Print Inspection: 3SBP

The findings of the re-licensure survey conducted 04/11/22 through 04/14/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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 first re-visit to the re-licensure survey of 04/14/22, conducted 08/09/22 through 08/10/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 04/14/22, conducted 12/12/22 through 12/13/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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 04/14/22, conducted 04/05/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

During the relicensure survey, conducted 04/11/22 through 04/14/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope and number of citations.

Refer to deficiencies in report.

1. Once a week the ED will have a meeting with RCC(s) and RN to review their department.

Clinical meetings conducted at least 2 times a week with RN and RCC(s)

Once a week ED will meet with Regional Director of Operations to review administrative oversight plan.

2. Meeting logs will be kept to ensure these meetings are being conducted according to plan and resident care and services are being addressed.

3. This will initially be done on a weekly basis by RDO and ED

4. ED and RDO will monitor this is being completed

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 visitors, and available for inspection at all times. Findings include, but are not limited to:

The main entrance and lobby of the MCC was observed on 04/11/22 at 9:00 am. Observations showed:

*  The Executive Director's name was posted as person in charge although the Executive Director was not in the building at the time. There was no system to display the designee in charge, posted by shift, or indicate when the administrator was out of the facility.

*  The most recent re-licensure survey, including two revisits and plans of correction was not posted, and no copy of the survey was available when requested by the survey team.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Administrator) and Staff 2 (ED) on 04/11/22. They acknowledged the findings.

1. A dry erase board was posted on 4/13/22 above the keypad to the lobby doors indicating who the manager on duty is at all times during each shift.

Most recent survey, revisit and letter of compliance was put into a binder and placed in the lobby in the glass cabinet under the TV on 4/14/22.

2. Med Tech who holds the staffing/after hours cell phone will write their name on the dry erase board once previous Med tech holding phone completes their shift exchange. This is apart of there shift change.

ED will ensure that the most recent Survey and any revisits are in the binder and located in glass cabinet in lobby.

3. Required Postings will be monitored by receptionist daily. Additionally, QA audits will be used to evaluate

4. The Business Office Manager will be responsible to see that the corrections are completed/monitored

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records for 2 of 7 sampled residents (#s 3 and 4) whose records were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 2017 with diagnoses including dementia.  

a. Between 02/09/22 through 04/11/22 staff documented in the progress notes the resident experienced three unwitnessed falls, two injuries of unknown origin, and was involved in a resident to resident altercation. Incident reports were requested on 04/12/22 at 8:30 am. Facility staff were not able to provide the reports until 04/13/22 at 2:00 pm. The reports contained incomplete documentation and the facility was unable to provide documentation that the reports had been reviewed and signed by the Administrator.

2. Resident 4 was admitted to the facility October 2021 with diagnosis including dementia and Parkinson's disease.

a. Between 03/14/22 through 04/04/22 staff documented in the progress notes the resident experienced at least six falls. Incident reports were requested on 04/12/22 and 8:30 am. Facility staff were not able to provide the reports until 04/13/22 at 2:00 pm. The reports contained incomplete documentation and the facility was unable to provide documentation that the reports had been reviewed and signed by the Administrator.

b. Resident 4 was receiving Hospice services from 03/08/22 through 04/11/22. Outside provider notes were requested for review on 04/12/22 at 8:30 am.  The documentation was not provided until 2:00 pm on 04/13/22. Staff were not able to locate the documentation initially stating "we changed our process" of handling the documents.

The need to ensure the preparation, completeness, accuracy, and preservation of resident and staff records was reviewed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) on 04/13/22. They acknowledged the findings.

1. For both resident 3 & 4 Administrator has signed all incident reports from dates 2/09/22 through 4/11/22 as of 4/25/22. Incident reports that were lacking documentation were updated and/or reported to state during time of survery visit. Resident records are currently being reorganized for a more speedy recovery of requested documents at any given time.

2. ED and RN will be reviewing all incident reports for completeness when reviewing and signing off. Since visit, resident binders, containing records, have been reorganized. Each binder will maintain a table of contents for med techs to properly file paperwork for ease in locating documents.

3. Binders will be purged and reviewed during each 90-day med review. Incident reports will be reviewed and signed off by Adminstrator or designatee in charge weekly

4. RN will be responsible for resident records

ED will be responsible for incident reports and there completeness of

Based on interview and record review, it was determined the facility failed to promptly investigate unwitnessed incidents and injuries of unknown cause to rule out abuse, and failed to document all required areas of an investigation for 2 of 2 sampled residents (#s 3 and 4) with falls or injuries of unknown cause. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 2017 with diagnoses including dementia.

A review of Resident 3's incident reports, post incident evaluations and progress notes dated 02/09/22 through 04/10/22 revealed s/he had three unwitnessed falls, was involved in a resident to resident altercation, and suffered two injuries of unknown cause. The incident reports did not document the information needed to immediately rule out abuse and neglect, including whether the service plan was being followed. The reports also lacked verification the incidents had been reviewed by the Administrator.

During an interview with Staff 2 (ED) on 04/13/22, the process for reporting and investigating incidents was discussed. Staff 2 acknowledged the incident reports did not include documentation needed to sufficiently rule out abuse or neglect as well as the date and review of the Administrator.

The need to ensure investigations contained the required documentation was discussed with Staff 1 (Administrator) and Staff 2 on 04/13/22. The incidents were self-reported to APS at request of the survey team, and confirmation was received during the survey.

2. Resident 4 was admitted to the memory care unit in 2021 with diagnoses including dementia and Parkinson's disease and had multiple unwitnessed falls.

During an interview with Staff 11 (MT) s/he stated Resident 4 was dependent on staff for most ADL care would often stand and walk independently and required stand by assistance of at least one person for transfers related to safety.

A review of Resident 4's incident reports, post incident evaluations and progress notes dated 01/10/22 through 04/10/22 revealed s/he had six unwitnessed falls. The incident reports did not document the information needed to immediately rule out abuse and neglect, including whether the service plan was being followed. The reports also lacked verification the incidents had been reviewed by the Administrator.

During an interview with Staff 2 (ED) on 04/13/22, the process for reporting and investigating incidents was discussed. Staff 2 acknowledged the incident reports did not include documentation needed to sufficiently rule out abuse or neglect as well as the date and review of the Administrator.

The need to ensure investigations contained the required documentation was discussed with Staff 1 (Administrator) and Staff 2 on 04/13/22. They acknowledged the findings and Staff 2 stated the electronic system would be modified to show the review and signature of the Administrator.

1. All incident reports for Resident 3 & 4 have been reviewed for completeness. Incidents that had not been clearly ruled out for abuse and neglect have been reported during time of survey (as stated on pg.13). All incident reports from that period have been signed off on from ED. (Resident 4 passed away on 4/21/22) All staff will be in-serviced on abuse reporting.

2. ED and RN will be reviewing each incident report before signing off and locking them to ensure complete and appropriate documentation has happened. Our policy and prodecure for abuse and neglect reporting has been reviewed with RCCs.

3. ED will initalling be reviewing incident reports with RCC's weekly to ensure proper documentation and reporting has occurred.

4. RN and ED will be responsible to see that the corrections are completed/monitored.  

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

The main facility kitchen and the four neighborhood kitchenettes were toured on 04/11/22 at 10:47 am. The following areas were in need of cleaning or repair:

* There was dirt and dust build-up on and surrounding the ceiling ventilation units;

* Multiple appliances throughout the kitchen had visible layers of dust, dirt, and / or food debris, including on the ice machine, the juice dispenser, the stand mixer, and the ovens;

* The three refrigerators had visible food debris and drips on the doors and the floors of the units;

* The handwashing sink near the beverage counter had a leak from the faucet;

* The small refrigerator under the beverage counter had black residue along the seal;

* The industrial can opener had black/brown grease in the holding sleeve;

* The standing freezer had dried food debris on the floor of the unit;

* The floor drains throughout the kitchen were covered in brown stains and food debris;

* Surfaces throughout the kitchen were covered with dust, stains, food debris, and dirt, including the shelves of the steam table, under the steam table, on the door by the prep counter, on shelving under the cutting boards, on the wall behind both handwashing sinks, on floors throughout the kitchen, and on the floor in the dry storage area;

* The metal back splash behind the three compartment sink had dried food debris and a white residue and the caulking was pink/black;

* The drawers in all four kitchenettes had food debris, dirt, staining and / or dust on the edges and within the drawers;

* The microwaves in all four kitchenettes had food debris inside the appliance and outside on the control panel;

* The cabinets and counter surfaces in all four kitchenettes had laminate lifting or worn sealant exposing particle board;

* The steam tables in two kitchenettes had food debris, spills, and brown markings; and

* Soiled cloth napkins and clothing protectors were left in the cabinets of two of four kitchenettes.

The areas needing cleaning and repair were reviewed with Staff 6 (Dining Services Director) and Staff 2 (ED) on 04/11/22. They acknowledged the findings.

1. a) MD (maintanence director) will clean all vents in the community.

b) Dining Service Team will thoroughly clean all kitchen appliances including and not limited to: ice machine, juice dispenser, stand mixer and ovens.

c) Dining Service Team will thorughly clean all refridgerators inside and out of all food debris.

d) Leak from the faucet in the handwashing station in kitchen has been repaired.

e) Fridge under beverage counter will be thoroughly wiped clean inside and out.

f) Can opener will be thoroughly wiped cleaned

g) Standing freezers on units will be thouroughly wiped clean

h) All surfaces in the kitchen including: shelves of the steam table, door by prep counter, shelving under cutting boards, walls behind handwashing sinks and all floors in kitchen will be thoroughly cleaned and wiped down.

i) Metal back splash and wall behind the three compartment sink will be thoroughly wiped clean. Caulking will be replaced.

j) Drawers in Kitchenettes will all be thorughly wiped clean inside and out.

k) Microwaves in all four Kitchenettes will be thoroughly wiped clean inside and out.

l) Counter and cabinet laminate will be replaced by the MD. For areas that are not easily replaced, apoxy will be applied in order to create a cleanable surface.

m) Steam Tables in Kitchenettes will be thoroughly wiped clean.

n) Soiled cloth napkins will be placed in an appropriately labeled bin in in cabinet of the kitchen.

2. *Maintanence Director will have a Quarterly vent and faucet inspection. This documentation will be kept in an inspection binder by the Maintanence Director.

*A cleaning and inspection log will be kept by the Dining Services Team that will encompass each individual example listed above and not limited to: Counter surfaces, floors, sinks, ice machines, juice machine, appliances, can opener, refidgerators, freezers, walls and shelves. For all cleaning needs that are to be met by Care staff, Dining staff will conduct an inspection of their kitchenettes and identify areas that pass or do not pass cleanliness inspection that include and are not limited to: Microwave, counters, drawers, cabinets, refridgerator, freezer, soiled linens and steam tables.

3. Inspections of Kitchenettes will occur weekly and cleaning logs for Kitchen will be done daily/semi-monthly/monthly. See below for more detail:

Daily: Counters, Sinks, Juice machine, Appliances, floors

Semi-monthly: Walls, Refridgerators, freezers, shelves

Monthly: Vents

4. *Dining services will ensure that the following corrections happen and montior their continuation, b, c, e, f, g, h, i, j, k, l, m & n  

* Maintanence Director will ensure a and d are corrected and monitored  

Based on observation and interview, it was determined the facility failed to ensure the kitchenettes and bistro were clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

The four neighborhood kitchenettes and bistro were toured on 08/09/22 at 9:20 am. The following areas were in need of cleaning or repair:

1. Community kitchenettes

* The cabinets and counter surfaces in all four kitchenettes had laminate missing, lifting or worn, exposing particle board;

* The drawers in all four kitchenettes had debris on the edges and fronts of the drawers;

* The refrigerator kickplate had food debris and dirt in all four kitchenettes;

* In the Broadway kitchenette, the right island cabinet front was missing; and

* In the Fremont kitchenette, the island right side panel had a gouge, exposing wood underneath.

2. Community bistro

* The countertop next to the sink was lined with dominoes that had green, orange, and red liquid debris on them;

* The refrigerator had food debris and drips on the inside bottom and doors of the unit;

* The refrigerator had debris along the seals of the doors; and

* The left cabinet bottom shelf had exposed particle board and yellow staining.

The areas needing cleaning and repair were reviewed with Staff 2 (ED) and Staff 30 (ED) on 08/10/22. They acknowledged the findings.

1) Community Kitchenette cupboards, drawers and fridge kickplates have been wiped clean. We have received 3 bids for countertop refinishing/replacement and will be making a decision on repairs this week. Maintenance Director has material to begin replacing missing laminate on cupboard doors and drawers in kitchenette's and community bistro. Domino's from counter in Bistro have been removed and leaking soap dispenser has been removed and will be replaced with a new dispenser by Maintenance director. Fridge in community bistro has been wiped clean and organized.

2) Maintenance Director will maintain an adequate supply of extra laminate to repair any damages on cupboards/drawers moving forward. Community Bistro cleanliness will be maintained daily by Activities Assistants and/or Director.

3) Damaged to cupboards/countertops will be reported on TELS for Maintanence director to address, Maintanence director will monitor countertops and cabinet faces for damages monthly and make repairs as needed. Activities staff will check off adequate cleanliness of their kitchenette area once weekly.

4) Maintanence Director and Activities Director

Based on observation and interview, it was determined the facility failed to ensure the kitchenettes and bistro were clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

The four neighborhood kitchenettes and bistro were toured on 12/12/22 from 10:15 am to 10:50 am. The following areas were in need of cleaning or repair:

1. Community kitchenettes

* Cabinets and counter surfaces in all four kitchenettes had laminate missing, lifting or worn, exposing particle board;

* Drawers in all four kitchenettes had debris on the edges and fronts of the drawers;

* In the Broadway kitchenette, the right island cabinet front was missing; and

* In the Fremont kitchenette, the island right side panel had a gouge, exposing wood underneath.

2. Community bistro

* The left cabinet bottom shelf had exposed particle board and yellow staining.

The areas needing cleaning and repair were reviewed with Staff 1 (ED)  on 12/13/22. She acknowledged the findings.

1. Countertop replacement and cabinets refinish is scheduled to be completed by Restoration and Cabinetry by January 31st, 2023 for each neighborhood Kitchenette (Extension Granted by Jeanne Bristol via email)

2. The Maintenance Director will examine kitchenette counter tops and cabinetry and make necessary repairs as they occur. Any damages that are beyond our ability to repair we will address with Restoration and Cabinetry

3. Monthly and as needed

4. Maintenance Director and ED

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and were followed, and failed to provide clear direction to staff for 3 of 5 sampled residents (#s 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 2018 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan updated 04/12/22 and 01/27/22 thru 04/11/22 progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas:

* Emergency evacuation status;

* Assisting dressing/undressing status;

* Bathing status;

* Communication status;

* Grooming;

* Oral hygiene and shaving status;

* Managing of glasses status;

* Assisting with toileting including use of urinal;

* Mobility status, use of wheelchair versus bed bound;

* Bed mobility status;

* Outside provider services; and

* Use of scoop mattress.

The need to ensure the resident service plans were reflective and provided clear directions to staff was discussed with Staff  2 (ED) on 04/13/22. Staff acknowledged the findings.

2. Resident 7 was admitted to the facility in 2021 with diagnoses including Alzheimer's disease.

Observations of the resident, interviews with staff and review of the service plan updated 09/27/21, showed the plan was not followed in the following areas:

* Walk to the kitchen with the resident for every single meal;

* Offer a chocolate protein shake when trouble eating; and

* Warming up food prior to giving it to the resident.

The need to ensure the resident service plans were followed was discussed with Staff  2 (ED) and Staff 3 (RN) on 04/13/22. Staff acknowledged the findings.

3. Resident 4 was admitted to the facility in 2021 with diagnoses including dementia and Parkinson's disease.

Observations of the resident from 04/11/22 through 04/13/22, a review of temporary service plans and the current service plan completed on 03/26/22, showed the plan was not reflective of the resident's needs and did not provide clear direction to staff in the following areas:

* Use of a geri-chair when out of bed and a tray during meals;

* Current precautions in place to prevent falls and injury from falls;

* Hospice services providing bathing assistance;

* Current activity needs and preferences;

* When and how to provide meal assistance, eating patterns and hydration; and

* Instructions for staff related to when to pull down their face masks to allow the resident to read their lips during communication.

In an interview on 04/12/22, Staff 4 (RCC) stated the resident's service plan was being reviewed by the resident's family member and had not yet been returned. Staff 4 stated the resident had been using the geri-chair as provided by Hospice. On 04/13/14, Staff 4 provided copies of temporary service plans (TSP's) that had been completed from 02/04/22 through 03/09/22. The TSP interventions had not been included in the evaluation or service plan completed on 03/26/22.

The need to ensure the resident service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff  2 (ED) on 04/13/22. They acknowledged the findings.

1. Service plan for resident #7 was updated and care conference was conducted with POA and Ombudsman (who joined via zoom) on 4/15/22.

Resident 4 passed away (4/22/22)  

Resident 5 passed away (4/14/22)

2. Direct care staff must read, sign and date resident service plans timely to indicate their understanding of what is in each residents service plan. When a TSP or Newly updated service plan is placed in the binder it will be flagged to inform direct care staff to review changes. RCCs will be in-serviced on Service planning, evaluations, TSPs and will in turn educate direct care staff of the importance of a service plan and how to provide person centered care using a service plan.

3. Signatures will be reviewed by Health Services team, once there are 5-10 signatures, TSP/Service plan will be unflagged.

4. RCC's will be responsible for the completion of these corrections as well as monitor that they continue to happen  

2.  Resident 10 was admitted to the facility in 03/2022 with diagnoses including dementia.

a.  During interviews with Staff 5 (RCC), Staff 11 (MT), Staff 28 (CG) and Staff 29 (MT) on 08/09/22, they described the following behaviors:

* Resident 10 threatened staff and residents with his/her cane;

* The resident was agitated and had behaviors daily, including wanting to go home;

* The resident was exit seeking and had a history of eloping;

* Staff made sure exit doors were closed quickly when visitors left the facility to reduce the opportunity for Resident 10 to leave with a visitor;

* Resident 10 accused staff of trying to "lock [me] up";

* Resident 10 frequently refused to take medications;

* There was a particular resident that staff had to direct Resident 10 away from;

* Staff offered the resident tea during times of agitation;

* Staff made plans with Resident 10 to get in touch with family;

* Keeping the door open to the bistro area helped minimize behaviors; and

* Walking away from the resident and re-approaching later was helpful to diffuse behaviors.

Resident 10 was observed during the survey to be in the Broadway neighborhood or bistro area. When interviewed on 08/09/22 at 11:13 am, Resident 10 stated s/he wanted to "get out of this place."

Resident 10's current service plan, dated 05/22/22, was not reflective of the resident's behaviors, including specific behaviors demonstrated, exit seeking and elopement history, nor were there specific instructions to staff regarding approaches to attempt when the resident was agitated.

b.  Resident 10's current service plan noted the resident required assistance with shaving his/her upper lip and chin. Staff were directed to assist the resident to the bathroom, have the resident stand at the sink, use shaving cream and a disposable razor to shave and provide a warm wash cloth to clean his/her face.

Resident 10 was observed on 08/09/22 and 08/10/22 to have long hair on his/her upper lip and chin.

During an interview with Staff 29 (MT) on 08/09/22 at 11:20 am, she verified the resident had facial hair on the upper lip and chin and had not been shaved.

Resident 10's service plan was not followed related to providing assistance with shaving.

Resident 10's service plan was discussed with Staff 2 (ED) and Staff 3 (RN) during the survey on 08/10/22. Staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, were readily available to staff, provided clear direction regarding the delivery of services and were followed for 2 of 4 sampled residents (#s 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 02/2020 with diagnoses including dementia and anxiety disorder.

Review of the service plan revealed the following:

a. The service plan, readily available to caregiving staff in the service plan binder on the unit, was dated 03/12/22. During an interview on 08/09/22 at 3:02 pm, the surveyor asked Staff 3 (RN) if the caregiving staff had any additional way to access the most recent service plan, dated 07/11/22. She confirmed the CGs only accessed the service plan through the binder located in the unit, and the most recent updated service plan was located in the locked medication room in the resident's chart.

b. Observations and interviews with staff revealed the service plan available to staff failed to provide clear direction to staff and was not reflective in the following areas:

* Bathing schedule for hospice staff and facility staff;

* ADL assistance and cueing; and

* Behavior management techniques related to the relationship with another resident.

The need to ensure a current service plan was available to staff, provided clear direction and was reflective of the residents' current needs was discussed with Staff 3 on 08/10/22 at 11:08 am, Staff 2 (Executive Director) and Staff 30 (Executive Director) on 08/10/22 at 12:42 pm, and Staff 2, Staff 3 and Staff 30 at survey's exit. They acknowledged the findings. No further information was provided.

1) Resident 9 and 10's service plans have been reviewed and updated appropriately to emcompass their behaviors, interventions and ADL needs. Care conferences have been scheduled with families to ensure satisfaction of changes/updates and updated Service plans have been placed on their perspective units for care staff to follow.

2) RCC's will ensure that TSP's are being placed on the floor when necessary, quarterly service plan reviews are taking place and when a service plan is updated it is printed and placed on the floor for staff to follow.

3) These updates will happen at least quarterly and as needed when changes happen with residents

4) RCC's and RN

2. Resident 14 was admitted to the facility in 10/2019 with diagnoses including dementia.

Observations of the resident and interviews with staff during the survey, and review of the clinical record including the 10/25/22 service plan and Temporary Plan of Care (TSPs) from 09/21/22 through 12/04/22, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Mobility status;

* Use of side rails;

* Emergency evacuation status; and

* Transfer status.

The need to ensure the service plan was reflective of Resident 14's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 18 (Resident Care Coordinator) on 12/13/22. 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' needs, were readily available to staff, and provided clear direction regarding the delivery of services for 2 of 4 sampled residents (#s 12 and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 03/2017. A review of the resident's clinical record showed the most current service plan was updated 11/17/22. The service plan was not available to direct care staff for review.

The resident's 11/17/22 service plan was reviewed and stated the following:

"... is at increased risk of choking and aspiration due to recent development of difficulty swallowing and several coughing/choking incidences. Please supervise at meals and offer [him/her] soft foods if [s/he] is unable to safely swallow the meal provided"

In an interview on 12/13/22 at 11:50 am, with Staff 18 (RCC) and Staff 36 (RN), they confirmed this updated information had not been made available to staff.

The need to ensure service plans were available to care staff, reflective of residents current needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 18 and Staff 36 on 12/13/22. They acknowledged the findings.

1. Service plans have been updated and distributed for all staff to review and sign. An audit of Service plan binders from each hall has been completed to ensure that most up to date service plans are available for staff.

2. A checklist has been implemented for RCC/RN to use when updating a residents service plan that includes ensuring the service plan is printed and readily available to staff. In addition, Service plan binders will be audited weekly to ensure staff have been reviewing any changes and most up to date service plans have been placed in binders.

3. Weekly

4. RN, ED & RCC

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Current service plans for Residents 1, 3, 4 and 5 were reviewed during the survey. There was no documented evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 04/13/22 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN). They acknowledged the findings.

1. Resident 4 & 5 have passed since survey has ended. Resident 1 & 3 have had service plan updates done by RCC, reviewed by RN and conducted care conferences with POA.

2. All service plan updates moving forward will have a signature from the RCC who was involved in updating the plan, Signature from the RN or ED who reviewed the updated plan and Signature from POA who attended the Care Conference and reviewed Service Plan with service planning team.

3. This will be done quarterly

4. Health Service Director and ED will be responsible to see that this is being done

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident or failed to monitor short term changes of condition through resolution for 4 of 4 sampled residents (#s 1, 3, 4 and 5) reviewed with changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 2021 with diagnoses including dementia.

The current service plan dated 03/24/22 noted the resident required assistance and cueing with ADLs. The resident was identified to have aggressive behaviors and there were clear directions on how to approach and provide care for the staff.  

Review of progress notes and incident reports between 01/10/22 through 04/07/22 noted the following changes of condition:

* 01/06/22 incident report noted the resident was observed standing over another resident and had a "small bruise to right cheek";

* 01/14/22 The resident "bit a staff member ...while attempting to provide care ..."

* 03/06/22 " ...hit resident in the head with a cup."

* 03/12/22 " ...resident punched MT in the face and broke glasses ..."

* 03/14/22 " ...suddenly [resident] grabbed my arm pulled me down and punched me in the [right] eye."

* 03/18/22 "...red rash in the groin area...apply barrier cream with each incontinence change."

Interviews with staff identified the resident was combative and at times aggressive during care.  

Resident 1 was observed during the survey to be primarily in bed sleeping or eating a meal in the dining room.

*There was no documented evidence the resident altercations were evaluated to determine new actions or interventions to attempt to minimize future occurrences and no documented evidence service planned interventions were reviewed to determine if they continued to be effective.

*There was no documented evidence the changes of condition dated 01/06, 01/14, 03/06 and 03/18 were monitored through resolution.

Reviewing changes of condition to determine if actions or interventions were developed or if service planned interventions were reviewed for effectiveness was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) on 04/13/22 at 1:00 pm.  No additional information was provided.

2. Resident 3 was admitted to the facility in 2017 with diagnoses including dementia and anxiety. A review of the clinical record revealed the following:

* On 02/09/22 Resident 3 experienced a fall, then fell again on 03/02/22. There was no documented evidence that service-planned interventions to prevent falls were reviewed for effectiveness or if new interventions were needed following each fall; and

* On 03/11/22 a progress note documented the discovery of an injury of unknown origin "Resident had a quarter sized yellow bruise above Left eyebrow". An incident report regarding the injury noted "possibly from found on floor incident 3/2". There was no documented evidence the injury was monitored until resolution.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution and that fall interventions were reviewed to determine if they were effective was shared with Staff 1 (Administrator) and Staff 2 (ED) on 04/13/22. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 2018 with diagnoses including dementia.

Observation and interview with staff during the survey indicated the resident required staff assistance with transfers and bowel and bladder management.

Progress notes dated 01/10/22 through 03/22/22 indicated the following:

* 01/27/22 - The resident was on alert charting due to episode of vomiting and high blood pressure.

There was no documented evidence the change of condition was monitored through resolution.

On 04/13/22, Resident 5's progress notes were reviewed with Staff 2 (ED). Staff acknowledged the findings.

4. Resident 4 was admitted to the facility in late 2021 with diagnoses including dementia and Parkinson's disease. A review of the clinical record revealed the following:

a. Resident 4 experienced six falls between February and April, 2022. The facility failed to determine if service-planned interventions were effective or if new interventions were needed following each fall. Additionally, there was no documented evidence the facility monitored and documented on the progress of skin injuries sustained, following the falls on 03/29/22 and 04/03/22, at least weekly until resolved.

b. On 03/09/22, the resident received physician orders to start two new medications. There was no documentation of monitoring any potential adverse effects or the effectiveness of the medications following starting them.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution and that fall interventions were reviewed to determine if they were effective was shared with Staff 1 (Administrator) and Staff 2 (ED) on 04/13/22. They acknowledged the findings.

1. In-service staff on alert charting, appropriate monitoring and reporting. Retraining on the 24-hour communication binders for both Med Tech and Care Partner. Policy and procedures have been reviewed with all direct care staff and management for this tag.

2. RCC and/or RN will review communication binders daily (See signature page for proof of review from RN/RCC). Change of Condition will be completed by RN within 24-hours and will review with Service planning team to include but not limited to: POA, Staff, resident, RCCs, Dining Service and any Outside Providers if necessary. Service plan will reflect current changes, needs that are specifc to that resident, or TSP will be implemented with personalized interventions.

Additionally, QA aduits will be used to evaluate

3. This will be evaluated by RN within 30-days of significant Change.

4. RN will be responsible to see that the correntions are completed/monitored.

2. Resident 6 was admitted to the facility in 10/2021 and had diagnoses which included dementia and insulin-dependent diabetes.

Resident 6's clinical record and progress notes 06/01/22 through 08/09/22 were reviewed and revealed the following:

a. On 06/13/22, s/he was placed on alert because s/he "threw [him/herself] off of [his/her] bed onto the floor ..." The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.

b. Resident 6 had a decrease in his/her insulin on 06/17/22. Monitoring was initiated, yet there was no documented evidence the facility monitored and documented on the short-term change in condition until resolved.

Additional information was requested on 08/10/22.

On 08/10/22 at 1:25 pm, Staff 3 (RN) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved. No further information was provided.

The need to ensure short-term changes in condition were monitored until resolution was discussed with Staff 2 (ED) on 08/10/22 at 1:35 pm. She acknowledged the findings.

4.  Resident 10 was admitted to the facility in 03/2022 with diagnoses including dementia.

Resident 10's clinical record, progress notes from 06/08/22 through 08/07/2, and physician communication records were reviewed and noted the following:

* On 07/02/22 a physician communication note revealed Resident 10 exhibited "...aggressive behaviors, hitting people with [his/her] cane ... really angry about not being able to go home and makes self harm threats."

There was no documented evidence the facility identified what actions or interventions were needed for the resident, and there was no evidence the resident had been monitored following the communication to the doctor.

Resident 10's short-term change of condition related to self harming threats and lack of evaluation to determine what actions or interventions were appropriate and monitoring until resolved was discussed with Staff 2 (Executive Director) and Staff 3 (RN) on 08/10/22. Staff acknowledged the finding.

3. Resident 9 was admitted to the MCC in 02/2020 with diagnoses including dementia and anxiety disorder.

The clinical record and progress notes, dated 06/14/22 through 08/08/22, were reviewed and revealed the following:

Resident 9 was placed on alert charting following a witnessed non-injury fall on 07/23/22. The facility initiated alert charting the same day. However, there was no documented evidence the facility monitored the resident weekly through resolution.

During an interview with Staff 3 (RN) on 08/10/22 at 11:08 am, additional documents were requested to support weekly monitoring through resolution for this short-term change of condition. No additional documents were provided by survey's exit.

The need to ensure the facility monitored short-term changes of condition with weekly progress noted until resolution was discussed with Staff 2 (Executive Director), Staff 3 and Staff 30 (Executive Director) on 08/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed when residents experienced changes of condition, communicate the actions and interventions to staff and monitored weekly progress until the conditions resolved for 4 of 4 sampled residents (#s 6, 8, 9 and 10) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder.

Resident 8's medical record was reviewed. The following deficiencies were identified:

a. A Physician Communication on 06/16/22 noted " ...abdominal pain when urinating. [S/he] has also been more emotional and had two episodes of diarrhea since yesterday." There was no documentation of actions or interventions determined or monitoring at least weekly until resolved.

b. Interventions for falls on 06/26/22 and 06/28/22 were not communicated to staff and monitored at least weekly until resolved.

The need to determine and document what actions and interventions were needed for the resident when s/he experienced short-term changes of condition, communicate them to staff, and monitor them at least weekly through resolution was discussed with Staff 2 (ED), Staff 3 (RN) and Staff 30 (ED) on 08/10/22. They acknowledged the findings.

1) Resident's 8, 6, 9 and 10 charts and progress notes have been reviewed and updated for monitoring and resolution.

2) Clinical meetings will be conducted to review progress notes, alert charting and end of shift binders in order to ensure monitoring and/or resolution is happening with residents who are placed on alert or have any type of change in condition.

3) Daily

4) Executive Director and RN

2.  Resident 6 was admitted to the facility in 2021 with diagnoses including dementia, and type II diabetes.

Resident 6's weight record was reviewed during the survey and revealed the following:

* 02/2022 - 141.8 pounds;

* 03/2022 - 152.6 pounds; and

* 03/31/22 - 153.3 pounds.

From 02/2022 to 03/2022, Resident 6 had gained 10.8 pounds or 7.6 % of his/her body weight, which represented a significant change of condition that required an RN assessment.

There was no documented evidence the facility RN assessed the resident's condition related to the weight gain.

On 04/13/22 at 1:30 pm with Staff 2 (ED) confirmed that there was no RN assessment related to the significant weight gain.

On 04/13/22 and 04/14/22, the need to ensure the facility RN completed an assessment for a significant change of condition was discussed with Staff 2 and Staff 3 (RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 3 sampled residents (#s 4 and 6) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in October 2021 with diagnoses including dementia and Parkinson's disease.

Progress notes, dated 02/23/22, showed Resident 4 was sent out to the hospital for evaluation and treatment of a significant change in behaviors and cognition. The resident returned to the facility on 03/06/22 and was sent out to the hospital again on 03/06/22 for a decline in cognition. Upon the resident's return to the facility on 03/08/22, s/he was admitted to Hospice services. The decline in the resident's condition and admission to Hospice services represented a significant change of condition.

In an interview on 04/12/22, Staff 2 (ED) and Staff 3 (RN) stated an RN assessment had not been conducted and there was no documentation available.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment for significant changes of condition was discussed with Staff 1 (Administrator), Staff 2, Staff 3, and Staff 26 (Nursing Consultant) on 04/13/22. They acknowledged the findings.

1. In-service staff on alert charting, appropriate monitoring and reporting. Retraining on the 24-hour communication binders for both Med Tech and Care Partner. Policy and procedures have been reviewed with all direct care staff and management for this tag.

2. RCC and/or RN will review communication binders daily (See signature page for proof of review from RN/RCC). Change of Condition will be completed by RN within 24-hours and will review with Service planning team to include but not limited to: POA, Staff, resident, RCCs, Dining Service and any Outside Providers if necessary. Service plan will reflect current changes, needs that are specifc to that resident, or TSP will be implemented with personalized interventions.

Additionally, QA aduits will be used to evaluate

3. This will be evaluated by RN within 30-days of significant Change.

4. RN will be responsible to see that the correntions are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN for 1 of 1 sampled resident (#9) reviewed for significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 02/2020 with diagnoses including dementia and anxiety disorder.

During the entrance conference on 08/09/22, staff reported the resident had a recent decline in ADL status and was currently on hospice services.

Review of the clinical record revealed the resident was admitted to hospice on 06/15/22 with a diagnosis of Alzheimer's disease. During an interview with Staff 3 (RN) on 08/10/22 at 11:08 am, she confirmed the resident's decline was sudden, and she observed the resident sleeping more frequently during the day, eating fewer meals, having increased difficulty with expressive communication, and exhibiting frequent changes in mood.

The decline in health and admission to hospice constituted a significant change in condition, for which an assessment by an RN was required. The surveyor requested the RN assessment on 08/10/22 at 11:08 am. The facility provided no documented evidence an RN assessment was conducted.

The need to ensure an RN assessment was completed following a significant change of condition was discussed with Staff 2 (Executive Director), Staff 3 and Staff 30 (Executive Director) on 08/10/22. They acknowledged the findings, and no additional documentation was provided.

1) Resident 9's chart and progress notes have been reviewed and updated for change in condition, admit to hospice. RN assessment has been completed

2) Clinical meetings will be conducted to review progress notes, alert charting and end of shift binders in order to ensure monitoring and/or resolution is happening with residents who are placed on alert or have any type of change in condition. RCCs, RN and ED with be in-serviced by nurse consultant team Allen Flores on significant change in conditions.

3) Daily

4) Executive Director and RN

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition which included documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#14) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 14 was admitted to the facility in 09/2019 with diagnoses including dementia.

During the entrance conference on 12/12/22, staff reported the resident had a recent decline in ADL status and was currently on hospice services.

The resident was observed on 12/12/22 in the dining room for lunch and required hands on assistance with meal intake.

Resident 14's progress notes from 09/22/22 to 12/12/22 and incident reports were reviewed during the survey and revealed the following:

* The resident had six falls including four emergency department visits;

* 09/24/22 progress note - The "resident is having a hard time wallowing [swallowing] the ABX [antibiotic];

* 10/15/22 note - "Resident appeared a little extra tired...was having a hard time eating...";

* 11/04/22 note - "Needing assistance sitting up";

* 12/05/22 note - Resident "is slowly declining. Cannot really walk and now has to be fed every meal..."; and

* 12/08/22 - The resident was admitted to the hospice service.

The decline in health and admission to hospice constituted a significant change in condition, for which an assessment by an RN was required.

There was no RN assessment for the significant change of condition at the time of survey.

In an interview on 12/12/22 at 2:00 pm, Staff 36 (RN) confirmed that she had not completed the assessment of the resident's condition.

The need to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 36 (RN/Director of Health Services) on 12/12/22 and 12/13/22. They acknowledged the findings.

1. The week prior to this revisit, our Nurse completed the Community Based Care course. During this course she was taught the guidelines of significant changes in community based care. The Nurse completed this change of condition before surveyors left. Going forward the RN will be notified of Significant changes in a timely manner

2. The Nurse will complete any Significant change of condition assessment within 48 hours of change in resident. Staff will be in-serviced on significant change and how to report to RN

3. Audit a random 4 residents once weekly

4. ED or designee

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 6) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

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

Resident 6's MARs, reviewed from 03/01/22 through 04/11/22, revealed insulin had been given by Staff 9 (CG/MT), Staff 10 (MT) and Staff 11 (MT) on multiple occasions.

Delegation records for Resident 6, were reviewed on 04/11/22 and 04/12/22 and revealed the following:

* There was no RN assessment including documented evidence to determine that the resident's condition was stable and predictable, prior to deciding to delegate the task;

* Transfer delegation was completed on 04/01/22. There was no documented evidence the incoming RN reviewed Resident 6's condition that there was no RN assessment for the resident's diabetic condition completed by the outgoing RN;

* There was no current facility RN assessment including how the RN determined the resident's condition was stable and predictable to continue delegation of the task, given the resident had experienced CBGs greater than 600 on multiple occasions;

* There were no documented evidence Staff 9, 10 and 11 were delegated for the insulin administration to Resident 6 including the staff's skills, abilities and willingness for the delegation tasks; and

* There was no rationale, based on the competency of the unlicensed staff, for how frequently the unlicensed staff should be supervised and re-evaluated.

The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (ED) and Staff 3 (RN) on 04/12/22 and 04/13/22. Staff acknowledged the findings.

1. RN will review all diabetic Orders for Insulin and CBG's and ensure parameters are specific to each resident and following community policy. MT training will be conducted on signing of medications, delegated staff per policy and regulation.

2. RN taking over delegations will include training, medication administration, delegation roles, signing of medications, parameters and who to call/when to call. 3.Nursing team (RN/RCC) to review insulin administration weekly to ensure this is being done properly.

4. RN will be responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to have a system to coordinate care with outside providers in order to ensure the continuity of care for 1 of 1 sampled resident (#4) who received services from an outside provider. Findings include, but are not limited to:

Resident 4's clinical record was reviewed during the survey. On 04/12/22, the surveyor requested outside provider notes for review. Multiple staff interviewed were unaware of where to locate the documentation. On 04/13/22, Staff 4 (RCC) provided copies of Hospice provider notes from visits from 03/25/22 through 04/04/22.

a. On 04/01/22, a Hospice provider documented "encourage staff to allow [patient] to rest in bed if drowsy, support with pillow on left side when awake in chair".  There was no evidence this recommendation had been reviewed and communicated for facility staff to follow.

b. The outsider provider notes lacked documented evidence they had been reviewed by facility staff for any recommendations made by outside providers.

In an interview on 04/03/22, Staff 4 and Staff 3 (RN) explained the facility was planning to start a new process for reviewing outside provider notes that would include having the notes reviewed by facility staff.

The need to coordinate on-site health services with outside service providers, ensure that staff were informed of new interventions and that the service plan was adjusted if necessary was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 on 04/13/22. They acknowledged the findings.

1. RN/RCC will be in-serviced on policy and procedures of receiving and documenting outside provider notes.

2. RN reviews all outsider notes and nuring team will taken outsider orders and TSP's, Service plans, communicate with staff of new orders or changes and ensure MT and other appointed staff are documenting on these changes.

3. Daily

4. RN will be responsible to see that the corrections are completed/monitored  

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight for safe medication administration systems and for 1 of 5 sampled residents (# 6) whose medication records were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 2021 with diagnoses including Type II Diabetes.

Resident 6 had a physician's order, dated 03/04/22, to check CBGs before meals and before bed.

* Resident 6's 03/01/22 through 04/11/22 MAR and progress notes from 03/01/22 through 04/11/22 revealed staff either did not check CBGs or checked CBGs after meals on multiple occasions.

* Resident 6 had CBG readings of 600 on 34 occassions between 03/01/22 and 04/11/22. Staff 2 (ED) and Staff 3 (RN) were interviewed on 04/12/22 and 04/13/22 and stated the facility glucometer could not register a CBG reading above 600. Direct care staff had not reported the readings to the facility RN.

Refer to citations C 282, C 303 and C 310 for additional information.

2.  On 04/13/22 at 02:30 pm, the findings were reviewed with Staff 1 (Administrator), Staff 2, Staff 3 and Staff 26 (Nursing Consultant). Facility staff were unable to provide evidence of who was responsible for oversight of the medication administration system.

3. Administrative Oversight of the medication and treatment administration system was also found to be ineffective, based on deficiencies in the following areas:

C 282: Delegation;

C 303: System: Medication and Treatment Orders;

C 310: System: Medication Administration; and

C 315: System: Treatment Administration.

The need to provide oversight and safe medication and treatment administration systems approved by a pharmacist consultant, registered nurse, or physician was reviewed with Staff 1, Staff 2, Staff 3 and Staff 26.  No additional information was provided.

1. RN will over see medication administration system, med tech trainings, administration and orders. All med techs will have completed a competency checklist, signed by RN. There will be doucmented in-services for medication policies

2. All med techs will have completed a competency checklist, signed by RN, prior to independently administering medication. RN and Nursing support team with review medication administration program weekly, during clinical meetings and recorded in minutes.

3. Weekly

4. RN and ED will be responsible to see that the corrections are completed/monitored

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 6 sampled resident (# 6) whose orders were reviewed. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 2021 with diagnoses including dementia, Type II Diabetes and delirium.

1. Resident 6 had a physician's order, dated 03/04/22, to check CBG (blood sugar level) before meals and at HS (before bed).

Resident 6's 03/01/22 through 04/11/22 MAR and progress notes from 03/01/22 through 04/11/22 revealed the staff either did not check CBGs or checked CBGs after meals on multiple occasions.

2. Resident 6 had a physician's order, dated 03/04/22, to administer Levemir (insulin to treat diabetes) 13 units two times daily.

Resident 6's 03/01/22 through 04/11/22 MAR revealed on 03/22/22, the insulin was not administered as prescribed without documented explanation.

3. Resident 6 had a physician's order, dated 03/04/22, to check monthly vital signs on the second of each month and fax MD (Doctor of Medicine) and notify RN if blood pressure top number greater than 160 or less than 100, or blood pressure bottom number greater than 100 or less than 50, pulse greater than 100 or less than 50.

Resident 6's 03/01/22 through 04/11/22 MAR revealed there was no documented evidence monthly vital signs were checked on the MAR.

4. Resident 6's 03/01/22 through 04/11/22 MAR and progress notes from 03/01/22 through 04/11/22 revealed the following medications were not administered as prescribed due to the medications not being available:

* Risperidone (a medication to treat to irritability) 0.25 mg two times daily, not administered on six occasions;

* Metformin (a medication to treat Type II Diabetes) 1000 mg two times daily, not administered on one occasion; and

* Pioglitazone (a medication to treat Type II Diabetes) 30 mg daily, not administered on two occasions.

On 04/13/22 and 04/14/22, the physician orders, the MARs and progress notes were reviewed with Staff 2 (ED) and Staff 4 (RCC). They acknowledged the findings.

1. During 90-day review RN will specify if care staff can assist with treatment orders and will review TAR with Pharmacy Rep.

2. Med techs will hold onto all treatments and ointments, when care staff apply these treatments the med techs will administer to care staff, confirm application and then document in the TAR.

3. Weekly

4. RCC and RN will be responsible to see that the corrections are complete/monitored.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters and staff instruction for 3 of 5 sampled residents (#s 4, 5 and 6) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 2018 with diagnoses including dementia.

a. Resident 5's 04/01/22 through 04/11/22 MAR was reviewed and revealed the following scheduled treatment:

* Nystatin 100,000 unit cream to apply two times daily; and

* Secura Protective 10 % cream to apply two times daily.

The MAR did not provide information including location for the administration of topical cream.

b. Resident 5's 04/01/22 through 04/11/22 MAR was reviewed and revealed the following:

* Lorazepam 0.5 mg as needed for anxiety.

The MAR did not provide information including how often the medication needed to be administered.

c. Resident 5's 04/01/22 through 04/11/22 MAR was reviewed and revealed the following:

* Multiple blanks on the MAR.

Resident specific parameters and accurate documentation of the MAR were discussed with Staff 2 (ED) and Staff 3 (RN) on 04/12/22 and 04/13/22. Staff acknowledged the findings.

2. Resident 6 was admitted to the facility in 2021 with diagnoses including dementia and Type II Diabetes.

a. Resident 6's 03/01/22 through 04/11/22 MARs and physician orders were reviewed and revealed the following:

* The resident received scheduled insulin two times daily; and

* Trulicity (an injectable medication to treat Type II Diabetes) weekly.

There were no parameters for holding the insulin administration for low blood sugar levels and there was no direction for staff when to notify the physician of high blood sugars.

b. Resident 6's 03/01/22 through 04/11/22 MARs were reviewed and revealed the following:

* Multiple blanks on the MAR.

c. Resident 6's 04/01/22 through 04/11/22 MAR and 04/04/22 - 04/12/22 progress notes were reviewed and revealed the following:

* 04/10/22 - Staff 9 (MT) signed on the MAR that she administered Levemir insulin when Staff 25 (MT) administered the insulin injection; and

* 04/11/22 - Staff 18 (MT/Trainer) signed on the MAR that she administered Levemir insulin when Staff 3 (RN) administered the insulin injection.

d. Resident 6's 03/01/22 through 04/11/22 MARs and physician orders were reviewed and revealed the following:

* Physician's order, dated 03/04/22, to check CBG before meals and at HS (before bed); and

* The MAR indicated staff signed they checked CBGs at 9:00 am when breakfast was served at 8:00 am.

The need to ensure accurate documentation of the MAR was discussed with Staff 2 (ED) and Staff 4 (RCC) on 04/12/22 and 04/14/22. Staff acknowledged the findings.

3. Resident 4's 03/01/22 through 04/11/22 MARs and physician orders were reviewed and revealed the following:

* The 04/09/22 dose of Carbidopa/Levo 100 mg tab to be administered at 1:30 pm was blank on the MAR;

* The 04/09/22 dose of Quetiapine 12.5 mg tab to be administered at 1:00 pm was blank on the MAR; and

* The 03/17/22 dose of Atropine drops to be administered at 9:00 pm was blank on the MAR.

The need to ensure accurate documentation of the MAR was discussed with Staff 2 (ED) and Staff 4 (RCC) on 04/13/22. They acknowledged the findings.

1. RN will over see medication administration system, med tech trainings, administration and orders. All med techs will have completed a competency checklist, signed by RN. There will be doucmented in-services for medication policies

2. All med techs will have completed a competency checklist, signed by RN, prior to independently administering medication. RN and Nursing support team with review medication administration program weekly, during clinical meetings and recorded in minutes.

3. Weekly

4. RN and ED will be responsible to see that the corrections are completed/monitored

Based on interview and record review, it was determined the facility failed to ensure an accurate TAR, with clear instructions to staff, accurate documentation and specific treatment orders by a legally-recognized practitioner for 2 of 2 sampled residents (#s 3 and 4) who received wound care. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 2017 with diagnoses including dementia and anxiety.

1. Resident 3's clinical record noted the following:

Resident 3's MAR included a section for treatment by med techs noting "wash area with wound wash or similar product. Approximate edges with moist cotton swab. Apply steri-strips  or transparent dressing - leave in place until loose. Check daily..."

There was no specific instruction or physician's order as to what kind of wound wash to use, how to approximate wound edges, or how to determine when to use steri-strips.

Progress notes and an incident report documented that on 04/07/22 Resident 3 was discovered with a skin tear. There was no documentation of wound care provided on the MAR/TAR.

The need to ensure the facility obtained signed physicians orders for treatments, included clear instructions for staff and documented treatments administered on the MAR/TAR was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 04/14/22. They acknowledged the findings.

2. Resident 4's clinical record noted the following:

Progress notes and incident reports reviewed from 01/10/22 through 04/10/22 revealed the following:

* 03/18/22:  an abrasion to the resident's head was covered with a bandage; and

* 04/03/22: "wound care" to a skin tear to the left knee was performed by the Med Tech.

There was no documentation of wound care provided on the MAR/TAR.

The need to ensure treatments administered were documented on the MAR/TAR was discussed with Staff 2 (ED) and Staff 3 (RN) on 04/13/22. They acknowledged the findings.

1. During 90-day review RN will specify if care staff can assist with treatment orders and will review TAR with Pharmacy Rep.

2. Med techs will hold onto all treatments and ointments, when care staff apply these treatments the med techs will administer to care staff, confirm application and then document in the TAR.

3. Weekly

4. RCC and RN will be responsible to see that the corrections are complete/monitored.

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

On 04/11/2022, at the survey entrance, fire drill and fire and life safety records for the past six months were requested. On 04/12/22, at 12:00 pm, Staff 2 (Executive Director) reported the facility was unable to provide the requested  records. The facility lacked documented evidence of the following required components:

* Fire drills were being conducted every other month.

* The escape route used;

* Number of occupants evacuated;

* Problems encountered and comments related to residents who resisted or failed to participate in the drills; and

* Documentation the facility provided fire and life safety instruction to staff on alternate months from fire drills.

The need to ensure fire drills were conducted every other month and required components were documented and life safety instruction was provided to staff on alternate months was discussed with Staff 2 on 04/12/22 at 12:10 pm. She acknowledged the findings.

1. Maintanence Director conducted a fire drill on 4/12/22 and Elopment drill on 4/27/22 with appropriate documentation. Next month He will be providing life and fire safety education at our all-staff meeting on 5/19/22. This will also be documented and signed by attendees and put in their employee files.

2. Maintanence director will continue this pattern, fire drill every other month, elopment drill quarterly and fire and life safety education on opposing months of fire drills. Appropriate documentation will be kept with Maintanence Director.

3. Fire drill every other month and life and fire safety education on the months we do not do Fire drills.

4. Maintanence Director

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code and residents were provided fire and life safety training annually. Findings include, but are not limited to:

On 04/11/2022, at survey entrance,  fire drill and life safety records for the past six months were requested. On 04/12/22, at 12:00 pm, Staff 2 (ED) reported that the facility was unable to provide the requested records. The facility lacked documented evidence of the following required Components:

* Alternate escape routes were used during fire drills;

* Documentation of problems encountered with residents who declined to participate, and changes made to ensure the evacuation standard was met; and

* Documented evidence residents were provided training and instruction on fire and life safety annually.

The need to ensure alternate escape routes were used during fire drills, documentation of problems encountered with residents who declined to participate, and changes made to ensure the evacuation standard was met, and residents were instructed on fire and life safety procedures annually, was discussed with Staff 2 on 04/12/22 at 12:10 pm. She acknowledged the findings.

1. Documentation for fire drills will be maintained by Maintanence Director. Fire drills will happen every other month. Documentation will include escape routes used, problems with residents who decline to participate and any changes made to ensure evacuation standards were met. On 5/19/22 we will be inviting all employees and residents to attend a fire and life safety meeting at 2:30pm. Documentation will include information covered and attendees.

2. Proper documentation and Reminders for drills and education will be maintained using TELS and/or hard copies of Documentation in fire and life safety binder.

3. Monthly and annually. Drills and education will be monitored monthly, resident education will be evaluated annually and set to occur again May 2023.

4. Maintanence Director

Based on interview and record review, it was determined the facility failed to re-instruct residents at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire, in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

On 08/09/22 Staff 7 (Maintenance Director) confirmed the facility had not provided annual fire and life safety training to residents.

The need to ensure fire and life safety instruction was provided to residents at least annually as required by the OFC was reviewed with Staff 2 (Executive Director) and Staff 30 (Executive Director) on 08/10/22. They acknowledged the findings.

1) POA's for each resident has signed and been educated on Fire and Life Safety for their loved one who resides in the community at time of move-in. Residents who have lived here her beyond 1-year has been send Fire and Life Safety document to review and sign.

2) When resident is edging toward their 1-year mark, their POA will be sent Fire and Life Safety document to review and sign to be returned.

3) annually

4) Business Office Manager and Maintanence Director  

Based on observations, 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 Z 142, Z 162, C 240, C 260 and C 280.

Refer to Z 142, Z 162, C 240, C 260 and C 280

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

The interior of the building was toured on 04/11/22. The following issues were noted:

* During the initial tour on 04/11/22, two of four kitchenettes had unlocked cupboards with peri-care cleanser and cleaning chemicals accessible to the residents;

* On 04/11/22, the need to ensure all toxic materials were maintained in locked storage was discussed with Staff 2 (ED). The findings were acknowledged at that time. During a follow-up inspection on 04/12/22, one of four kitchenettes continued to have unlocked cupboards with cleaning chemicals accessible to the residents.  The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 24 (CG); and

* During another follow-up inspection on 04/13/22, two of four kitchenettes continued to have unlocked cupboards with cleaning chemicals accessible to the residents. This included one kitchenette that did not previously have chemicals accessible to the residents.

The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) on 04/13/22. They acknowledged the findings.

1. All Chemicals and other toxic substances will be removed from kitchenettes and placed in locked drawers, cupboards or custodial closet

2. During Morning walk through's Maintanence Department will check cabinets for improperly stored chemicals, Notify care staff and immediately return them to the locked custodial closet if needed. A sign will be placed on cabinet under the sink in Kitchenette's indicating that chemicals may not be stored anywhere except the locked custodial closet and/or other locked cabinets and/or drawers.

3. Daily

4. Maintanence Director

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were stored in a locked storage unit. This is a repeat citation. Findings include, but are not limited to:

The interior of the building was toured on 08/09/22. The following issues were noted:

* The Burnside kitchenette had a one gallon container of antibacterial hand soap in an unlocked cabinet underneath the sink;

* The Hawthorne kitchenette had a spray bottle of multipurpose cleaner in an unlocked cabinet underneath the sink; and

* The Bistro had six different cleaning chemicals in an unlocked cabinet underneath the sink.

All of these chemicals were accessible by residents.

The need to ensure all toxic materials were kept in locked storage was discussed with Staff 2 (ED) and Staff 30 (ED) on 08/10/22. They acknowledged the findings.

1) All chemicals and hand soaps have been removed from unlocked cabinets and placed in locked custodial closets.

2) Notices have been posted inside unlocked cabinets under sinks in kitchenettes and Bistro notifying staff not to store chemicals or soaps in these cabinets and to only store in locked custodial closets when not using them.

3) Daily

4) Maintenance Director and Housekeeping

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

Observations of the facility on 04/11/22 through 04/12/22 showed the following areas were in need of cleaning and/or repair:

In the central room:

* Entrance doors to the MCC showed damaged paint;

* Couch with stains and food debris around cushions; and

* Stained chair near the beauty salon.

On the 100 Hall:

* Stained couch cushions;

* Odors noted near rooms 101 and 102;

* Gouged cabinet door near the custodian room;

* Two large sideboards with damaged tops and exposed wood; and

* Laundry room ceiling vent clogged with dust.

On the 200 Hall:

* Stained chair near courtyard exit;

* Baseboards damaged and with dust build up;

* Two large sideboards with damaged tops and exposed wood; and

* Laundry room ceiling vent clogged with dust.

On the 300 Hall:

* Couch stained and with food debris;

* Damaged corner baseboard near the shared bathroom;

* Two large sideboards with damaged tops and exposed wood; and

* Laundry room ceiling vent clogged with dust.

On the 400 Hall:

* A black table with peeling paint near the courtyard entrance;

* Room 403 with wall and door damage;

* Room 405 with damaged door seal;

* Two large sideboards with damaged tops and exposed wood; and

* Laundry room ceiling vent clogged with dust.

The need to ensure the environment was kept clean and in good repair was discussed with Staff 2 (ED) and Staff 7 (Maintenance Director) on 04/12/22, they acknowledged the findings.

1. *Doors to MCC will be repainted

*A punch list has been created of furniture that is stained. Summit (who we use to clean our carpets) will be coming in to remove stains from all furniture of concern.

* Odor between 101 and 102 has been addressed by thoroughly cleaning 101, 102 and their bathrooms.

* All cabinets in neightborhoods have been examined and repairs will be made by Maintanence Director

* All vents have been cleaned

* Baseboards in neighborhoods and all other common areas have been wiped clean of dust and build up by housekeeping team

* Damaged corner baseboard near shared bathroom in 300 has been repaired

* Black table in 400 will be completed by Activities team and sealed to protect from paint peeling.

* 403 wall and door damage will be repaired during room flip in the month of may

* 405 damaged door seal will be repaired

2. Policies and procedures as it pertains to environment have been reviewed with new Maintanence Director who will maintain the environment of our community, including and not limited to: Clean base boards, repair all wall damages, door and baseboard damages, Clean all vents in laundry rooms, identify and address odors and ensure counters and table tops are in good repair and addressing any gouges or chips. 3. These issues and needed repairs will be evaluated weekly

4. Maintanence director will be responsible to see these corrections are completed/monitored.

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 limited to:

Refer to C 150, C 152, C 155, C 231, C 240, C 420, C 422, C 510 and C 513.

See plan of correction for C150, C152, C155, C231, C240, C420, C422, C510 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 C240, C422 and C510.

Refer to C240, C422 and C510

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 240.

Refer to C 240

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 sampled newly hired staff (#s 19 and 21) completed all required pre-service orientation prior to performing any job duties, 2 of 2 sampled long term staff (#s 14 and 17) had completed the required 16 hours of annual in-service training, and 4 of 4 sampled staff (#s 9, 12, 13 and 14) lacked competency training in the area of medication administration prior to providing care and services independently.  Findings include, but are not limited to:

Staff training records were reviewed on 04/13/22. The following deficiencies were identified:

1. Staff 21 (CG) was hired 03/03/22.

There was no documented evidence s/he had completed the following elements of the required pre-service orientation prior to performing any job duties:

* Resident rights and values of CBC care;

* Fire safety and emergency procedures; and

* Written job description.

Staff 19 (Cook) was hired 07/27/21.

There was no documented evidence s/he had completed the following elements of the required pre-service orientation prior to performing any job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

2.  Staff 17 (CG) was hired on 12/01/20 and Staff 14 (CG and MT) was hired on 03/19/21.

There was no documented evidence that either staff member had completed the required 16 hours of annual training related to provisions of care in CBC, including six hours related to dementia care.

The facility's failure to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 2 (ED) and Staff 18 (Trainer) on 04/13/22. They acknowledged the findings.

3.  Staff 12 (MT) hired 02/25/22, Staff 9 (CG/MT) hired 11/01/21, Staff 13 (MT) hired 07/23/20 and Staff 14 (MT) hired 03/19/21 had no documented evidence they had demonstrated competency within 30 days of hire or prior to working independently with residents in the area of medication administration.   

During an interview on 04/12/22 at 3:08 pm, Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) verified there was no documented evidence of medication administration competencies for staff.

At approximately 5:44 pm the survey team requested a plan to ensure MT's had received observation and training prior to administering medications. A plan was submitted and accepted on 04/13/22.   

The need to ensure the facility had a system which included documented methods to determine competency of direct care staff through evaluation, observation or written testing, was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN) on 04/13/22.  Staff acknowledged the findings.

1. All Employee files have been audited and Employees with any missing documentation have been notified. Missing documents have been being collected by our Trainer and has also added a section to each direct care staffs folder for coninuted education.

2. Each week our staff have an opportunity to earn continued education hours and each month there is a required video assigned to staff on Relias that will cover the 6-hours of dementia specific training.

Competency checklists for both Cargegivers and Med techs will be located in their employee files and completed prior to them working without a trainer. Upon completion of Orientation and training, all documentation regarding life and fire safety, job descriptions, abuse and neglect reporting, residents rights and standard infection control will be found in each employee file.

3. Monthly

4. The trainer will be in charge of communicating with staff regarding continued education and training and the Business office manager will be in charge of Orientation paperwork such as job desciption, residents rights, background checks, etc.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly hired staff (#s 31 and 32) completed all required pre-service orientation and/or dementia training prior to performing job duties. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 08/09/22 and 08/10/22. The following deficiencies were identified:

1. Staff 31 (CG) was hired 07/15/22.

There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to starting job duties:

* Resident rights and values of community-based care;

* Abuse reporting requirements;

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

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

2. Staff 32 (CG) was hired 07/13/22.

There was no documented evidence she had completed the following elements of the required pre-service dementia training prior to starting job duties:  

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

The need to ensure newly hired staff completed pre-service orientation and dementia training prior to starting job duties was discussed with Staff 2 (ED) and Staff 30 (ED) on 08/10/22. They acknowledged the findings.

1) All missing documents from identified staff members have been collected

2) During Orientation and Training, all required training documents will be collected prior to working independently

3) With each new hire

4) Business Office Manager and ED

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 260, C 262, C 270, C 280, C 282, C 290, C 300, C 303, C 310 and C 315.

Refer to C260, C262, C270, C280, C282, C290, C300, C303, C310 and C315

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 C260, C270 and C280.

Refer to C260, C270 and C280

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 280.

Refer to C 260 and C 280

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 3 of 3 sampled residents (#s 1, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Resident 1, 3, and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and that their service plans had been individualized to reflect the following:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations needed to participate;

* Identification of activities for behavioral interventions; and

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

On 04/13/22, the lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN). They acknowledged the findings.

1. Activities team will be take all of our residents life stories, current knowledge and assesments and create a more formal assesment for each residents that will touch base on the following categories: Current abilities and skills, emotional/social needs and patterns, physical abilities and limitations, adaptions needed to participate, identification of activities for behavioral interventions and how oftern staff and how staff need to assist resident to/with activities.

2. Activities team will keep their own collection of activities assesments for each resident. Once complete they will also add this information into the residents service plan on PCC. This will be done at admission, and will be refreshed when quarterly service plan updates occurs as well.

3. At admission and then every 90-days

4. Life Enrichment Director

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 04/11/22. Residents rooms 101, 109, 112, 208, 212B, 303, 305, 405, 406, 409 and 411A lacked individualized identification markers required to assist residents in recognizing their rooms.

The need to ensure each resident room was identified for the resident was reviewed with Staff 2 (ED) on 04/13/22. She acknowledged the rooms lacking identification.

1. Resident rooms 101, 109, 112, 208, 212B, 303, 405, 409 & 411A have all since had their shadow boxes filled with personal identifiers. Resident rooms 305 and 406 are vacant.

2. Upon move in, Activites team will prepare the new residents shadow box with something that helps indentify that resident.

3. This will need to be corrected or evaluated whenever we have new move-ins and/or move outs

4. Life Enrichment Director