Staff 1 (ED) stated the facility's designated Infection Control Specialist, Staff 4, did not have a health professional education background or experience in infection control or in health inspector. Staff 1 confirmed the facility's designated Infection Control Specialist completed the required training during the survey.

The need to ensure establishment and maintenance of infection prevention control protocols and compliance with the facility's designated Infection Control Specialist qualification and completed required training in a timely manner was discussed with Staff 1, Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23 at 9:30 am. They acknowledged the findings and no further information was provided.

1. Care staff have been educated to assist residents with hand washing before and after meals. The LPN has been assigned the Infection Control Specialist role and will complete the Infection Control Specialist training on OCP.

2. Hand washing/hygeine to be taught to all staff at next staff meeting. This will include the importance of hand washing/hygeine for residents also. The LPN will complete the OCP Infection Control Specialist Training.

3. Monthly, Quarterly.

4. Nursing and Administrator

2. Resident 1 was admitted to the facility in 09/2018 with diagnoses including diabetes and dementia.

A review of the 10/01/23 through 10/16/23 MAR and current physician's orders revealed the following:

Resident 1 had a physician order for Novolog, give 5 units in the morning and evening with meals and give 8 units every day at noon with meal. Hold for CBG less than 100. On two occasions, 10/11/23 at 12:00 pm and 10/16/23 at 8:00 am, the medication was given outside the parameters when it should have been held.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 5 (RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure insulin orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 7) whose insulin orders were reviewed. Findings include, but are not limited to:

1. Resident 7 moved into the facility in 10/2022 with diagnoses including type II diabetes and Wernicke's dementia. The resident's insulin administration records dated 09/01/23 through 10/16/23 and physician orders were reviewed and revealed the following:

Resident 7's current physician orders included:

* Check CBG three times daily; and

* To administer 6 units of Aspart insulin with each meal and based on the resident's CBGs additionally;

: 0 - 149 = 0 unit

: 150 - 199 = 6 units

: 200 - 249 = 8 units

: 250 - 299 = 10 units

: 300 - 349 = 14 units

: 350 - 399 = 16 units

: 400 - 499 = 18 units

: 500 - 600 = 20 units

The 10/01/23 - 10/17/23 insulin administration records was reviewed. The records showed staff documented the resident's CBG results, a range of 153 to 507 daily. However, there was no documented evidence additional sliding scale insulin was administered to the resident.

On 10/19/23 at 3:20 pm, the surveyor reviewed insulin administration records and physician orders with Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations). They confirmed there was no verification the correct amount of insulin was administered to Resident 7.

The need to ensure physician orders were carried out as prescribed and documented was discussed with Staff 1 (ED), Staff 5, Staff 6 and Staff 7 on 10/20/23. They acknowledged the findings.

1. Resident 7's sliding scale insulin is now separate from the fixed dose that is given at each meal. Resident 1 has clear parameters in place to ensure insulin is being held appropriately. LPN and RN are currently administering insulin.

2. RN will audit insulin orders with each initial delegation, subsequesnt re-evaluations, and with any insulin changes. New orders will be reviewed during the clinical meeting for MAR accuracy.

3. Daily, Quarterly, and as needed

4. RN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 1 of 1 sampled resident (#16) whose orders were reviewed. Findings include, but are not limited to:

Resident 16 was admitted to the facility in 10/2024 with diagnoses including depression with psychotic features, generalized anxiety, left-side affected stroke, and vascular dementia.  

Review of the resident's medical record, current physician orders, and MAR, dated from 11/01/24 through 12/10/24, revealed the following:

Resident was hospitalized from 11/25/24 through 11/27/24, discharge instructions dated 11/27/24 contained the following orders:

* Hydrocodone-acetaminophen 5-325 mg: Take one to two tablets by mouth every four hours as needed for pain for up to seven days;

* Oxycodone-acetaminophen 5-325 mg: Take one tablet by mouth every four hours as needed for pain for up to 16 doses; and

* Morphine ER 15 mg 12 hour tablet: Take 15 mg by mouth two times daily.

There was no documented evidence oxycodone-acetaminophen 5-325 mg and morphine ER 15 mg were available for administration.

The facility administered oxycodone on 11/27/24 and 11/28/24 to control pain. However, the facility did not have a current order for administration of oxycodone during that time.

In an interview on 12/11/24 at 9:44 am, Staff 11 (MT) stated "Only oxy [oxycodone] was available [for administration] on the MAR". The hydrocodone-acetaminophen 5-325 mg was approved for dispensing by the MT on 12/01/24.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24. They acknowledged the findings.

1. Resident 16's 90 day orders were reviewed and sent to the PCP for review and signature.  The morphine order has been discontinued.  

2. The nursing department will train and evaluate competence for all med techs in the 3-check system for processing orders. In the moment training will occur when an issue is identified related to order review. The nursing department will provide education with med techs on how to complete a MAR reconcilication when a care transition occurs. Nurses will review their own medication reconciliation with each care transition. A review of medication exceptions and variances will be completed during the daily clinical meeting with follow up the same day. LPN, RN, and the Adminstrator will complete the NurseLearn course "Managing Care Transitions."

3. Daily, Weekly

4. Administrator, Nurses, RCC

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 16 and 17) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia.

The resident's 12/01/24 through 12/09/24 MAR was reviewed and the following was identified:

The following PRN medications prescribed for agitation related to dementia lacked instructions for sequential order of use:

* Quetiapine; and

* Haloperidol.

The need to ensure the resident's MAR was accurate and included resident-specific instructions for PRN medications was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.  

2. Resident 16 was admitted to the facility in 10/2024 with diagnoses including depression with psychotic features, generalized anxiety, left-side affected stroke, and vascular dementia.  

Resident 16's MARs from 11/01/24 through 12/10/24 and physician orders were reviewed, and revealed the following:

a. The following PRN medications lacked instructions for sequential order of use:

* Acetaminophen 325 mg (for pain);

* Diclofenac 1% gel 50 gm (for pain); and

* Oxycodone 5mg (for pain).

b. The following PRN medications lacked resident specific parameters for use:

* Albuterol 90 mcg inhaler (for wheezing); and

* Hydroxyzine 25 mg (for anxiety).

The need to ensure the MAR was accurate and included resident-specific parameters and instructions for PRN medications was reviewed with Staff 26 (ED) and Witness 1 (Consultant RN) on 12/11/24. They acknowledged the findings.

1. PRN parameters are complete for resident 16 and 17. PRN parameters will be reviewed for all residents and updated as needed.

2. An audit of all orders will be completed by Consonous pharmacy. A review will be conducted of all residents to ensure 90-day orders are current. The Nursing team will complete a medication reconciliation with any transition of care/return to community. A review of medication exceptions and variances will be completed during the daily clinical meeting with same day follow up. 90-day orders will be reviewed with quarterly with the service plans.

3. Daily, Quarterly

4.) Administrator, Nurses

Based on observation, interview, and record review, it was determined the facility failed to ensure they had been consistently staffing to the posted staffing plan. Findings include, but are not limited to:

The facility's Acuity Based Staffing Tool (ABST) entries, staff schedule, calculated staffing hours, and posted staffing plan were reviewed with Staff 26 (ED) and Witness 1 (Consultant RN).

The facility posted staffing plan was as follows:

* The facility operated on 12 hours shifts, running from 6:00 am to 6:00 pm;

* 6:00 am to 6:00 pm: One CG and one MT in Cottage A and B and two CGs and one MT Cottage C and D; and

* 6:00 pm to 6:00 am: One CG in Cottage A, one CG and one MT in Cottage B, two CGs Cottage D, and two CGs and one MT in Cottage C.

The staff schedule, dated 12/04/24 through 12/10/24, was reviewed. On 12 out of 14 occasions, the number of MTs that worked did not meet the posted staffing plan and on seven out of 14 occasions, the number of CGs that worked did not meet the posted staffing plan.

On 12/10/24 at 12:02 pm, Staff 26 reported staffing had been challenging over the past two weeks, particularly from Sunday to Wednesday, and the facility was unable to meet the required staffing levels during that period.

On 12/10/24, an anonymous staff member reported s/he could not always pick up the morning or afternoon snacks from the kitchen for the residents as s/he was alone on the unit.

The need to ensure the facility staffing plan and staff working on the floor exceeded the ABST staffing calculations and that the posted staffing plan matched the current staffing plan was discussed with Staff 26 and Witness 1 on 12/11/24 at 9:09 am. They acknowledged the findings.

1.) Staff recruitment is ongoing. ABST is updated multiple times per week with resident change of condition and service plan updates.

2.) The community is contracted with a recuriter to assist with the identification of potential employees. Additional agency contracts will be secured.

3.) Weekly

4.) Administrator, Staffing Coordinator

Based on observation, interview and record review, it was determined the facility failed to develop a staffing plan as the results of the facility's acuity-based staffing tool (ABST). Findings include, but are not limited to:

The facility had 64 residents at the time of survey and consisted of four cottages.

The facility's posted staffing plan revealed the following:

* 2 Caregivers and 1 Medication Aide from 6:00 am to 6:00 pm in each cottage; and

* 1 Caregiver and 1 Medication Aide from 6:00 pm to 6:00 am in each cottage.

The facility's ABST was reviewed on 10/18/23 at 1:45 pm and discussed with Staff 2 (RCC). Staff 2 reported the facility used "Frontier Acuity Tool" and planned the staffing level based on the acuity tool. Staff 2 stated the facility updated the staffing plan weekly. However, Staff 2 reported the facility was not able to staff at the staffing level as the facility acuity tool indicated. Staff 2 stated the facility acuity tool indicated the facility required 2 CGs and 1 MA in each cottage and 2 CGs and 1 MA, floating between cottages from 6:00 am to 6:00 pm.

During the survey, the facility staffing levels in each cottage revealed the following:

* 10/16/23 from 6:00 am to 6:00 pm, 1 CG and 1 MA in Cottage A, 1 CG in Cottage B and C, and 1 MA floating between Cottage B and C;

* 10/17/23 from 6:00 am to 6:00 pm, 1 CG and 1 MA in Cottage A, 1 CG in Cottage B and C, 1 MA floating between Cottage B and C, and 3 CGs including 2 trainees and 1 MA in Cottage D; and

* 10/18/23 from 12:00 pm to 6:00 pm, 2 CGs and 1 MA in Cottage A and B, 3 CGs including 1 trainee and 2 MAs including 1 trainee in Cottage C, and 3 CGs including 2 trainees and 1 MA floating between Cottage D and other Cottage.

The need to ensure the facility developed a staffing plan as the results of the facility acuity-based staffing tool was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

1. The community is actively recruiting for care staff positions and are utilizing agency staff until adequate staff is hired.

2. The ABST will be updated with quarterly service plan updates, with each new admission and with change of condiiton as the service plans are updated. Agency staffing will continue until enough care staff hired. The ABST will be reviewed by the administrator for accuracy.

3. Weekly, Monthly.

4. RCC, Administrator

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool to determine appropriate staffing levels. This is a repeat citation. Findings include, but are not limited to:

On 06/11/24 at 12:25 pm, Staff 25 (Acting ED) reported the facility was under a new management company as of 06/01/24. She indicated they had been using a proprietary ABST with their former management company. Staff 25 stated she printed the ABST data on 06/02/24 and would provide a copy. She reported she would be entering the ABST data into the new management company's proprietary ABST soon.

On 06/12/24, Staff 25 reported she was unable to find the printed copy of the previously-used ABST and that she did not yet have access to the new management company's ABST to input resident data.

The need to implement an acuity-based staffing tool and determine staffing levels from the data was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consultant RN) on 06/12/24. They acknowledged the findings.

1.)  Executive Director has been granted access to Oregon state ABST tool and ABST has been updated for facility.

2.)  The ABST will continue to be updated with quarterly service plan updates, new admissions and change of conditions.  

3.)  Weekly, Monthly

4.)  Scheduler, Executive Director, Assistant Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure all residents were entered into the staffing tool and to use the results of the tool to develop and routinely update the facility's staffing plan. This is a repeat citation. Findings include, but are not limited to:

The facilities acuity-based staffing tool (ABST) was reviewed on 09/11/24 and the following was identified:

* Not all current residents were entered into the tool;

* Multiple former/past residents were still noted in the tool; and

* A non-sampled resident receiving one-on-one staffing related to monitoring behavioral conditions or symptoms did not have the hours reflected in ABST.

There were no staffing issues observed and resident needs were met.  

The need to ensure all residents were entered into the staffing tool, and potential inaccurate staffing calculations was discussed with Staff 26 (ED) on 09/11/24. She acknowledged the findings.

1.) ABST updated with all current residents, removed past residents, updated with correct hours for 1:1 resident.

2.)ABST will be updated with all service plan updates, new admission, discharges and change of conditions.

3.) Daily, weekly, Monthly

4.) Scheduler, Exectuive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 1 of 3 sampled residents (# 17) whose Acuity Based Staffing Tool (ABST) was reviewed. Findings include, but are not limited to:

Resident 17 was admitted to the facility in 04/2024 with diagnoses including dementia.

The resident's service plan, Interim Service Plans, ABST, and Charting Notes, dated 11/09/24 through 12/09/24, were reviewed. Staff were interviewed and Resident 17 was observed. The resident's ABST was reviewed and was not reflective of care time needed in the following areas:

* Safety checks and fall prevention;

* Monitoring behavioral conditions or symptoms;

* Non-drug interventions for behaviors;

* Repositioning in bed; and

* Bowel and bladder management.

The need to accurately capture care time on the resident's ABST was discussed with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.  

1. Resident 17 ABST time was updated in ABST.  All residents ABST time has been updated concurrent with service plan updates.

2. Continued updates of the ABST multiple times per week.   

3. Daily, Weekly

4. Administrator, Staffing Coordinator

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 C 231, C 260, C 270, C 361, and C 513.

Refer to plan of corrections for C231, C260, C270,C361 and C513

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 231, C 260, C 270, C 361, and C 513.

Refer to plan of corrections for C231; C260; C270; C361; and C513

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 231, C 260, C 270.

Refer to C231, C260 and C270

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 231, C 260, and Z 164.

See POC for C 231, C 260, Z 164

Based on observation and interview, it was determined the facility failed to ensure storage was provided for all maintenance equipment and all chemicals and toxic materials were maintained in locked storage. Findings include, but are not limited to:  

On 10/16/23 at 1:50 pm, the surveyor conducted a walk-through of the facility and the following was observed:

* An outdoor courtyard area contained miscellaneous maintenance equipment and supplies being stored outside; and

* The soiled laundry room contained toxic chemicals and was unlocked/accessible.

The need to ensure the facility provided storage for all maintenance equipment, and chemicals and toxic materials were secured in locked storage was discussed with Staff 4 (Environmental Services Director) on 10/18/23 at 9:45 am. He acknowledged the findings.

1. All outdoor maintenance equiment and supplies are now stored in locked storage. All toxic chemicals also stored in locked storage.

2. Scheduled walk throughs several times per week done by maitenance director and administrator. Staff trainign on ensuring laundry room remains locked and unaccessble to residents.

3. Weekly.

4. Maintenance Director and Administrator

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

During a tour of the interior of the facility on 10/16/23 at 1:50 pm, carpet throughout the common area hallway and in the four cottages (A, B, C and D) was stained.

The following doors were gouged and scraped: B8, C7 and C8.

In the common area of B cottage a maroon recliner was observed to have stained/worn arms.

The surveyor toured the environment with Staff 4 (Environmental Services Director) on 10/18/23 at 9:45 am. He acknowledged the findings.

1. Administrator is working to obtain quotes for carpet replacement. The doors for B8, C7, and C8 have been repaired and the recliner has been disposed.

2. Daily walk throughs by maintenance director and administrator. Staff will be trained to notify maintenance of repair needs.

3. Daily, Weekly

4. Maintenance director and Administrator

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

During the survey, between 06/10/24 and 06/12/24, it was observed that much of the carpet in the facility had been replaced with vinyl flooring and that many of the resident units still had stained carpet.

In an interview on 06/11/24 at 12:30 pm, Staff 4 (Environmental Services Director) reported they were not finished replacing all the carpet but were working on it slowly.

On 06/12/24 at 12:40 pm, Staff 25 (Acting ED) reported they had been replacing the carpet with vinyl flooring in one resident room a month with their former management company. She stated the facility was under new management as of 06/01/24. When asked what the timeline was to complete the carpet replacement, she stated she was unsure what the new management company planned to do.

The need to ensure interior surfaces were kept clean and in good repair was discussed with Staff 2 (RCC), Staff 5 (Health Services Director/RN), Staff 25 (Acting ED), Staff 26 (ED-in-Training), and Witness 2 (Consultant RN) on 06/12/24. They acknowledged the findings.

1.)  Quotes have been obtained for replacement flooring and audit of rooms completed, starting with the rooms that need replacement first.  Rooms are still being kept clean while awaiting vinyl flooring in all resident rooms.  

2.) Maintenance Director, Executive Director and Assistant Executive Director will continuing working on list of rooms to replace the flooring, currently replacing 2 rooms per month.

3.)  Daily, Weekly

4.)  Maintenance Director, Executive Director, Assistant Executive Director.  

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

During the survey, between 09/10/24 and 09/11/24, the carpets were observed to be soiled and stained in the following areas:

*A cottage rooms 2, 5, 7, 8 , and 10;

*B cottage rooms 1, 2, 3, 6, 7, and 9;

*C cottage rooms 5, 8, 10, and 11; and

*D cottage rooms 1, 4, 8, 10, and 11.

The need to ensure interior surfaces were kept clean and in good repair was discussed with Staff 26 (ED) and Witness 2 (Consultant RN) on 09/11/24. They acknowledged the findings.

1.) Quotes for replacement have been obtained and audit of rooms completed. Rooms are being kept clean while awaiting vinyl flooring.

2.) Starting with cottage A in the back room 10 working forward, completing 2 rooms at a time.

3.) Daily, Weekly

4.) Maintenance Director, Executive Director

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit for multiple sampled and unsampled residents. Findings include, but are not limited to:

Refer to C 200.

Refer to plan of correction for C200

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

Review of records for Residents 12, 13, and 14 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms.

Interviews with care staff on 09/10/24 and 09/11/24 identified residents were not provided keys to there rooms.

The need to ensure all residents were provided keys to their units was discussed with Staff 26 (ED) on 09/11/24. She acknowledged the findings.

1.) Residents 12, 13 and 14 service plans were updated regarding keys hung in their apartment.

2.) Executive Director and nursing team updated all service plans for all residents. All residents will be given an apartment key and have it accessible.

3.) Daily, Weekly, Monthly

4.) Executive Director, Maintenance Director

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 242, C 295, C 361, C 510 and C 513.

Refer to C 231, C 242, C 295, C 361, C 510 and C513.

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

Refer to C 231, C 361, and C 513.

Refer to plan of corrections for C231, C260, C270,C361 and C513     

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

Refer to C 152, C 200, C 231, C 361, and C 513.

Refer to plan of corrections for C152; C200; C231; C361 and C513

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

Refer to C 231, C 360 and C 362.

Refer to C231, C360 and C362

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

Refer to C 231.

See POC for C 231

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

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

Refer to C 252, C 260, C 270, C 280, C 282 and C 303

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

Refer to C 260 and C 270.

Refer to plan of corrections for C231, C260, C270,C361 and C513     

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

Refer to C 260 and C 270.

Refer to plan of corrections for C260 and C270

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

Refer to C 260, C 270, C 303, and C 310.

Refer to C260, C270, C303, and C310

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

Refer to C 260.

See POC for C 260

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 1 of 2 sampled residents (#6) whose service plans were reviewed for weight loss. Findings include, but are not limited to:

Resident 6 was admitted to the MCC in 04/2022 with diagnoses including occipital lobe dementia and congestive heart failure.

Observations made on 10/17/23 through 10/19/23, showed Resident 6 was dependent on staff for all ADLs and required hands-on assistance to eat meals.

The resident had experienced severe weight loss over the past six months and was dependent on staff to meet nutrition and hydration needs. There was no individualized hydration and nutrition plan identified for the resident and the service plan lacked information and instructions on interventions to monitor for weight loss.

The need to provide a daily meal program for nutrition and hydration based upon the resident's preferences and needs, available throughout each resident's waking hours and documented in the resident's service plan was discussed with Staff 1 (ED), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.  

1. Resident 6 will have the individualized nutrition and hydration plan updated in service plan and communicated to staff. All service plans will be updated with individualized nutrition and hydration plans that will provide information on how to meet hydration needs, asssistance needed, and include interventions to maintain and monitor weight.

2. The consultant will provide training on how to service plan for nutrition and hydration and will review updated service plans. Nutrition and hydration plans will be included in the initial evaluation and service plan; updated with any changes and quarterly.

3. Quaterly and with change of condition.

4. RCC, Nurses, and Adminiatrator.

Based on observation, interview, and record review, it was determined the facility failed to evaluate each resident for activities and develop an individualized activity plan for each resident based on the activity evaluation for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose activity plans were reviewed. Findings include, but are not limited to:

During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend, and participate in activities. The facility offered a couple of group activities including morning exercise and packing candies which a few residents attended in cottages A, B, and C. There was no other group or individual activities in cottages A, B, C and D. Majority of residents did not attend the activities and instead stayed in their rooms or walked around the facility. All residents were diagnosed with some type of dementia.

The activity section of Resident 1, 2, 3, 4, 5 and 6's current service plans were reviewed. Though there was some information about each resident's past or current interests, the facility had not fully evaluated the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for participation; and

* Activities that could be used as 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. There were no instructions for providing activities for residents who did not participate in group activities.

The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed with Staff 1 (ED), Staff 5 (Health Services Director, RN), Staff 6 (Regional RN) and Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

1. Residents 1, 2, 3, 4, 5, & 6 evaluations will be updated to include all necessary components and service plans updated to include all required elements. All service plans will be updated with individualized activity plans.

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

3. Quarterly and with change of condition.

4. Marketing director or assigned caregiver until activity director hired. RCC and administrator.

Based on observation, interview, and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation, for 2 of 3 sampled residents (#s 15 and 17) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 15's and 17's records were reviewed and observations were made during the survey. The current activity evaluations did not address one or more of the following required components:

* Current abilities and skills; and

* Emotional/social needs and patterns.

The current activity plans were not individualized to each resident based on their activity evaluation and not included on the resident's activity service or care plan.

In an interview with Staff 33 (Lifestyle Director) on 12/10/24 at approximately 3:15 pm, she confirmed that the residents did not have an individualized activity plan included on their service plans.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 33 on 12/10/24 and with Staff 26 (ED), Staff 36 (LPN Assistant Health Services Director), Staff 37 (RN Health Services Director), and Witness 1 (Consultant RN) on 12/11/24 at 9:39 am. They acknowledged the findings.  

1. Resident 15 and 17 activity evaluations have been updated to address current abilities and skills, and emotional/social needs and patterns.

2. The Activity Director has updated the life enrichment form to include emotional and social needs and patterns related to activities. The Activity Director will review and update all residents indvidual activity plans.

3. Weekly, Monthly, Quarterly

4. Administrator, Activity Director

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 4 of 4 sampled residents (#s 4, 9, 19, and 20) whose records were review. This is a repeat citation, Findings include but are not limited to:

Resident 4, 9, 19, and 20 service plans and activity evaluations were reviewed. There was no documented evidence the facility had fully evaluated and developed individualized plans based on the residents' 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, if necessary.

Resident 4 was identified as not always being able to verbalize his/her needs. On 04/22/25, the resident was observed walking in a hallway with two staff members. Staff 11 (MT/CG) had one of the resident's favorite rock band's music playing on her phone. The resident showed signs of intently listening to the music, and when the chorus began, s/he sang along with perfect accuracy while smiling. This activity was not reflective in Resident 4's service plan.

Resident 20 was observed to require staff assistance with escorting to activities and one-on-one meal assistance. The resident was in the common area most of the time without engaging in any group or 1:1 activities.

On 04/22/25 approximately at 2:10 pm, the need to ensure the facility developed individualized activity plans based on the activity evaluation was discussed with Staff 43 (ED), Staff 44 (Consultant), Staff 45 (RN), Witness 1 (RN Consultant), and Witness 2 (RN Consultant). They acknowledged the findings.

1. Resident #9 no longer resides in the community. For residents 4, 19, 20, the community has updated the residents individual activity plans based on the activity evaluation.

2. All other residents will have an individual activity plan updated at their next quarterly review, change in condition, or move in. All other resident charts will be audited to ensure there is a current individual activity plan in place. Designated staff have received in depth training on individual service and activity plans.  

3. Random, individual activity plan review will be conducted monthly for 3 months to assure they are individualized and reflect resident's current status.

4. The Administrator will be responsible for assuring that individualized activity plans are monitored on-going.

2. Resident 2 moved into the MCC in 10/2023 with diagnoses including Alzheimer's disease.

Review of the resident's 09/28/23 move-in evaluation indicated that at 3:00 pm, the resident "starts sundowner, tries to wander away." The resident had behaviors including "shaking, grabbing and pushing and curses". Staff documented "COPs were called on 9/20/23. Resident was trying [to] leave."

There was no service plan for the resident. During an interview on 10/17/23 at 1:18 pm, Staff 20 (CG) confirmed there was no service plan for the resident.

The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 5 (Health Services Director, RN), Staff 6 (Regional RN), Staff 7 (VP of Operations) on 10/20/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service or care plan for 2 of 4 sampled residents (#s 2 and 4) who had challenging behaviors in the MCC. Findings include, but are not limited to:

1. Resident 4 was admitted to the MCC in 10/2022 with diagnoses including Wernicke's dementia and acute encephalopathy.

Record review and observations made during the survey revealed Resident 4 frequently exhibited escalated verbal behavior including yelling at staff and residents when agitated and exhibited rocking back and forth.

The current service plan, dated 07/25/23, lacked resident-specific information that informed staff of the specific behaviors of concern and lacked individualized interventions for staff to try when responding to the behaviors.

The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 5 (Health Services Director, RN), and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

1. Resident 2 & 4 will have their service plans updated to include behavioral symptoms that negatively impact others in the community, including interventions. All resident service plans to be reviewed and updated for any behavioral symptoms and interventions. Consultant will provied training on how to add indivudualized interventions to the service plan and provide staff traingin to staff on how to implement the interventions.

2. Service plans will be reviewed to ensure they include behavioral symptoms and interventions. Service plans will be evaluated at each quarterly update and with change of condition.

3. Quarterly and with changes.

4. RCC, Nurses, Administrator

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to:

During a tour of the facility grounds on 10/16/23, two exit doors leading to an outdoor courtyard area were locked. The exit doors remained locked throughout the first two days of the survey. On the third day of survey, the doors were unlocked.

Interviews with staff during the survey confirmed they were unaware who had the ability to lock/unlock the courtyard doors and when they should be locked/unlocked.

On 10/20/23 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) and Staff 6 (Regional RN). They acknowledged the findings.

1. All care staff have a key that unlocks the courtyard. The Key to rooms also work for the courtyard. All staff have been retrained how and when to lock and unlock the doors.

2. RCC and Administrator walk throughs.

3. Daily

4. RCC and Administrator

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:

The MCC was toured on 10/17/23 at 1:50 pm. Resident rooms including, but not limited to A3a, A6, A10b, B7a, C7a/b, C9a, C10a/b, D2a, D4b, D9b and D11b lacked any means of identifying the room for the resident.

The need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 1 (ED) and Staff 6 (Regional RN) on 10/20/23. They acknowledged the findings.

1. Marketing director is currently working on getting placards up with identifying information to help residents identify their apartment.

2. Administrator and activity director (once hired) walk throughs.

3. Daily, weekly

4. Administrator, Marketing director until activity director is hired.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to:

During the survey, observations of resident rooms revealed they were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open all residents' rooms.

In an interview with caregiving staff on 09/10/24 and 09/11/24, they explained resident room doors were all routinely locked to prevent wandering residents from entering.

The need to ensure residents were not locked outside their rooms was discussed with Staff 26 (ED). She acknowledged the findings.

1.) All resident rooms that were locked were immediately unlocked.

2.) Staff educated regarding not locking residents out of their room even if it was done out of precautionary measure for wandering.

3.) Daily, Weekly, Monthly

4.) Executive Director