Print Inspection: 033D

The findings of the Change of Ownership combined with the Facility Enhanced Oversight and Supervision surveys, conducted 05/13/24 through 05/15/24, are documented in this report. The surveys were conducted to determine compliance with the 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 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 first re-visit to the Change of Ownership combined with the Facility Enhanced Oversight and Supervision survey of 05/15/24, conducted 09/23/24 through 09/25/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

2. Resident 1 was admitted to the facility in 02/2024 with diagnoses including Alzheimer's disease.

During the acuity interview, Resident 1 was identified as being in an intimate relationship with Resident 2. The resident's 02/05/24 to 05/13/24 progress notes and temporary service plans (TSPs), current service plan dated 03/04/24, and facility policy titled "Intimacy Among Residents with Dementia" were reviewed, observations of the residents were made, and interviews with staff, the family, and the resident were conducted. The following was identified:

* The facility policy, "Intimacy Among Residents with Dementia" listed several procedures, including "[f]ill out an Incident Report and Administrator or designee to complete the investigation and document in electronic computer program what was observed and reported," and "[u]pdate the Growth and Wellness Plans for both residents involved to reflect the relations or relationship including any pertinent details team members should know."

* A 04/22/24 progress note stated, "[r]esident was engaged in a sexual encounter with another resident this afternoon."

* An incident report regarding the encounter was requested from Staff 2 (Health Wellness Director) at 10:30 am on 05/14/24. She stated no incident report had been completed.

* The current service plan provided some information and instructions for staff, but failed to provide identifying information regarding the other resident, or other pertinent information to support the health and safety of the resident.

During an interview at 3:50 pm on 5/14/24, Staff 1 (Memory Care Director), Staff 2, and Staff 3 (Community Nurse) acknowledged the policy had not been implemented.

The need to implement written policies to promote high quality services, health, and safety for residents was discussed with Staff 1, Staff 2, Staff 3, Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement written policies to promote high quality services, health, and safety for 2 of 2 sampled residents (#s 1 and 2) who were in an intimate relationship. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.

During the acuity interview, Resident 2 was identified as being in an intimate relationship with Resident 1. The resident's 02/13/24 to 05/13/24 progress notes and temporary service plans (TSPs), current service plan dated 05/02/24, and facility policy titled "Intimacy Among Residents with Dementia" were reviewed, observations of the residents were made, and interviews with staff, the family, and the resident were conducted. The following was identified:

* The facility policy, "Intimacy Among Residents with Dementia" listed several procedures, including "[f]ill out an Incident Report and Administrator or designee to complete the investigation and document in electric computer program what was observed and reported," and "[u]pdate the Growth and Wellness Plans for both residents involved to reflect the relations or relationship including any pertinent details team members should know."

* A 04/22/24 progress note stated, "[r]esident was engaged in a sexual encounter with another resident this afternoon."

* An incident report regarding the encounter was requested from Staff 1 (Memory Care Director) at 8:00 am on 05/14/24. She stated no incident report had been completed.

* The current service plan provided some information and instructions for staff, but failed to provide identifying information regarding the other resident, or other pertinent information to support the health and safety of the resident.

During an interview at 4:02 pm on 5/14/24, Staff 1, Staff 2 (Health Wellness Director), and Staff 3 (Community Nurse) acknowledged the policy had not been implemented.

The need to implement written policies to promote high quality services, health, and safety for residents was discussed with Staff 1, Staff 2, Staff 3, Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

1. Investigation and incident reports related to resident 2 and resident 1's interactions of sexual expression. Safety plans put in place immediately for staff to intervene.

2. Education of" Sexuality and persons with Dementia" with all Memory Care Direct staff members to be complete through Oregon Care Partners by June 21st. Going forward training will be provided with new hire paperwork prior to staff working alone.

3. One final audit will be completed on June 21st to ensure incumbent staff have completed all training, any staff incomplete at this time will be addressed and pulled from schedule to complete training. Ongoing training will be completed with each new hire. BOM will bring training tracker to each CQI meeting monthly to capture each staff member's progress.

4. BOM is responsible to track completed trainings. Administrators will support monthly as needed.

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

During the survey, conducted 05/13/24 through 05/15/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes and satisfaction was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse) and Staff 25 (Regional Director). No additional information was provided.

Refer to the deficiencies in the report.

1. CQI program implemented. Initial meeting Scheduled for 6/12/2024 and will be held routinely monthly going forward.

2. CQI Meetings with Core Team will be held on a routine monthly basis.

3. Will have CQI meeting weekly x3 with first one held on 6/12/2024, then monthly going forward.

4. Each department will be responsible to bring forth their relative documentation, Administrator will be responsible to oversee that each department brings needed documents.

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 for 1 of 3 sampled residents (#3) and multiple unsampled resident. Findings include, but are not limited to:

1. The Memory Care Community was toured on 05/13/24 through 05/15/24.

Resident-occupied rooms 101, 104, 106, 107, 110, 114, 115, and 117 lacked the lenses for the peephole, creating a hole with visibility directly into the residents' living area.

The missing peephole lenses creating lack of privacy were observed and discussed with Staff 1 (Memory Care Director) and Staff 10 (Maintenance Director) on 05/14/24. They acknowledged the findings.

2. During the acuity interview on 05/13/24 at approximately 1:00 pm, the following apartments were noted to have double occupancy:

104;

107;

110; and

115.

Additionally, one of the residents that resided in each of the above-mentioned apartments was identified to require ADL assistance from staff.

During a tour of the memory care community on 05/15/24 at 8:10 am, apartments 104, 107, 110 and 115 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 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director).  Staff acknowledged the lack of privacy.

3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.

Resident 3's service plan dated 04/03/24 noted the resident required assistance with ADL care.  

A tour of Resident 3's room revealed a window without blinds or curtains and a view to the parking lot used by staff and visitors. Resident 3's bed and reclining chair were within view of the window and there was no opportunity to provide privacy if requested.

The lack of privacy for Resident 3 was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). Staff acknowledged the lack of privacy.

4. Meal observations were conducted 05/13/24 and 05/14/24. Multiple caregiving staff were observed assisting unsampled residents with eating. The staff were standing over the residents instead of sitting next to them.

The need to ensure residents' right to be treated with dignity and respect was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

1.

a. Peepholes have been ordered with expected delivery of 06/07/2024; installation will be completed by 07/12/2024.

b. Privacy screens have been ordered for sampled apartments with expected delivery of 06/07/2024. Installation will be completed by by 07/12/2024 dependent on delivery of items.

c. One way window cling to be installed in resident 3's room. Installation to be completed by 06/07/2024.

d. Staff education regarding dining with dignity provided to immediate staff observed on the unit.

2.

a. Peepholes to be reviewed during monthly maintenance walk-throughs for 3 months, then quarterly thereafter.

b. Privacy screens will be available and installed for all double rooms at all times.

c. One Way window cling will be on hand as needed. This is an individual care plan need due to specific resident behaviors related to resident removing window blinds and curtains.

d. Training provided for all MC Direct care staff to be completed by June 21st.

3.

a. Peepholes will be evaluated with each maintenance walk through monthly for 3 months, then quarterly ongoing.

b. Privacy screens will be installed in double rooms, and evaluated for availability monthly for 3 months, then quarterly ongoing.

c. One way window cling will be evaluated for effectivness related to individual residents behavior weekly for 4 weeks, then once monthly ongoing with service plan direction to report to Administrators any discrepancies in the cling.

d. Final audit will be completed on June 21st, then ongoing with new hires. Monthly training tracking will be presented at CQI meetings.

4.

a. Maintenance is responsible to order and install

b. Memory care director is responsible to order, maintenance responsible to install.

c. Maintenance director to install, memory care director is responsible for behavior monitoring and weekly inspection of window cling.

d. BOM will monitor training tracking, notifying RCC's and Administrators of needed training. RCC's and Admin will be responsible to follow up with direct care staff.   

2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.

Resident 3's service plan dated 04/03/24 and clinical and observation notes dated 02/05/24 through 05/11/24 were reviewed.  Resident 3 was noted to require standby to full assistance with ADL care.  On 02/05/24 Resident 3 was noted to be found on the floor with a skin tear to the left "cheek/jaw" area. On 04/01/24 the resident was noted to have a bruised and swollen left pinky finger.

Although both incidents were monitored and subsequently resolved, there was no documented evidence the injuries of unknown cause were investigated promptly to rule out abuse and/or reported to the local SPD office if abuse could not be ruled out.  

During an interview on 05/15/24 at 12:30 pm, Staff 1 (Memory Care Director) was directed to report the injuries of unknown cause to the local SPD office if the investigation could not be located. No additional information was provided by the facility.

The need to ensure injuries of unknown cause were investigated promptly to rule out abuse and to report the injuries of unknown cause to the local SPD office when abuse or suspected abuse could not be ruled out was discussed on 05/15/24 at approximately 12:30 pm with Staff 1, Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local Seniors and People with Disabilities (SPD) office unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse for 2 of 2 sampled residents (#s 1 and 3) reviewed with injuries of unknown cause. Findings include, but are not limited to:

1. Resident 1 was admitted to facility 02/2024 with diagnoses including dementia.

Review of Resident 1's progress notes noted an alert on 04/12/24 regarding a swollen hand. There was no documented evidence how the facility determined that was not the result of neglect or abuse. The incident was not reported to the local SPD office at the time of the incident.

In an interview on 05/15/24 at 11:30 am, Staff 1 (Memory Care Director) stated Resident 1 injured his/her hand when he/she punched a window.  

The need to thoroughly investigate all incidents to rule out suspected abuse and/or neglect and report to the local SPD office if abuse/neglect could not be ruled out, was discussed with Staff 1 and Staff 2 (Health Wellness Director) on 05/16/24. They acknowledged the findings.

1. Resident 1: Incident Report completed on 5/29/2024 by MC director. Follow up progress note to be done by RN,  MC director to complete note on events leading up to the incident related. Report has now been filed. Resident 3's IR 4/1/24 is acknowledged that Abuse and Neglect report has not been filed with APS. Fall related to 2/5/24 facility acknowledges that this information is not readily available or complete.

2. Current system is that staff are to complete IR in ECP, LN's and Admin to follow up with investigation and report as needed. Going forward IR's will be reviewed daily and reported immediately: For purposes of reporting to APS or law enforcement (if a crime is suspected), "immediately" means within 24-hours of when the abuse or suspected abuse was observed, found or learned of. LN's and Admin will be taking the Abuse reporting with Oregon Care Partners.

3. This system will be evaluated weekly x4 weeks, then bi-weekly x8 weeks, then every month at CQI meetings to ensure that all IR's with suspected abuse or neglect continue to be reported on an immediate basis.

4. LN's and Admin will be responsible daily to review incidents and any needed reports, Administrator will be repsonsible to oversee that reports are completed timely.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and failed to indicate who was involved in the evaluation process for 1 of 1 sampled resident (#1) whose evaluation was reviewed. Findings include, but are not limited to:

Resident 1's move-in evaluation, dated 01/25/24, lacked information regarding the following required elements:

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

* Cognition including confusion and decision making abilities;

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

* Eating; and

* Ability to manage medications.

There was no indication regarding who was involved in the evaluation process.

In an interview on 05/15/24 at 11:30 am, Staff 1 (Memory Care Director) stated that she did not normally complete the new move-in evaluation for residents and acknowledged she missed the above noted areas.

The move-in evaluation including an indication of who was involved in the evaluation process  and the required elements was reviewed with Staff 1, Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Medication room supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

1. Facility has updated growth and wellness plan on 5/30 to reflect missing information as indicated by SOD.

2. Policy training has been conducted with LN's and admin's to include LN completing initial evaluation with Administrator to complete secondary review that all required elements are captured.

3. System will be reviewed with each new move-in and at monthly CQI meetings.

4. Administrator or designee will be responsible to ensure all elements of move-in evaluations are complete.

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 RN for an assessment and service plan updated as needed and/or failed to determine and document what action or intervention was needed for residents, communicate actions to staff on each shift and document weekly progress through resolution for 3 of 3 sampled residents (#s 1, 2, and 3) reviewed with changes of condition. Resident 3 experienced ongoing weight loss. Findings include, but are not limited to:

1.  Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.

During the acuity interview on 05/13/24 at 1:00 pm, Resident 3 was identified to have experienced weight loss.

A physician order dated 07/07/23 directed staff to weigh the resident monthly. The only documented weights available in the resident record were recorded on an After Visit Summary and noted the following weights:

*09/05/23 - 215 pounds; and

*02/13/24 - 187 pounds.

During the six-month period between 09/2023 and 02/2024, Resident 3 lost 28 pounds or 13.02% of his/her body weight resulting in a severe weight loss and significant change of condition. There was no documented evidence the significant change of condition had been evaluated or referred to the facility RN for assessment.  

The resident's current service plan dated 04/03/24 noted the resident needed food to be cut up into bite-sized pieces, encouraged to take small bites, and would not eat if s/he felt like staff was "nagging" him/her.

On 05/13/24 at 3:40 pm, Resident 3's lunch plate consisting of a sandwich, roll, chips and pink liquid was removed by staff from the resident's apartment and nothing had been eaten. The resident was given crab salad and water for a snack.

On 05/14/24 at 9:20 am, staff delivered a breakfast tray to Resident 3 in his/her apartment.  Staff removed the uneaten crab salad from the previous day and served the resident eggs, bacon, toast, juice, water and hot chocolate. The food was not cut up into bite-sized pieces. During an interview at 9:50 am Staff 22 Personal Care Associate reported the resident ate toast and hot chocolate for breakfast.

Resident 3's lunch plate on 05/14/24 at 3:30 pm was removed from his/her apartment. Lunch consisted of meat balls, mashed potatoes, and gravy, all of which remained untouched on the resident's plate. Resident 3 ate a piece of cake for lunch.

On 05/15/24 at 8:50 am, Resident 3 was noted to have eaten 100% of breakfast in his/her apartment and at 11:38 am, ate approximately 50% of lunch in the dining room.

During interviews with caregiving staff on 05/13/24 through 05/15/24 the following was noted:

*Resident ate in his/her apartment and at times came out to the dining room;

*Refused food, "a lot";

*S/he was worried about gaining weight;

*Was picky about food;

*Often requested ham and cheese sandwich or a cheeseburger; and

*Resident had lost weight related to pants fitting loosely.

Resident 3 was weighed during the survey and noted to be 176 pounds, an additional 11 pounds or 5.8% of his/her body weight since the previously documented weight in 02/2024, over a three month period of time.

Resident 3 was noted to have a severe weight loss without documented evidence the significant change of condition was evaluated or referred to the facility RN for assessment. The resident continued to lose weight.

Resident 3's weight loss was discussed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.

2. Resident 1 was admitted to the facility in 02/2024 with diagnoses including dementia.

A review of the resident's clinical records, 02/05/24 through 05/13/24, indicated the following changes of condition had not been reviewed by the facility and/or monitored to resolution:  

* 03/16/24 - Alert for spouse moving into the ALF;

* 03/30/24 - Behaviors with staff;

* 04/10/24 - Swollen hand; and

* 04/26/24 - Start new prescription of Citalopram.  

There was no documented evidence the facility had determined actions or interventions specific to each change of condition, and/or monitored the above documented changes of condition to resolution.  

The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and monitored until resolution was updated was discussed with Staff 1 (memory Care Director), Staff 2 (Health Wellness Director) and Staff 3 (Community Nurse) on 05/15/24. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.

The resident's 02/13/24 to 05/13/24 progress notes and temporary service plans (TSPs) and service plan dated 05/02/24 were reviewed, observations of the resident were made, and interviews with staff were conducted. The following was identified:

a. There was no documented evidence the facility determined actions or interventions and provided written communication to staff on each shift for the following short term changes of condition:

04/29/24 - Sexually inappropriate comments to staff in front of other residents;

05/01/24 - Sexually inappropriate activity in community living room;

05/01/24 - Injury fall; and

05/02/24 - Non-injury fall.

b. There was no documented evidence the facility monitored the following short-term changes of condition with weekly progress noted to resolution:

02/15/24 - Resident-to-resident altercation;

02/20/24 - New medication, cephalexin (an antibiotic); and

03/18/24 - Urinary tract infection;

04/29/24 - Sexually inappropriate comments to staff in front of other residents; and

05/01/24 - Sexually inappropriate activity in community living room.

The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift and monitoring was completed at least weekly with progress noted to resolution for short-term changes of condition was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). They acknowledged the findings, and no further information was provided.

1.

a. Change of conditino SP for res #3 initiated, SP updated with related elements, monitoring increased with weekly weights to be reviewed.

b. Safety plans in place for resident #1 and Res #1, SP updated with changes of conditino and interventions.

2.

a. Change of condition class through Oregon Care Partners to be taken by LN's and Administrator.

b. Role of the RN class will be taken by LN's

c. System going forward will be potential COC reviewed in daily clinicals as LN's available.

3.

a. This will be monitored once with compliance date.

b. This will be monitored once with compliance date.

c. COC's will be monitored weekly x4 weeks, and then monthly at CQI meetings.   

4. Administrator and LN's will monitor this.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced significant changes of condition. Resident 3 experienced on going weight loss. Findings include, but are not limited to:

1.  Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.

During the acuity interview on 05/13/24 at 1:00 pm, Resident 3 was identified to have experienced weight loss.

During the six-month period between 09/2023 and 02/2024, Resident 3 lost 28 pounds or 13.02% of his/her body weight resulting in a severe weight loss and significant change of condition. There was no documented evidence the significant change of condition had been evaluated or referred to the facility RN for an assessment which included findings, resident status, and interventions made as a result. Resident 3 continued to lose weight.

Refer to C 270, example 1.

2. Resident 1 was admitted to the facility 02/2024 with a diagnosis of dementia.

The resident's clinical records including progress notes, evaluation, service plan and temporary plans of care were reviewed during the survey. A progress note dated 04/22/24 reported the resident had a sexual encounter with another resident. There was no documented evidence of previous sexual encounters. This was a new behavior for the resident and constituted a significant change of condition.

There was no documented evidence an RN assessed Resident 1's significant change of condition.

The need to ensure an RN assessment was completed for Resident 1's significant change of condition was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC), and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.

During the acuity interview, the resident was identified as being in an intimate relationship with Resident 1.

The resident's 02/13/24 to 05/13/24 progress notes and temporary service plans (TSPs) and service plan dated 05/02/24 were reviewed, observations of the resident were made, and interviews with staff were conducted. The following was identified:

* A 04/22/24 progress note stated, "resident was engaged in a sexual encounter with another resident."

* During an interview at 11:50 am on 05/14/24, Staff 12 (MT) stated the resident did not have a history of sexual activity since admitting to the facility.

* Review of the clinical record did not reveal any recent history of sexual activity for Resident 2.

* Subsequent progress notes indicated the sexual activity continued.

The resident's new onset of sexual activity constituted a significant change of condition which required an RN assessment including findings, resident status, and interventions made as a result of the assessment. During an interview at 4:02 pm on 05/14/24, Staff 3 (Community Nurse) stated no RN assessment had been completed.

The need to ensure an RN assessment was completed for significant changes of condition that included findings, resident status, and interventions was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director).

1. RN identified and assessed for change of condition of each resident identified for c 280. RN has since continually made progress notes related to the interactions of residents sampled.

2. The LN and RN have enrolled in the Role of the RN course to review requirements in facility for nursing services.

RN will make weekly notes and implement interventions for all change of condition identified within the community. RN, LN and/or administrator will meet daily Mon-Friday to identify any clinical needs for change of condition.

3. Weekly x4 and then monthly at CQI meetings going forward.

4. Administrator and LN's will be responsible to ensure change of condition charting and assessments are complete.

Based on observation, interview, and record review, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist and to maintain infection prevention and control protocols during dining service and for 1 of 1 sampled resident (#3)  who received ADL care. Findings include, but are not limited to:

1.  During an interview on 05/13/24 Staff 1 (Memory Care Director) stated Staff 3 (Community Nurse) was designated as the facility's Infection Control Specialist.

During a subsequent interview on 05/14/24 at 11:30 am, Staff 1 verified there was no documented evidence Staff 1 had completed specialized training in infection prevention and control protocols.

The requirement to have a designated Infection Control Specialist with documented evidence of specialized training in infection prevention and control was discussed on 05/15/24 at approximately 12:30 pm with Staff 1, Staff 2 (Health Wellness Director), Staff 3, Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.

2.  Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia.

The resident's current service plan dated 04/03/24 noted the resident required standby assistance with ADL care, including incontinence care.

Staff 19, Personal Care Associate, (PCA) and Staff 22 (PCA) were observed to provide incontinence care for Resident 3 on 05/14/24 from approximately 9:20 to 9:50 am. The following was noted:

*Gloves were donned to provide incontinent care to the resident in the bathroom;

*Soiled briefs and clothing were removed and placed on the floor;

*Staff grabbed the door handle to to come out of the bathroom and grabbed clean clothing for the resident while wearing the same gloves;

*The resident's hair was combed while using the same gloves;

*Staff removed soiled clothing from a recliner chair to the floor while wearing the same gloves;

*Staff doffed gloves after care was completed without washing hands.

The need to ensure the facility maintained infection prevention and control protocols was discussed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). No additional information was provided.

3. Observations of meal service and snack delivery service were conducted from 05/13/24 to 05/15/24. The following was identified:

a. Caregiving staff were observed feeding residents and delivering food to residents' rooms without wearing a protective covering over their potentially contaminated clothing.

b. Food and beverages were delivered around the community to residents in their rooms and in common areas without a covering to protect from contamination.

The need to ensure the facility maintained infection prevention and control protocols was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

1.

a. Infection control specialist identified as the RN with LN back-up.

b. Infection control training verbally provided to staff named in observation.

c. Aprons have been provided to all staff for meal service, staff instructed on covering trays/food/drinks when delivering outside of dining area.

2.

a. Infection Control Specialist training completed by RN and LN as of 5.31.24

b. Dining with dignity training, and Infection control training to be completed by July 14th.  In-Service to be provided to all memory care team members specifically regarding use of clothing protectors.

c. Specific food covering and Apron use in-services to be completed with all-staff meeting on June 10th, and in-service to capture all staff by June 21st.

3.

a. Infection control has been evaluated and correction has been made.

b. Training and in-services will be evaluated weekly until completed, and ongoing with monthly CQI meeting to ensure all staff training is up to date.

c. Infection control training to be completed with all ongoing new-hires.

4. BOM will manage the tracking of training, Administrator manages the Infection Control Specialist assignment with RN.  

2.  Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.

The resident's 05/01/24 to 05/13/24 MAR and current prescriber orders were reviewed and the following was identified:

a. The following medications lacked a reason for use:

* Calcium;

* Clotrimazole 1%;

* Diclofenac Sodium 1%;

* Docusate Sodium;

* Levothyroxine;

* Melatonin;

* Metformin;

* Nystop;

* One-A-Day 50+;

* Propranolol;

* Resperidone;

* Sertraline; and

* Vitamin D3.

b.  Resident 3 was prescribed routine Clotrimazole, apply to affected area twice a day, Diclofenac Sodium, apply topically to affected area four times a day and Nystop, apply to affected area twice a day. There was no medication-specific instructions related to where the medication was to be applied.  

The need to ensure residents' MARs included documented reasons for use and resident specific instructions for administration was discussed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). No additional information was provided.

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

1.  Resident 1's 05/01/24 through 05/13/24 MAR was reviewed and revealed the following:

Resident 1's MAR revealed multiple medications that lacked reasons for use for the following medications;

* Aspirin;

* Lisinopril;

* Donepezil;

* Quetiapine;

* Lorazepam; and

* Citalopram.

In an interview with Staff 1 (Memory Care Director) at 11:30 am on 05/15/24, she acknowledged the lack of reasons for use on Resident 1's medications.

The need to ensure medications had reasons for use was reviewed with Staff 1, Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the MARs were not accurate.

3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.

The resident's 05/01/24 to 05/13/24 MAR and current prescriber orders were reviewed and the following medications lacked a reason for use:

* Cephalexin; and

* Quetiapine.

The need to ensure the MAR included medication reasons for use was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

1. Resident #1's medication list has been audited and updated, #3's has been audited and updated.

Full audit of resident med lists to be completed to ensure each medicaiton has reason for use.  

2. LN to complete final check with all new orders to ensure that reason for use is entered with each medication.

3. Med list audit of each new order to be pulled weekly for 4 weeks, then monthly for 3 months then quarterly thereafter.

4. LN's to be responsible that audits are completed.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented as ineffective prior to PRN psychotropic medications being administered for 2 of 2 sampled residents (#s 1 and 3) who were prescribed as-needed psychotropic medications. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.

The resident's 04/01/24 through 05/13/24 MAR and prescriber orders were reviewed.

Resident 3 had a physician order for lorazepam, 0.5 mg tabs one tab per day as needed for anxiety, insomnia or agitation.

The MAR indicated the resident received the PRN medication nine times between 04/01/24 and 05/12/24. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication.

During an interview, Staff 12 (MT) verified there was no documented evidence non-pharmacological interventions had been attempted and documented as ineffective prior to administering PRN medication.

The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.

2. Resident 1 was admitted to the facility in 02/2024 with diagnoses including dementia and mood disorder.

The resident's 05/01/24 through 05/13/24 MAR and prescriber orders were reviewed.

Resident 1 had a physician order for lorazepam, 0.5 mg tabs one tab every eight hours as needed for anxiety or agitation.

The MAR indicated the resident received the PRN medication three times between 05/07/24 and 05/09/24. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication.

During an interview, with Staff 3 (Community Nurse) verified there was no documented evidence non-pharmacological interventions had been attempted and documented as ineffective prior to administering PRN medication.

The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed on 05/15/24 at approximately 11:30 am with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3, Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director).  The findings were acknowledged.

1. Resident #3's lorazepam order has been updated w/individually recognized behaviors and interventions; Resident #1's lorazepam order has been updated w/individually recognized behaviors and interventions.

Audit of PRN psychotropic meds to be completed by 6/28/24 to ensure all interventions are written in to orders.

2. All PRN orders for psych meds to be reviewed by RN and administrator to determine and identify behaviors and interventions.

3. Full audit to be completed by June 28, going forward all psychotropic medications to be reviewd monthly with CQI meetings with quarterly pharmacy review to continue to be in place.

4. LN's and Administrator responsible for monthly auditing.

Based on interview and record review, it was determined the facility failed to employ an administrator that obtained a full Residential Care Facility Administrator license. Findings include, but are not limited to:

Staff 1 (Memory Care Director) was acting as the administrator of the Residential Care Facility, Endorsed Memory Care Facility.

During an interview on 05/14/24 at 11:30 am, Staff 1 stated she had not yet obtained her Residential Care Facility Administrator license.

In an interview on 05/15/24 at 12:30 pm, Staff 1 verified the finding.  

1. Facility recognizes that Administrators named were not fully licensed.

2. Going forward the Administrators will obtain full licensure.

3. This will be evaluated on an annual basis related to the Administrators license date.

4. Regional Director will monitor Administrator licenses.   

Based on interview and record review, it was determined the facility failed to review and update an Acuity-Based Staffing Tool (ABST) at least quarterly and to accurately reflect all the ADLs for 2 of 3 sampled residents (#s 2 and 3) and multiple unsampled residents. Findings include, but are not limited to:

The ABST must address all the required activities of daily living for each resident and the amount of staff time per resident needed to provide care. The ABST must be reviewed and updated at least quarterly.

a. The facility staffing tool was reviewed with Staff 1 (Memory Care Director) on 05/15/24. Ten residents' ABSTs lacked evidence they were reviewed at least quarterly.

b. Interviews with staff, observations of the residents, review of current service plans and progress notes were completed. The facility ABST showed numerous ADL care areas which were not reflective of Resident 2 and 3's current care needs. The number of staffing minutes noted on the ABST tool did not accurately reflect the amount of time staff spent with residents providing care in the areas including:

* Safety checks;

* Time spent ensuring non-drug interventions for behaviors;

* Monitoring behavioral conditions and symptoms; and

* Dressing and undressing.

The need to accurately address the amount of staff time needed to provide care for residents and to ensure all resident ABST entries were reviewed quarterly was reviewed with Staff 1 on 05/15/24. She acknowledged the findings.

1. ABST has been audited and updated with current care plans of all residents.

2. ABST documentation will be reviewed with each care plan held quarterly.

3. This will be reviewed weekly x4 weeks, then monthly with CQI meetings.

4. Administrators and Resident Care Coordinators will be responsible to monitor that ABST is complete.

Based on interview and record review, it was determined the facility failed to maintain documentation regarding each direct care staff's demonstrated competency and maintain written documentation of all training completed by each employee. Findings include, but are not limited to:

During a review of staff training records on 05/14/24 and 05/15/24, Staff 4 (Business Office Manager) was unable to provide documented evidence sampled staff administering medications and providing personal care had completed pre-service orientation, pre-service dementia training, and demonstrated competency in all duties they were assigned before working independently with residents, and that sampled long term staff had completed annual training including infectious disease prevention

The requirement to maintain written documentation of training completed by each employee was discussed with Staff 1 (Memory Care Director), Staff 7 (Med Room Supervisor/RCC) and Staff 24 (RCC) on 05/15/24. They acknowledged the findings.

Refer to C 372 and Z 155.

1. Pre-Service Orientation provided to identified staff.

Demonstrated competency completed with identified staff.

Full Audit to be conducted by 6/14/24 to identify any missing pre-service training. Pre-service training to be completed by all staff no later than 7/14/24.

Competency checklists will be completed for all staff by 7/14/24

2. System correction going forward: Staff will not begin floor training until all pre-service training is completed, staff will not be placed on the schedule alone until competency checklist is completed.

3. This will be evaluated at each CQI meeting by BOM providing the tracking beginning 6/12/24.

Based on record review and interview, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 19 and 20) completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 05/14/24 and 05/15/24.

Staff 19 Personal Care Associate (PCA) hired 02/04/24, and Staff 20 (PCA), hired on 04/03/24, did not have documented evidence First Aid and abdominal thrust training had been completed within 30 days of hire.

The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (Memory Care Director) and Staff 24 (RCC) on 05/15/24. They acknowledged the findings.

1. Facility has identified staff in need and have been provided abdominal thrust training. Full audit of training will be completed by 6/12/2024, any identified staff missing this training will be completed by 7/14/24.

2. This training going forward will be included with new hire pre-service training. Staff will not begin shifts alone without this training being completed.

3. A full audit will be completed by 6/12/24, then ongoing will be monitored each month by CQI meeting for all new hires.

4. BOM monitors the tracking of this and will be responsible to follow up with employees in need of training.

Based on interview and record review, it was determined the facility failed to provide fire and life safety training at least every other month. Findings include, but are not limited to:

Fire and life safety records, reviewed between 10/2023 and 04/2024, revealed fire and life safety training was not documented as completed every other month alternating with fire drills.

In an interview on 05/14/24, Staff 10 (Maintenance Director) acknowledged there was no documented fire and life safety training.

On 05/14/24, the need provide fire and life safety training was reviewed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. Upon Audit all fire drills were held in each month except for April 2024 when Maintenance director was out of the community for an extended period. Facility acknowledges that this required drill was not held per regulation.

2. Going forward the Administrator will monitor the TELS system for required fire and life safety documentation.

3. This will be monitored monthly at CQI meetings to determine that the monthly fire drills have been held accordingly.

4. Maintenance director and Administrator will be responsible to manage monthly fire drills.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material, accessible and maintained in good repair and measures were taken to prevent pests. Findings include, but are not limited to:

The exterior of the facility was toured on 05/13/24 through 05/15/24. The following was identified:

* Exterior concrete pathways and patios contained multiple drop-offs measuring from two to four inches from the concrete to the planting bed surface. These drop-offs created potential hazards for residents that frequently walked the pathway; and

* Wasps and wasp nests were noted in eves of the north patio in the interior courtyard.

The building's exterior was toured with Staff 1 (Memory Care Director) and Staff 10 (Maintenance Director) on 05/14/24 and 05/15/24 . They acknowledged the findings.  

1. Facility removed wasp nest immediately and have added this to the monthly pest control contract.

Exterior concrete pathway and planting bed surfaces have been evaluated by landscaping company.

2. Wasp control has been added to the pest control contract.

Landscaping company to schedule build up of planting bed surfaces.

3. Will be monitored monthly on a walk-through and brought report to CQI meeting monthly beginning 6/12/24.

Will be completed once, and then monitored with monthly walk-throughs of building. Completion will be dependent on landscaping companie's ability to complete project.

4. Maintenance director will be responsible to ensure each piece is complete, administrator will be responsible to monitor.  

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

The facility was toured on 05/13/24 through 05/14/24. The following areas in disrepair and in need of cleaning were observed:

* The baseboards in dining room had spills and splatters;

* The handrails outside the dining room were damaged and un-cleanable;

* The counter in the dining room was damaged, gouged, and un-cleanable;

* The flooring in laundry room was damaged and un-cleanable;

* The wall behind the toilet in the common bathroom at the back of the facility was damaged;

* The toilet paper holder in back common bathroom was broken;

* The door jamb of the bathroom in 107 was damaged; and

* The ceiling vents in the hall and resident rooms had a build up of dust and debris.

The areas were reviewed and toured with Staff 1 (Memory Care Director) and Staff 10 (Maintenance Director) who acknowledged the areas needed to be repaired and/or cleaned.

1. Baseboards have been cleaned, hand rail will be re-painted by 7/14/24; Bids have been obtained for countertop replacement, laundry flooring replacement, wall behind toilet in common area bathroom. The toilet paper holder has been ordered, the door jamb in apt. 107 has been repaired, the ceiling vents in the hall have been cleaned.

2. The cleaning of baseboards and ceiling vents have been put onto the task list for housekeeping team. Monthly walk-through's will be completed to ensure all areas of the community are in good repair.

3. Weekly walk-Throughs x4 weeks, then Monthly walk-throughs to be completed and results brought to CQI meeting, any issues will be addressed as arise.

4. Maintenance director will monitor the building, and the Administrator will follow up to ensure complete.

Based on observation and interview, it was determined the facility failed to ensure a manually operated emergency call system was provided in each toilet and that exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

The facility was toured on 05/13/24 through 05/15/24. Observations and interviews with staff during the survey confirmed the doors by which residents could exit the facility to the inner courtyard did not have a working alarm or other acceptable system to alert staff when residents exited the building.

The emergency call system in the common bathroom at the front of the Memory Care Community had a pull string approximately six inches long and three feet above the ground.  

The need to ensure the emergency call system in common bathrooms were accessible and exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (Memory Care Director) and Staff 10 (Maintenance Director) on 05/14/24. They acknowledged the findings.

1. Door alarms have been ordered and will be installed by 6/21/24 as available from vendor.

Pull string was repaired to appropriate specs.

2. This is a one-time fix and will be monitored as needed during monthly walk throughs.

3. Weekly walk-throughs x4, then monthly with results brought to CQI

4. Maintenance director with administrator support as needed.

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

H 1517: OAR411-004-0020 (1)(c): Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

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

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

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

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

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

Refer to H 1518.

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 154, C 156, C 200, C 231, C 350, C 361, C 365, C 372, C 420, C 510, C 513, and C 555.

1. See each related POC regarding noted tags

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s  13, 19, and 20) completed pre-service orientation and dementia training prior to beginning their job responsibilities and had documented evidence of demonstrated competency in all required areas within 30 days of hire, and 2 of 2 long term, non-direct care staff (#s 8 and 11) completed required annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 4 (Business Office Manager) on 05/14/24. The following was identified:

a. There was no documented evidence Staff 13 (MT), hired 04/08/24, Staff 19 Personal Care Associate (PCA), hired 02/04/24, and Staff 20 (PCA), hired 04/03/24, completed all required pre-service orientation topics and pre-service dementia training prior to beginning job duties.

b. Staff 13, Staff 19, and Staff 20 lacked documented evidence they had completed all of the required training and demonstrated competency in all job duties within 30 days of hire. In an interview on 05/15/24, Staff 7 (Med Room Supervisor/RCC) acknowledged Staff 13 had not demonstrated competence in medication pass prior to working independently as a MA. Staff 7 agreed to ensure Staff 13 demonstrated competence prior to independently passing medications.

c. Staff 8 (Dietary Services Director), hired 06/22/21, and Staff 11 (Housekeeper/Bus Driver), hired 09/06/22, lacked documented evidence of completion of annual infectious disease training.

The need to ensure all staff completed pre-service orientation and dementia training, demonstrated competence in job duties within 30 days, and completed required infectious disease training annually, was discussed with Staff 2 (Health Wellness Director), Staff 1 (Memory Care Director), Staff 7, and Staff 24 (RCC) on 05/15/24. They acknowledged the findings.

1. Staff # 13, 19 and 20 have completed training asrequired with pre-service orientation topics, and pre-service dementia topics.

Staff 12, 19 and 20 have all demonstrated competency

Staff 8 and staff 11 have been provided and completed training in annual infectious disease training.  

2. PCA's will not work on the floor independently until all pre-service and pre-service dementia training is complete. Staff will not work indpendently without completing annual infectious disease training. Going forward infectous disease training will have an annual due date for all team members.

3. This will be evaluated monthly with tracking completed by BOM.

4. Each department head will be responsible to ensure that team members do not work independently without required training. Business office manager will be responsible for tracking that training is complete.  

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

Refer to C 252, C 270, C 280, C 295, C 310 and C 330.

See Plan of correction for noted violations

Based on observation, interview, and record review, it was determined the facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents for multiple sampled and unsampled residents, and to evaluate residents for activities and develop an individualized activity plan based on the evaluation for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:

a. Observations of the community were conducted from 05/13/24 to 05/15/24. A bowling activity was completed with one resident at 3:15 pm on 05/13/24. No other activities were observed. During an interview at 3:25 pm on 05/13/24, Staff 22 Personal Care Associate stated the facility Activities Director was on leave and "we try to do them if we have time."

b. Residents 1, 2, and 3's most recent evaluations and service plans were reviewed. The records did not address one or more of the required elements:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no individualized activity plan developed based on the evaluation that reflected the resident's activity preferences and needs for Residents 1, 2 and 3.

The need to ensure the facility provided meaningful activities, evaluated each resident for activities, and developed an individualized activity plan based on the evaluation was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

1. a. Activity calendar updated with daily activities, expectations of activity conduct reviewed with PCA team members.  

b. Service plans for resident 1, 2, and 3 have been updated to include required elements.

2.

a. Activity Calendar will be reviewed on a monthly basis with Activity director and Administrator.

b. The use of electronic service planning program encompasses the required elements and will be utilized related to elements required in service planning.

3. The area will be evaluated quarterly for all residents in the community.

4. Memory care administrator and resident care coordinator to be responsible for managing updates of care plans. Activity director responsible to update activities based on resident preferences.  

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 1 of 3 sampled residents (#3) who had documented behaviors. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression, and a history of schizophrenia.

The resident's clinical record including progress notes dated 02/05/24 through 05/11/24, physician orders, evaluation and service plan dated 04/03/24 were reviewed, interviews were conducted, and observations made between 05/13/24 through 05/15/24. The following was noted:

* Behaviors including screaming and yelling were noted on multiple occasions;

* The MARs noted multiple refusals of medications including psychotropic medications;

* Changes with psychotropic medications;

* Staff reported the resident often screamed and yelled for help, felt like s/he didn't get enough attention, didn't like people looking at him/her, would get overwhelmed by lots of people and noise, was destructive to personal property at times; and

* One-on-on attention, going outside, compliments, and praise helped diffuse the behaviors.

Although the service planned identified the resident had behaviors and offered some interventions to attempt there was no documented evidence the behaviors were evaluated to include what agitation and anxiety looked like for the resident, triggers to behaviors, review of medications and interventions most frequently used by staff.  

Resident 3's behaviors were discussed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.

1. Service plans have been updated regarding the noted residents.

2. Going forward the LN, resident care coordinator and administrator will receive education and training regarding required and best practice elements for service planning.

3. LN, resident care coordinator and administrator will demonstrate completion of training no later than 7/14/24. This system will be evaluated quarterly with each required quarterly service plan.

4. MC administrator and LN will monitor and audit growth and wellness plans (also known as service plans.)  

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 facility was toured on 05/13/24 through 05/15/24. Occupied resident rooms  101, 102, 106a, 108a, 109b, and 116a lacked any individually specific means of identifying the room for the residents. Shadow boxes outside each room were empty.

The need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 1 (Memory Care Director) on 05/13/24. She acknowledged the findings.

1. ID tags have been created for each of the named rooms, and all rooms missing identification for resident specific names.

2. All doors will have name plates created prior to moving in.

3. This will be evaluated on monthly walk throughs by Maintenance and Administrator.

4. Maintenance director and administrator will monitor name plates.