Print Inspection: 9H38

The findings of the re-licensure survey, conducted 10/04/22 through 10/07/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit survey to the re-licensure survey of 10/07/22, conducted 03/21/23 through 03/22/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.

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 revisit to the relicensure survey of 10/07/22, conducted on 05/17/23 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 004 Home and Community Based Services Regulations and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the facility failed to ensure resident to resident altercations were immediately reported the local SPD office for 1 of 1 sampled resident (#4) who was involved in resident to resident altercations. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 12/2021 with diagnoses including Alzheimer's disease and vascular dementia.

Progress notes, dated 08/25/22 through 10/03/22, were reviewed and identified the following:

* 08/25/22 - at 3:25 pm, Resident 4 was ramming his/her walker into another resident's foot;

* 08/25/22 - at 6:30 pm, the resident tried to push and hit another resident;

* 09/05/22 - the resident was agitated, taking it out on the other residents around him/her. The resident cursed and attempted to slam his/her walker into another resident that was walking by;

* 09/08/22 - the resident was ramming, throwing his/her walker into the walls, and then attempted to pull his/her pants and brief down in front of another resident;

* 09/11/22 - the resident hit another resident on his/her right arm;

* 09/19/22 - the resident was walking into other residents' rooms without their permission which upset the other residents. The resident walked into another residents' room while they were watching TV, stood, and stared at them. The resident would not leave; and

* 10/03/22- the resident tried ramming his/her walker into other residents, upsetting residents and blocked the other residents from leaving the area.

Observations during the survey showed staff were consistently redirecting the resident for challenging behaviors.  

There was no documented evidence the facility immediately reported the incidents to the local SPD office.

The need to ensure all resident to resident altercations were reported to the local SPD office was discussed with Staff 2 (Administrator) and Staff 4 (Nurse Manager) on 10/07/22 . They acknowledged the findings. The surveyor requested and received verification that the above incidents were reported to the local SPD office on 10/07/22.

1. Resident to resident altercations were reported to APS on 10/7/22. Resident #4 chart audited for any further altercations. Resident #4 was placed on a behavior monitor, PCP was contacted and psych consult is scheduled. New Nurse Managers provided further training and will attend 3-day nurse practices in community-based care training.

2.Additional training will be added to onboarding process, with increased focus on resident to resident altercations and policy review of abuse reporting. Reporting of altercations or concerns between residents will be added to daily stand-up meeting agenda and daily change of shift agenda.

3. Nurse Manger or designee will review all resident chart notes daily.

4. Nurse Manager, Quality Improvement Manager & Administrator

Completion date 12/6/22  

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:

On 10/05/22, the facility's main kitchen was observed to need cleaning and repair in the following areas:

* The ceiling tiles throughout the kitchen had rust colored spots and water stains;

* The ceiling vents throughout the kitchen had a buildup of dirt, dust, and debris;

* The shelving units in the walk-in cooler had areas of peeling coating and rusted metal; and

* The metal flooring in the walk-in cooler was soft and spongy when stepped on.

The areas that required cleaning and repair were discussed with Staff 2 (Administrator) on 10/07/22. She acknowledged the findings.

1. The ceiling tiles and vents were cleaned and added to weekly cleaning list. Work orders have been submitted for monthly checks of the vents. Shelving units in the walk-in cooler will be replaced. The metal flooring in the walk-in cooler has bid out to be replaced.

2. Weekly cleaning checklists. Monthly walk-through by Food and Beverage Manager or designee and report to Administrator. Quarterly walk-through by Quality Assurance Manager.

3. Weekly, monthly, & quarterly

4. Food & Beverage Manager & Administrator

Compliance 12/6/22

Based on interview and record review, it was determined the facility failed to address all required elements on the move-in evaluation for 1 of 1 sampled resident (#2) and ensure quarterly evaluations were reflective of residents' current status for 1 of 1 sampled resident (#4) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia. The move-in evaluation, dated 07/19/22 was reviewed and the following required elements were not addressed:

* Customary routines including eating and bathing;

* Interests, hobbies, social and leisure activities;

* Spiritual, cultural preferences and traditions;

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

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

* Nutrition habits and fluid preferences; and

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

The need to address all required elements in the move-in evaluation was discussed with Staff 2 (Administrator) and Staff 3 (Nurse Manager) on 10/07/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2021. The resident's quarterly evaluation, dated 07/01/22, progress notes, dated 04/04/22 through 10/03/22 were reviewed and interviews with staff between 10/05/22 and 10/06/22 revealed the evaluation was not accurate or not reflective of the resident's current care needs or health status in the following areas:  

* Increased behaviors; and

* Falls and interventions.

The need to ensure quarterly evaluations were reflective of the resident's current health status was discussed with Staff 2 (Administrator) and Staff 4 (Nurse Manager) on 10/07/22. They acknowledged the findings.  

1. Residents #2&4 service plans have been updated. All service plans will be audited by Nurse Managers and caregivers for accuracy and person-centered care. Training on requirements for assessments and service plans given to Nurse Mangers and will be updated on nurse onboarding checklist.

2. Social history and costumery routine form will be provided to residents and families prior to move in to complete and return. Instructions will be added to assessment to ensure all areas are completed and or marked if N/A. Service plans will be will be reviewed by caregivers prior to each service plan meeting to ensure reflect residents current care needs. A service plan agenda will be used by all nurse managers to guide the correct information being included in the service plan. Quality Assurance Manager will audit 4 assessments and 4 service plans a quarter.

3. Weekly, monthly & quarterly.

4. Nurse Mangers, Quality Assurance Manager & Administrator

Compliance by 12/6/22

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were being followed, were reflective of residents' current status and provided clear caregiving instruction for 3 of 3 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia.

The resident's 08/21/22 service plan and temporary service plans were reviewed. Resident 2's spouse was interviewed on 10/05/22 at 12:00 pm and caregiving staff were interviewed. The resident's room was observed. The service plan was not reflective of or failed to provide clear caregiving instructions in the following areas:

* Conflicting information relating to wheelchair use;

* Air over-lay mattress instruction including what to monitor for and who to report to if the equipment was not working properly;

* In-room activities including which music stations the resident preferred;

* An electrolyte beverage to increase hydration supplied by his/her spouse;  

* PRN psychotropic gel relating to behaviors and care;

* Interventions to attempt prior to administering the PRN psychotropic gel;

* Behavior triggers;

* Bed baths as interventions for shower refusals;

* Spouse involvement;

* Suicide ideation interventions; and

* Range of motion exercises provided by home health for the staff to complete.

The need to ensure service plans were reflective of resident's current status and provide clear caregiving instruction was discussed with Staff 2 (Administrator) and Staff 2 (Nurse Manager) on 10/07/2022. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 02/2022 with diagnoses including dementia.

The resident's 08/27/22 service plan was reviewed and caregiving staff were interviewed. The service plan was not being followed, was not reflective of or failed to provide clear caregiving instruction in the following areas:

* Lotion application to upper and lower extremities in the morning and evening;

* Limit utensils during meals to avoid confusion;

* Preferred flavor of a nutritional supplement;

* Interventions for behaviors;

* Interventions to encourage food intake;

* Applying cream to buttocks with each brief change;

* Needing an additional caregiver if the resident was experiencing behaviors when "sun downing;"

* Gait belt use for transfers;

* How the resident exhibits behaviors;

* Partial denture use; and

* Spouse involvement.

The need to ensure service plans were being followed, were reflective of resident's current status and provided clear caregiving instruction was discussed with Staff 2 (Administrator) and Staff 3 (Nurse Manager) on 10/07/2022. They acknowledged the findings.

3. Resident 4 was admitted to the memory care community in 12/2021 with diagnoses including Alzheimer's disease and vascular dementia.

Observations of the resident, interviews with staff, review of the clinical record and the most recent service plan dated 06/29/22, indicated the service plan was not reflective and did not provide clear direction to staff in the following areas:

* Episodes of unresponsiveness;

* Increased behaviors and aggression toward staff and other residents;

* Required two staff for assistance with care and redirection at times;

* Areas of pain, pain monitoring, non-pharmaceutical interventions;

* Full assistance with ADLs;

* Toileting assistance and frequency;

* One to one feeding assistance;

* Fall risk and interventions; and

* Skin condition and treatment.

The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was reviewed with Staff 2 (Administrator) and Staff 4 (Nurse Manager) on 10/07/22. They acknowledged the findings.

1. Residents #2,3 &4 service plans have been updated with specific information regarding staff instructions on how to provide services and reflect care needs.

2. Service plans will be will be reviewed by caregivers weekly the first 30 days after move-in and adjustments will be communited to the charge nurse at the time they are identified. Additionally, they will be reviewed by not only the Nurse Manger, but caregivers prior to each service plan meeting to ensure they reflect residents current care needs. A service plan agenda will be used by all nurse managers to ensure the correct information is included in the service plan. Quality Assurance Manager will audit 4 assessments and 4 service plans a quarter.

3. Weekly, monthly & quarterly.

4. Nurse Mangers, Quality Assurance Manager & Administrator

Compliance by 12/6/22  

Based on observation, interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored at least weekly through resolution and actions or interventions were determined, documented, and communicated to staff on all shifts for 2 of 3 sampled residents (#s 2 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia.

The resident's progress notes dated 07/18/22 through 10/03/22 and temporary service plans were reviewed.

a. The following skin issues were identified:

* The resident was admitted to the facility with a rash in his/her groin area. There was no documented evidence the area was monitored weekly through resolved.

* A progress noted dated 08/02/22 identified the resident had a "scratch" on his/her right hip which resulted from a fall. There was no documented evidence it was monitored weekly through resolution.

* A progress note dated 09/20/22 identified the resident having a small, pink circle on his/her right knee that was white in the middle. There was no documented evidence it was monitored weekly through resolution.

b. The following verbalizations of wanting to "die" were identified:

* Progress notes dated 08/07/22 and 08/28/22 identified Resident 2 expressing that s/he wanted to "die." There was no documented evidence the resident was monitored relating to the statements nor that the facility implemented interventions and monitored them for effectiveness.

c. There were multiple medication refusals documented in the resident's record. There was no documented evidence the resident was monitored after the refusals.

The need to ensure short term changes were monitored at least weekly through resolution, develop and implement interventions, communicate the interventions to staff on all shifts, and monitor the interventions was discussed with Staff 2 (Administrator) and Staff 3 (Nurse Manager) on 10/07/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2021 with diagnoses including dementia.

Observations were made of the resident and staff were interviewed. The resident's 06/29/22 service plan, 04/04/22 through 10/03/22 progress notes, and incident reports were reviewed. The resident experienced multiple short-term changes of condition in the following areas:

* Increased behaviors and resident to resident altercations;

* Medication refusals; and

* Skin integrity.

There was no documented evidence the facility consistently evaluated the resident, determined actions or interventions specific to each change of condition, updated the service plan as needed, or monitored and documented on the progress of the condition at least weekly until resolved.

The need to ensure the facility evaluated, determined and documented what actions or interventions were needed for changes of conditions and to monitor the effectiveness of interventions was reviewed with Staff 2 (Administrator) and Staff 4 (Nurse Manager) on 10/07/22. They acknowledged the findings.

1. Resident 2 & 4 evaluation and services plan reviewed and updated. Progress note updated with late entries include resolution of short-term changes of condition. Policy and procedure to be reviewed, revised, updated and used to train nurses and med-techs on Alert Charting, TSP's and 24-hour report.

2. 24-hour alert monitoring and charting will be reviewed daily by Charge nurse. Care staff will update nurse for resident current status regarding need for monitoring past 72 hours. Nurse will keep track of and document all resolution of short-term changes of condition. Nurse and med tech staff will review monitoring status of resident's short-term change of condition in hand off shift reports. Will be included on change of shift agenda. Each resident placed on monitoring for a short tem change of condition will have documentation reviewed by nurse and a specific, signed and dated note indicating condition has been resolved. Admission orders will be reviewed and updated to include instructions for refusals. Current orders will be reviewed and MD's will be contacted about refusal parameters if needed. Psychotropic medications will be reviewed and MD's contacted if medication should be admistered prior to interventions.

4. Nurse Managers & Administrator

Compliance by 12/6/22  

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#4) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 4 was admitted to the memory care community in 12/2021 with diagnoses including Alzheimer's disease and vascular dementia.

Resident 4's clinical records from 04/04/22 through 10/03/2022, observations made during survey and interviews with staff indicated the resident had experienced an overall increase in behaviors, including resident to resident altercations, medication changes for behaviors, increased physical and verbal aggression toward staff and other residents.

The increase in behaviors represented a significant change of condition.

There was no documented evidence the RN had assessed the significant change in behaviors, documented findings as a result of the assessment, developed interventions related to the resident's significant change of condition or updated the service plan.

The lack of an RN assessment regarding Resident 4's significant change in condition was reviewed with Staff 2 (Administrator) and Staff 4 (Nurse Manager) on 10/07/22. They acknowledged the findings.

1. Significant change of condition assessment completed for Resident #4. Service plan updated to include behavior plan and Physician contacted.

2. Change of condition policy reviewed and updated. Training provided to MC Nurse Manger including 3 day CBC nurse course at end of November. Change of condition added to weekly radar meeting. Administrator will attend weekly meeting on a regular basis.

3. At time of any change per OAR with resident, weekly and quarterly.  

4. Nurse Manager and Administrator.  

Compliance by 12/6/22  

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 2 sampled residents (#s 2 and 4) who had documented medication and treatment refusals. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia.

The resident's 09/01/22 through 10/04/22 MARs and physician's orders were reviewed and the following medications were documented as refused:

* Docusate (for constipation) on 09/23/22 through 09/25/22, 09/26/22, and 10/01/22 through 10/04/22;

* Flomax (for urinary retention) on 09/04/22, 9/24/22, 09/25/22, and 10/02/22 through 10/04/22;

* Lidocaine patch (for pain) on 09/04/22 and 09/25/22;

* Cozaar (for hypertension) on 09/04/22, 09/10/22, 09/12/22, 09/17/22, 09/18/22, 09/23/22 through 09/25/22 and 10/03/22;

* Depakote (for irritability) on 09/03/22, 09/10/22, 09/12/22, 09/17/22, 09/18/22, 09/23/22 through 09/25/22 and 10/01/22 through 10/03/22; and

* Voltaren gel (for pain) on 09/10/22, 09/16/22 and 10/03/22.

There was no documented evidence the facility consistently reported each refusal to the resident's physician.

The need to notify the physician of resident medication refusals was discussed with Staff 2 (Administrator) and Staff 3 (Nurse Manager) on 10/07/22. They acknowledged the findings.

2. Resident 4 was admitted in 12/2021 with diagnoses including Alzheimer's disease.

The resident's 09/01/22 through 10/04/22 MARs and physician's orders were reviewed and the following medications were documented as refused:

* Losartan (for hypertension) on 09/04/22, 09/05/22 and 09/07/22;

* Allopurinol (for gout) on 09/04/22, 09/05/22 and 10/01/22.

There was no documented evidence the resident's physician was notified of the refusals.

The need to ensure resident refusals of medications were reported to the physician was discussed with Staff 2 (Administrator) and Staff 4 (Nurse Manager) on 10/07/22. They acknowledged the findings.

1. MD was notified of past refusals and request for notification instructions were sent and response documented.

2. Orders and refusal policy and procedures reviewed and updated. Admission orders changed to refusal instructions. The right to refuse and procedure training to occur with all MT's and LN's. MAR will be audited for refusals and corresponding MD notification if needed.Nurse Manager or designee to review MAR for any medication occurances daily including refusals

3. Daily

4. Nurse Manger & Administrator

Completed by 12/6/22

Based on interview and record review, it was determined the facility failed to ensure there were documented non-pharmacological interventions tried with ineffective results prior to the administration of a PRN psychotropic medication used to treat behaviors for 1 of 1 sampled resident (#2) who was prescribed as-needed psychotropic medication. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia.

The resident's 09/01/22 through 10/04/22 MARs and physician's orders were reviewed.

On 09/02/22 and 09/03/22, the MAR reflected Resident 2 was administered ABHR gel (for anxiety, agitation and combativeness) which is made with lorazepam (a psychotropic medication), diphenhydramine, haloper-dol (a psychotropic medication) and metoclopramide.

On 10/05/22 at 2:30 pm, Staff 13 (MT) was unable to find the information of what interventions to try prior to the administration of the medication in the electronic MAR system. On 10/05/22 at 2:35 pm, Staff 3 (Nurse Manager) confirmed the interventions were not documented for staff to attempt prior to the administration of the gel.

The need to ensure the facility documented non-pharmacological interventions tried with ineffective results prior to administering PRN psychotropic medication was discussed with Staff 2 (Administrator) and Staff 3 on 10/07/22. They acknowledged the findings.

1. Physician contacted and order to administer without interventions as intended was obtained.

2. Education provided to Nurse Managers about OAR. Psychotropic medication policy reviewed and updated to reflect rule. Reviewed with MT's and LN's.  Psychotropic review to include parameter review added to weekly radar meeting to assure all parameters are in place.

3. At time of admission, with all new orders, and weekly.

4. Nurse Manager & Quality Assurance Manager

Completion 12/6/22

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#7) who was prescribed PRN medications for agitation/behaviors. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 12/2022 with diagnoses including dementia.

Resident 7 had a physician's order for Haloperidol 1 mg tablet by mouth once daily as needed for agitation/behaviors.

Review of MARs from 01/01/23 - 03/21/23 revealed staff administered PRN Haloperidol on 11 occasions. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.

In an interview on 03/21/23 at 12:10 pm, Staff 13 (MT) reviewed the MAR and progress notes. She acknowledged staff were not documenting non-drug interventions attempted prior to administering the PRN.

The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 2 (Administrator), Staff 3 (Nurse Manager) and Staff 5 (RCC) on 03/22/23 at 12:15 pm. They acknowledged the findings.

1.Nurse Manager or designe will check daily to assure intervention charting has been complete for resident 7.   

2. Further education provided to Nurse Managers about OAR. Psychotropic medication policy reviewed and updated to reflect rule. Reviewed with MT's and LN's.  Psychotropic review to include parameter review added to weekly radar meeting to assure all parameters are in place. Double check at meeting.

3. At time of admission, with all new orders, and weekly.

4. Nurse Manager & Quality Assurance Manager

Completion 4/26/2023

Based on observation, interview and record review, it was determined the facility failed document instructions for caregivers on the correct use and precautions of the device for 1 of 1 sampled resident (#2) who was observed to have siderails attached to their bed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2022 with diagnoses including dementia.

The resident's 08/21/22 service plan and temporary service plans were reviewed. Resident 2's spouse was interviewed on 10/05/22 at 12:00 pm and caregiving staff were interviewed. Bilateral siderails were observed attached to the resident's hospital bed.

During an interview with Staff 21 (CG) on 10/06/22 at 11:32 am, she reported she wasn't sure what to do if the siderails were to become loose or were in disrepair. When asked who she could report the issue to, Staff 21 stated, "The Nurse Manager."

There was no documented evidence the facility had instructed caregivers on the precautions related to the use of the device nor were the siderails reflected on the resident's service plan.

The need to ensure caregiving staff were instructed on the precautions related to the use of a supportive device with potentially restraining qualities and were included in the resident's service plan was discussed with Staff 2 (Administrator) and Staff 3 (Nurse Manager) on 10/07/22. They acknowledged the findings.

1. Service Plan has been updated with specific instructions related to safety checks and specific and limited use of the side rails for resident #2. Documentation for the evaluation is located in the chart.

2. The policy and procedure has been reviewed and updated. Policy has been reviewed by nurse managers, and includes risks/benefits explained to resident; less restrictive alternatives will be used and evaluated prior to use of more restricted devices and all care staff will be trained to follow use and safety precautions as stipulated on the resident's service plan. All caregivers, MT's and LN's will be provided training on policy.  

3. At time of placement of potential restrictive device and quarterly assessment will be completed by RN to determine continued need and safe use and will be included in the resident's service plan.

4. Nurse Manager & Quality Assurance Manager

Completed by  12/6/22

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

Fire and Life Safety records, dated 04/2022 through 09/2022, were reviewed and Witness 1 (Spouse) was interviewed on 10/06/22 at 3:24 pm.

There was no documented evidence the facility instructed the resident or family within 24 hours of admission or re-instructed at least annually on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places inside or outside the building in the event of an actual fire.

Witness 1 confirmed s/he did not receive fire and life information when his/her spouse was admitted in 07/2022.

The need to ensure residents received training in fire and life safety requirements within the first 24 hours of admission and at least annually thereafter was discussed with Staff 2 (Administrator) on 10/07/22. She acknowledged the findings.

1. Residents and/or POA's will be provided instructions on Fire and Life Safety instructions.

2. Instructions will be included verbally in Resident Council meeting and also in writing annually by Administrator.

3. Annually

4. RCC and Administrator

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

Refer to C330 and Z165.

1. Survey POC added to weekly leadership meeting agenda.

2. Schedule annual MOC surveys

3. Until resolved

4. Administrator

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

Refer to C 231, C 240 and C 422.

Refer to C231, C240 and C422

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff completed the orientation relating to infectious disease prevention training, 2 of 2 newly hired staff completed all pre-service dementia training, 2 of 2 long term, non-direct care staff completed the infectious disease prevention training and 3 of 3 long term staff completed a total of 16 hours of annual in-service training, including six hour of dementia care topics. Findings include, but are not limited to:

Training records were reviewed on 10/05/22 and 10/06/22. The following deficiencies were identified:

1. Staff 24 (Dietary), hired on 08/12/22, lacked documented evidence of orientation relating to infectious disease prevention training.

2. Staff 19 (Certified Nursing Assistant), hired on 08/29/22, and Staff 20 (CG), hired on 08/19/22, lacked documented evidence of the following pre-service training:

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

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

3. Staff 23 (Housekeeper) and Staff 22 (Life Enrichment Assistant), both long-term staff members, lacked documented evidence of the completion of the infectious disease prevention training.

4. Staff 12 (MT), annual training reviewed from 10/2021 through 10/2022; Staff 14 (MT), annual training reviewed from 08/2021 through 08/2022; and Staff 17 (MT), annual training reviewed from 07/2021 through 07/2022, lacked documented evidence of the minimum 16 hours of in-service training which included six hours of dementia care topics.

The need to ensure staff had all the required pre-service orientation and training, infectious disease prevention training and the minimum of 16 hours of annual training which included six hours of dementia care topics was discussed with Staff 2 (Administrator) and Staff 6 (Staff Development and Training Coordinator) on 10/06/22. They acknowledged the findings.

1. Audit completed to determine training compliance. Staff contacted to complete all required training.

2. We hired a Training and Development Coordinator this year who will work with staff and Managers to assure compliance. We have contracted with Relias to assure all training meets all licensing requirements. We have instituted a annual competency fair.

3. At time of hire, 30 days, monthly, and annually.

4. Training and Development Coordinator and Administrator

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

Refer to C 252, C 260, C 270, C 280, C 305, C 330 and C 340.

Refer to C252, C260, C270, C, 280, C305, C330, and C340

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled resident (#4) with documented behaviors. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 12/2021 with diagnoses including Alzheimer's disease.

The resident's progress notes, temporary service plans, and incident reports were reviewed. Between 04/04/22 and 10/03/22, Resident 4 had documented behaviors, including exit seeking, agitation, negative physical and verbal aggression towards other residents including multiple resident-to-resident altercations where the resident was the aggressor.

There was no documented evidence the facility evaluated Resident 4's behavioral symptoms.

The 06/29/22 service plan available to staff lacked information about the resident's current behaviors and failed to provide specific interventions or instructions to guide caregivers in monitoring the resident or responding to the resident's behavioral symptoms.

On 10/07/22, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 2 (Administrator) and Staff 4 (Nurse Manager). They acknowledged the findings.

1. Individualized behavior plan was completed for resident #4. Physician was notified and consult requested.

2. Policy and procedure reviewed and updated to reflect OAR. Behaviors added to weekly radar meeting so assure policy and procedure is being followed. Nurse Manger or designee to review chart notes for behaviors daily.  

3. Daily, weekly, and quarterly

4. Nurse Manager & Quality Assurance Manager.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled resident (#5) with documented behaviors. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 01/2022 with diagnoses including dementia with behaviors, major depressive disorder and delusions.

During the acuity interview on 03/21/23 it was reported the resident had a peer-to-peer altercation.

The resident's progress notes, current evaluation and service plan dated 01/18/23, temporary service plans, and incident reports from 02/03/23 through 03/16/23 were reviewed.

The quarterly evaluation dated 01/18/23 identified Resident 5 needed "minimal assistance with resolving conflicts" and the service plan indicated "usually easy to re-direct."

During an interview on 03/22/23 with Staff 4 (Nurse Manager), it was reported Resident 5 needed more substantial supervision for behavioral management.

Between 02/21/22 and 03/08/23, Resident 5 had the following documented behaviors:

* 02/21/23 a peer-to-peer altercation where the resident was the aggressor;

* 02/15/23 reports of combativeness and difficulty giving care;

* 02/24/22 aggressive and agitated when trying to give care and attempt to give shower;

* 03/01/23 grabbing at staff/residents in halls/DR (dining room) on three separate occasions;

* 03/01/23 running in hallway/pacing on two separate occasions;

* 03/04/23 refusing cares;

* 03/05/23 grabbing at staff/residents in halls/DR;

* 03/07/23 running in hallway/pacing on two separate occasions;

* 03/08/23 grabbing at staff/residents in halls/DR on two separate occasions;

* 03/08/23 running in hallway/pacing on two separate occasions;

* 03/08/23 refusing cares;

* 03/08/23 progress note indicated resident "was triggered by [resident room number], resident was then put into a rage. Resident then went after another peer [resident room number], resident then reached out with an open hand and placed hand on this MT's neck and went to squeeze." The incident involved three staff to ensure the other residents safety;

* 03/09/23 grabbing at staff/residents in halls/DR, refusing cares on two occasions and running in hallway once;

* 03/10/23 refusing cares; and

* 03/14/23 grabbing at staff/residents and refusing care on one occasion.

A temporary service plan (TSP) written on 03/01/23 for "Change in behavior or mentation" instructed staff to follow interventions listed on corresponding behavior monitoring log.

A review of the behavior monitoring log from 03/01/23 through 03/15/23 interventions included the following:

* Give stuffed animal;

* Offer food/fluid;

* Toilet him/her;

* Look for signs of pain;

* Walk with him/her; and

* Distraction.

Interventions attempted on eight occasions using all interventions noted above resulted in "unchanged" behavior. Behavior monitoring was resolved on 03/15/23 and the following interventions to toilet, look for signs of pain and distraction were not updated on the individualized behavior plan.

Although there were some behaviors and interventions identified in the service plan, there was no documented evidence the facility evaluated Resident 5 after the physical altercation with another resident on 02/21/23 and the altercation with residents and staff on 03/08/23. The facility failed to immediately put interventions in place and update the care plan regarding the altercation, potential triggers for the altercations, and what individualized behavior interventions staff were to use following the incidents.

On 03/22/23, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 2 (Administrator) and Staff 4 (Nurse Manager). They acknowledged the findings.

1. Individualized behavior plan was completed for resident #5. Workign with team and physican to determine triggers and adjust medication. Add to the Root Cause Analysis (RCA) Team.

2. Policy and procedure reviewed and updated to reflect OAR. Behaviors added to weekly radar meeting so assure policy and procedure is being followed. Nurse Manger or designee to review chart notes for behaviors daily. Adminstrator to attend weekly radar meeting.  

3. Daily, weekly, and quarterly

4. Nurse Manager, Quality Assurance Manager and Admistrator.

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The facility's outdoor environment was toured on 10/05/22. There were multiple chairs and tables in the secured courtyard that were not of sufficient weight or design to prevent injury or aid in elopement.

The secured courtyard was toured with Staff 1 (Director of Health and Clinical Services), Staff 7 (Vice President of Environmental Services) and Staff 8 (Maintenance Manager) on 10/07/22 at 10:30 am and the findings were acknowledged.

1. Items were removed or secured in place to assure safety.

2. Staff education provided to assure items are not placed in garden without Administrator approval. 3. Monthly walk through with documentation to be reviewed by Administrator to assure compliance.

4. Quality Assurance Manager & Administrator

Completed by 12/6/22