Print Inspection: 9UIK

The findings of the re-licensure survey, conducted 10/18/21 to 10/21/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 10/21/21, conducted 01/19/22 through 01/20/22, 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 second re-visit to the re-licensure survey of 10/21/21, conducted 04/19/22 through 04/20/22, 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. The facility was found to be in substantial compliance with the regulations.   

Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, and failed to implement effective methods of infection control for 1 of 1 sampled resident (#9). Findings include, but are not limited to:

Resident 9 was admitted to the facility in 2016.

Observations, interviews with the resident and staff, and review of the clinical record revealed s/he was dependent on staff for ADL care including incontinence care needs, had bilateral ½ siderails, and staff washed his/her bed linens and personal laundry.

a. On 01/19/22 at 11:30 am, the surveyor obtained permission and observed two CGs provide incontinent care to Resident 9. During the observation, the CGs removed the soiled brief (saturated with urine and feces) and wiped the resident's perineum with wet wipes. The soiled brief and wipes were not immediately placed into a trash bag/receptacle but placed on the floor next to the bed. Neither staff changed gloves after handling the soiled incontinence products or wiping urine/feces from Resident 9's perineum. Wearing the same soiled gloves, both staff touched the resident's clothing, clean incontinent brief, bed linens, Hoyer lift and wheelchair handles.

After care was completed, the CGs removed their gloves and left the room. No hand hygiene was observed. As they walked down the hall, one of the CGs removed their face shield and adjusted their face mask.

Review of staff training documentation on 01/20/22 revealed only one of the two CGs had received infection control training.

The above observation was discussed with Staff 1 (Executive Director) on 01/20/22 at 1:10 pm. She acknowledged appropriate infection control practices were not implemented. She stated the CGs would receive infection control training. No further information was provided.

b. Observations on 01/19/22 at 11:25 am revealed a strong urine odor permeated Resident 9's room. Bed linens were on the floor at the foot of the bed. Soiled personal laundry was observed on the floor of the room and closet.

In an interview with the resident on 01/19/22, s/he stated "staff always place my wet laundry [wet with urine] on the floor. I should have a laundry basket. They need to put it in the basket and wash it right away."

The above information was discussed with Staff 1 on 01/20/22 at 1:10 pm. The room was immediately toured. Staff 1 acknowledged the strong urine odor and stated linens should never be placed onto the floor.

c. Resident 9's bed was observed on 01/19/22 with raised ½ siderails on both sides of the bed. When touched, the rails were loose and not secured to the bed frame. Additionally, there were gaps between the mattress and rails.

The current service plan instructed staff to notify the Maintenance Director, Wellness Director or Executive Director if the rails were loose or broken.

The surveyor and Staff 1 observed the rails on 01/20/22 at 1:10 pm. She said staff had not informed her that the rails were loose. She acknowledged the rails were not secured to the bed frame and stated she would have maintenance staff tighten them immediately.

1. The residents side rails were reviewed and adjusted to ensure they were securely fastened to the hospital bed. The carpet in the apartment has been cleaned.

2. All direct care staff will receive additional training on Infection Control: Soiled Laundry and Equipment and Handwashing/Hand Hygiene.

3. Observations will be completed upon hire and annually per the Qulaity Assurance - Health Services Review Schedule.

4. The Executive Director will be responsible for ensuring that the corrections are completed.  

Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local SPD office or conduct an immediate investigation which reasonably concluded and documented the physical injuries were not the result of abuse, for 2 of 2 sampled residents with injuries of unknown cause (#s 5 and 6.) Findings include, but are not limited to:

1. Resident 5 was admitted to the memory care unit with diagnoses including dementia and had multiple falls.

During an interview with Staff 9 (Wellness Director) s/he stated Resident 5 was dependent on staff for most ADL care.

A review of Resident 5's progress notes dated 07/28/21 through 10/18/21 revealed s/he had six unwitnessed falls from 7/29/21 through 10/18/21, resulting in multiple skin tears, lumps, and bruising.  Additionally, progress notes on 7/31/21, 8/20/21, 9/10/21 and 9/29/21 documented four injuries of unknown cause. There was no documented evidence the injuries of unknown cause had been investigated to reasonably rule out abuse nor had the injuries been reported to the local SPD.

During an interview with Staff 1 (Executive Director) on 10/20/21, the process for reporting and investigating incidents was discussed. Staff 1 verified the facility had not conducted an investigation within 24 hours of some of the falls and the four injuries of unknown cause.

The surveyor asked Staff 1 to report the incidents to the local SPD office. Confirmation of the self report to the local SPD office was received on 10/20/21.

The need to ensure resident incidents were investigated immediately to rule out abuse or reported to the local SPD office when abuse could not be ruled out was discussed with Staff 1 and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

2. Resident 6 was admitted to the memory care unit in 3/2020 with diagnosis including dementia with behavioral disturbance.

Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents:

* Progress note dated, 9/9/21, indicated Resident 1 had a wound on the left calf. Progress note dated, 9/21/21, indicated the wound on left calf was related to a fall.

* Progress note dated, 9/22/21, indicated Resident had an unwitnessed fall with bruising on the right knee. An incident report was completed at the time the incident was discovered; however, the incident was not reviewed by the administrator until 10/18/21.

These represented unwitnessed falls and injuries of unknown cause. There was no documented evidence the facility either conducted an immediate investigation of the unwitnessed falls and injuries which reasonably concluded and documented that the falls or injuries were not the result of abuse or neglect. There was no documented evidence the facility reported the injuries to the local SPD office as suspected abuse or neglect.

The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. Staff 1 did not provide any documentation the injuries were investigated, and abuse was ruled out. The facility was asked to report the incident to local SPD office. Verification of self- report was received before surveyors exited the facility.

1. The Executive Director completed self reports of the incidents for resident # 5 and resident #6 on 10/20/2021.

2. The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Abuse Investigations & Reporting Policy, and the Incident/Accident Report Policy. The Executive Director will receive additional training on the Oregon Abuse Reporting Guide.

3. The Wellness Director and Executive Director will review and investigate Incident Reports daily following the Quality Assurance - Health Services Review Schedule.

4. The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local SPD office or conduct an immediate investigation which reasonably concluded and documented the physical injuries were not the result of abuse, for 1 of 1 sampled resident (#10) with an injury of unknown cause. This is a repeat citation. Findings include, but are not limited to:

Resident 10 was residing on the memory care unit with diagnoses including dementia.

During an interview on 01/20/22, Staff 3 (RN) stated Resident 10 had a skin wound that was being monitored.

A review of Resident 10's progress notes, dated 01/02/22, revealed staff noticed a skin tear on the resident's bottom during a shower. An incident report, dated 01/18/22, was reviewed and identified the skin wound as an injury of unknown cause. Staff were unable to determine how the resident sustained the injury. There was no documented evidence the injury of unknown cause had been investigated to reasonably rule out abuse nor had the injury been reported to the local SPD office.

During an interview with Staff 1 (Executive Director) on 01/20/22, the process for reporting and investigating incidents was discussed. Staff 1 verified the facility had not conducted an immediate investigation of the injury and it had not been reported as it was initially believed to be a pressure wound.

The need to ensure resident incidents were investigated immediately to rule out abuse or neglect and reported to the local SPD office when abuse could not be ruled out was discussed with Staff 1 on 01/20/22. She acknowledged the findings. The surveyor asked Staff 1 to report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 01/20/22.

1. The Executive Director reported the incident for resident #9 on 1/20/22.

2.The Executive Director and Wellness Director(s), will receive additional training on the Incident/Accident Report Policy.

3. The Wellness Director and Executive Director will review and investigate Incident Reports daily following the Quality Assurance - Health Services Review Schedule.

4. The Executive Director will be responsible for ensuring corrections are completed and monitored.

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

Observations made between 10/18/21 and 10/21/21 in the RCF unit of the facility revealed many of the activities on the calendar did not take place.

During an interview on 10/21/21 at 10:00 am, Staff 6 (Life Enrichment Director) stated she was pulled from activity duties to complete other tasks such as taking residents to their appointments and working as a MT on the MCC unit. She further stated she was not able to follow all of the activity calendar as outlined. Additionally, everyday, Staff 6 spent half a day in the RCF unit and the other half of the day in MCC unit providing activities.  

The following observations were made on the memory care unit between 10/18/21 and 10/20/21:

* Bingo, scheduled at 10:00 am did not take place on 10/18/21;

* Sit and Be Fit, scheduled at 10:45 am did not take place on 10/18/21 and (Conductorcise) 10/20/21;

* Hand aromatherapy, scheduled at 11:30 am did not take place on 10/19/21 10/20/21 and 10/21/21;

* Scenic drive, scheduled for 10:00 am on 10/21/21 did not occur;

* There were no activities observed occurring after 2:30 pm on 10/18/21, 10/19/21 or 10/20/21;

* Residents sat out in the common areas for long periods of time watching TV, people-watching or remained in their rooms; and

* A resident was observed pacing the halls frequently without being approached to engage in any individual or group activity.

Multiple facility staff, interviewed on 10/18/21 and 10/19/21, stated the direct care staff usually needed to conduct activities as time allowed between resident care because the activity staff were needed to drive residents to appointments, provide medication technician duties or conduct activities in other areas of the facility.

On 10/21/21, Staff 6 revealed an evaluation of the residents' activity preferences and history was obtained when the resident first arrived at the facility, and quarterly thereafter, and stated many of the evaluations were behind schedule for updates.  

The need to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large was discussed with Staff 1 (Executive Director) on 10/21/21. No additional information was provided.

1. An Activity Assessment will be completed for all residents with programming adjusted to meet resident preferences for individual and group interests, physical, mental, and psychosocial neededs.

2.  The Executive Director and Life Enrichment Director will receive additional training on the Life Enrichment Program for Residents Policy and Procedure.    

3.  The Life Enrichment Director will review this area weekly per the Quality Assurance - Activities Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to:

a. Observations made between 01/19/22 and 01/20/22 in the RCF unit of the facility revealed many of the activities on the calendar did not take place.

The following observations were made on the RCF unit between 01/19/22 and 01/20/22:

* There were no activities observed occurring before 1:30 pm on 01/19/22;

* Scenic drive, scheduled for 10:00 am on 01/20/22, did not occur; and

* Balance and Stretch, scheduled for 11:15 am on 01/20/22 did not occur.

During an interview on 01/19/22 at 1:50 pm, Staff 17 (Wellness Director) stated there was "no activity staff this time". She further stated, the direct care staff or MT usually conducted activities as time allowed between resident care and MT duties.

b. The following observations were made on the memory care unit between 01/19/22 and 01/20/22:

The activity calendar posted on the unit and observations made revealed the following for 01/19/22:

* 10:00 am Sit and Be Fit (did not occur);

* 10:30 am Pretty Nails (did not occur. A balloon ball game was provided at 11:00 am);

* 1:30 pm One on Ones (did not occur);

* 3:00 pm Activity Boxes (did not occur); and

* A staff was observed assisting one resident with painting nails at 2:00 pm.

On 01/20/22:

* 10:00 am Scenic Drive (did not occur);

* 11:15 am Balance and Stretch (did not occur. A ceramic painting activity was held with four residents attending);

* 1:30 pm Portrait painting (did not occur);

* 3:00 Bingo (did not occur); and

* 4:00 Tech Corner (a movie was playing on the television).

On 01/20/22, residents were observed sitting in common areas for long periods of time watching television, people-watching or remained in their rooms. A resident was observed pacing the halls frequently without being approached or engaged in any individual or group activities.

Interviews on 01/19/22 and 01/20/22 with multiple facility staff revealed there was no activity staff and that one housekeeping staff was assigned to conduct activities in both areas of the facility (RCF and MCC Units). Staff confirmed that many of the posted activities did not occur due to a lack of staff available.

The need to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Services) on 01/20/22. They acknowledged the findings and stated the facility was working on hiring an activity staff person.

1. The new Life Enrichment Director will adjust the program schedule to meet resident preferences for individual and group interests, physical, mental, and psychosocial neededs.

2.  The Life Enrichment Director will receive training on the Life Enrichment Program for Residents Policy and Procedure.    

3.  The Life Enrichment Director will review this area weekly per the Quality Assurance - Activities Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

3. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and Parkinson's Disease.

During the survey, Resident 3 required assistance with toileting, grooming and bathing. S/he was unable to use utensils and required finger foods to eat independently.

The service plan, dated 7/27/21, and ISP's were reviewed and were not reflective of the resident's needs in the following areas:

* Receiving hospice services;

* Weight loss; and

* Use of a private caregiver.

The service plan did not provide clear direction to staff regarding set up for independent eating and risk of weight loss.

The need for service plans to be reflective of resident's needs and provide clear direction for staff to follow was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 2015 with diagnoses including edema.

Observations of Resident 4, interviews with staff, review of the service plan dated 07/15/21 and ISP's during the survey revealed the following were not reflective of the resident's needs:

* Oral health status; and

* Diet status.

The service plan was not followed by staff in the following areas:

* Providing oral care; and

* Use of Ted/compression stocking.

The need for service plans to be reflective of resident's needs and to follow was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

2. Resident 5 was admitted to the memory care in 2020 with diagnoses including anxiety and dementia. During observations and interviews on 10/18/21, caregivers reported Resident 5 needed help with ADL care and recently needed help eating, s/he wore glasses but they were "unable to locate his/her glasses at this time", was incontinent of bladder frequently and needed assistance daily with incontinence care.

The service plan, dated 8/3/21, and ISP's (Interim Service Plan) were reviewed and were not reflective of the resident's needs in the following areas:

* Use of glasses;

* Weight loss and meal assistance needed;

* Receiving Hospice services;

* Incontinence of bladder and need for assistance with toileting; and

* Current skin injuries requiring treatment.

The service plan did not provide clear direction to staff in the following areas:

* Fall interventions;

* How/when to use a thera-bear and weighted blanket provided by hospice; and

* Interventions to follow to prevent falls.

The need for service plans to be reflective of resident's needs and provide clear direction for staff to follow was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs, provided instructions for staff as to what, when, how and how often services would be provided and were followed for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1.  Observations of resident care on 10/19/21 through 10/21/21, interviews with staff, and review of the resident's current service plan and temporary service plans were conducted during the survey.

Resident 6's current service plan, dated 7/13/21, was not reflective of the resident's current care needs and lacked clear instructions for staff in the following areas:

* Incontinent of bowel and bladder and use of incontinent supplies;

* Need for assistance with wheelchair mobility; and

* Skin issues related to frequent bruising and skin tears to bilateral lower extremities.

The need to ensure service plans were reflective of the resident's current care needs and provided clear instructions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings.

1. All resident service plans will be reviewed to ensure the plans are reflective of resident needs and with clear instruction regarding delivery of service.

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy. All direct care staff will receive additional training on delivery of service.

3. The service plan schedule will be reviewed weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

4. Resident 4 was admitted to the facility in 2015 with diagnoses including diabetes.

Observations of Resident 4, interviews with staff, review of the service plan dated 12/15/21, and ISP's during the survey revealed the following was not reflective of the resident's needs or not followed by staff:

* Oral health status; and

* Transfer status, one-person assist versus two-person assist.

The need for the service plan to be reflective of the resident's needs and followed by staff was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Services) on 01/20/22. They acknowledged the findings.

2. Resident 8 was admitted to the memory care unit in 01/2021 with diagnoses including hypertension and macular degeneration.

During observations and interviews on 01/20/22, caregivers reported Resident 8 had been slowly declining over the past two months and needed help with ADL care including transfers, walking and dressing, was incontinent of bowel and bladder, and needed assistance daily with incontinence care.

The service plan, dated 11/16/21, and ISP's (Interim Service Plans) were reviewed and were not reflective of the resident's needs in the following areas:

* Exit seeking behaviors;

* Mobility, escort needed (to meals and activities);

* Toileting assistance needed; and

* Current concerns and interventions regarding constipation.

The need for the service plan to be reflective of the resident's needs was discussed with Staff 1 (Executive Director) on 01/20/22. She acknowledged the findings.

3. Resident 6 was admitted to the facility in March of 2020 with diagnoses including dementia and kidney disease.

The quarterly service plan, provided by Staff 1 (Executive Director) to the surveyor during the revisit, was dated 07/13/21.

During an interview on 01/19/22 at 2:30 pm, the surveyor asked Staff 1 (Executive Director) if the service plan had been reviewed and updated since 07/13/21. She reviewed the record and stated a quarterly review had not been completed since July 2021.

The need to ensure service plans were reviewed quarterly was reviewed with Staff 1 on 01/20/22 at 2:30 pm. She 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, provided clear direction regarding the delivery of services, were followed by staff, and reviewed quarterly for 4 of 4 sampled residents (#s 4, 6, 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted in 2016.

The quarterly service plan, provided by Staff 1 (Executive Director) to the surveyor during the revisit, was dated 07/09/21.

During an interview on 01/20/22 at 11:30 am, the surveyor asked Staff 18 (Director of Health Services) if the service plan had been reviewed and updated since 07/09/21. She reviewed the record and stated a quarterly review had not been completed.

The need to ensure service plans were reviewed quarterly was reviewed with Staff 1 on 01/20/22 at 1:10 pm. She acknowledged the findings.

1. All resident service plans will be reviewed to ensure the plans are reflective of resident needs and with clear instruction regarding delivery of service.

2.  The Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy. All direct care staff will receive additional training on delivery of service.

3. The service plan schedule will be reviewed weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 3, 4, 5 and 6).  Findings include, but are not limited to:

Resident 3, 4, 5 and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 10/20/21 and 10/21/21, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist).  They acknowledged the findings.

1. All resident service plans will be developed by a service planning team.  

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy, Pre-Service Plan Review, and the Service Plan Development and Meeting Notes.

3.  The Wellness Director(s) will review this area weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 4 sampled residents (#s 4, 6 and 9).  This is a repeat citation. Findings include, but are not limited to:

Resident 4, 6 and 9's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 01/20/22, Staff 1 (Executive Director) and Staff 18 (Director of Health Service) confirmed there was no documented evidence of a Service Planning Team for Residents 4, 6 and 9.

1. All resident service plans will be developed by a service planning team.  

2.  The Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy, Pre-Service Plan Review, and the Service Plan Development and Meeting Notes.

3.  The Wellness Director(s) will review this area weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to evaluate changes of condition, monitor according to evaluated needs, identify and implement interventions for 4 of 4 sampled residents (#s 3, 4, 5 and 6) reviewed for changes of condition. Residents 3 and 5 experienced ongoing significant weight loss and other changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in June of 2019 with diagnoses including Parkinson's Disease and dysphagia (difficulty swallowing).

During the survey, Resident 3 required assistance with toileting, grooming and bathing. S/he was unable to use utensils and required set up with finger foods to eat independently.

A review of Resident 3's clinical records revealed the following:

* 05/01/21  Weight recorded was 168 lbs;

* 05/07/21  RN Quarterly Assessment documented "ability to eat: independent", "nutrition adequate", and "Weight 187 lbs.";

* 06/01/21  Weight recorded was 156 lbs, (a loss of 12 lbs or 7% weight loss in 30 days);

* 07/01/21  Weight recorded was 157 lbs;

* 07/20/21  The "diet information sheet" updated to "please provide finger food";

* 07/26/21  Weight recorded as 145 lbs  (a loss of 12 lb or 7.5% weight loss in 30 days)

* 07/27/21  Resident 3's quarterly service plan was developed with no mention of weight loss; and

* 09/22/21  Hospice note documented the resident was served food they could not eat (mashed potatoes and soup).

Resident 3 experienced a significant weight loss from 5/1/21 to 6/1/21, when s/he lost 7% of body weight. The resident continued to lose weight, an additional 7.5% of body weight from 7/1/21 to 7/26/21.

There was no documented evidence Resident 3 had been evaluated, consistently monitored, interventions with resident-specific instructions communicated to staff, or the service plan updated with interventions related to declining meal intake, weight loss, and the need for finger foods at meals.

In an interview on 10/20/21, Staff 1 (Executive Director) and Staff 2 (Operations Director) were asked to weigh Resident 3, and recorded the weight at 144 lbs.  

Observations of meals on 10/20/21 and 10/21/21 showed the resident was served finger foods per the service plan and was able to eat independently. On 10/21/21 Resident 3 was served oatmeal and a caregiver assisted with eating.

Staff 1 and Staff 2 acknowledged the lack of monitoring of Resident 3's weight loss, and confirmed no weights were taken in August, September, or October despite a physician's order for monthly weights.

b. Further review of Resident 3's clinical records revealed additional changes of condition that had not been monitored to resolution, or for which no actions or interventions were determined and communicated to staff:

*  A home health noted dated 10/8/21 documented Resident 3 was experiencing painful urination with a foul smell, and notified the physician. There was no documentation of an evaluation, response from the physician, or monitoring to rule out UTI or infection;

* A note dated 10/10/21 documented "res was found on floor 4 abrasions, one on right side of head 3 on right arm"; and

* A home health note dated 10/14/21 documented "concerned with heavy blood during bms [bowel movement], up to a cup of blood during a bm, rectal exam completed.  Instructions for care team:  MAR bms call with 24/7 if more bleeding noted."

There was no documented evidence the painful urination, skin abrasions from a fall, or bleeding during bowel movements were evaluated or monitored.

The need to ensure the facility developed actions or interventions, communicated actions and interventions to staff and monitored all changes of condition to resolution was discussed with Staff 1 and Staff 2 on 10/21/21. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 2015 with diagnoses including a diabetic ulcer.

The resident's clinical records dated 07/23/21 through 10/18/21 indicated the following:

* 7/28/21 staff documented on a facility progress note the resident was on alert for "Redness and rash persist to abdominal and groin skin folds with moderate foul odor and moisture ..."

There was no documented evidence the resident's short-term change of condition related to skin was consistently monitored and progress documented weekly through resolution.

The need to ensure the facility monitored the resident's changes of condition weekly through resolution was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia.  

a. During the survey, s/he was identified to have recently been admitted to hospice and needed assistance to eat.

A review of Resident 5's clinical records revealed the following:

* 5/01/21 weight recorded was 139.2 lbs;

* 6/01/21 weight recorded was 140.0 lbs;

* 7/28/21 resident returned to the facility following an extended stay at a skilled care facility. The facility RN assessment stated the resident was eating poorly;

* 8/20/21  the facility RN documented a current weight would be obtained and referral made to hospice services;

* 8/24/21 weight recorded was 122.0 lbs (a 17.2 lb loss or 12.8%);

* 8/31/21 hospice evaluation completed and documented "recent significant weight loss";

* 9/23/21 weight recorded was 108.0 lbs (a 14 lb loss or 11.4% in one month);

* 10/03/21 weight recorded was 106.8; and

* 10/11/21 weight recorded was 106.0 lbs.

Resident 5 had a severe weight loss in 3 months, from June to August, when s/he lost 12.8% of body weight. There was no RN assessment to address the weight loss. The resident continued to lose weight, 11.4% from August to September with no RN assessment or interventions for the weight loss.

Resident 5's 08/03/21 evaluation and service plan for change of condition states the resident "does not have any current or known history of weight gain/loss". The service plan stated the resident did well with finger foods and instructed staff to "notify the Wellness team" s/he misses a meal or refuses to eat.

During interviews on 10/19/21 and 10/20/21, Staff 9 (Wellness Director) stated the resident had been declining and recently needed assistance to eat. Staff 3 (Regional RN) stated an assessment for weight loss had not yet been completed.

On 10/18/21, observations of the lunch meal showed Resident 5 sat in the dining room but needed cuing to stay awake and eat. Resident 5 was handed a bread stick and could eat several bites when it was in his/her hand. The resident was not able to feed him/herself. A caregiver assisted the resident to eat three bites of food, however, the resident was not able to remain awake to eat any more and was assisted back to bed.

On 10/20/21, Resident 5 was asleep in his/her room until 11:35 am. Hospice staff and facility staff helped to get the resident up and walk part of the way into the common area. A Med Tech made a jelly sandwich and handed it to Resident 5 who ate the sandwich, feeding it to him/her self.  Resident 5 required staff to assist with drinking water from a cup.

There was no documented evidence Resident 5 had been evaluated, consistently monitored, interventions with resident-specific instructions communicated to staff, or the service plan updated with interventions related declining meal intake, weight loss, and the need for meal assistance.

In an interview on 10/20/21, Staff 1 (Executive Director) and Staff 2 (Operations Director) stated the RN was working on the assessment and interventions were identified to address the weight loss.

b. Further review of Resident 5's clinical records revealed additional changes of condition that had not been monitored to resolution, or for which no actions or interventions were determined or communicated to staff.

Progress notes reviewed from 7/28/21 through 10/18/21 documented the resident had the following skin injuries:

* 7/31/21 - lump on his/her head;

* 8/20/21 - wound to left arm;

* 9/10/21 - cut and bruising to left eye, skin tear to elbow and "severe bruising" to hip; and

* 9/29/21 - cut above right eyebrow.

There was no documented evidence the skin injuries had been treated and monitored at least weekly to resolution.

c. Progress notes documented the resident experienced falls on 7/29/21, 8/15/21, 9/17/21, 9/29/21, and 10/18/21.

There was no documented evidence the facility had identified interventions to address the pattern of falls and monitor the interventions for effectiveness.

During interviews with Staff 1 and Staff 3 (Regional RN) on 10/18/21 and 10/19/21, staff were aware of the falls and skin injuries, but were unable to provide additional documentation of interventions or monitoring.

The need to ensure the facility developed actions or interventions, communicated actions and interventions to staff and monitored all changes of condition to resolution was discussed with Staff 1 and Staff 2 on 10/21/21. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 3/2020 with a diagnosis of dementia with behavioral disturbance. During the acuity interview on 10/18/21, Resident 6 was identified as a fall risk who had a history of falls.

Progress notes, incident reports, service plans and temporary service plans were reviewed during the survey.

The facility failed to adequately determine and document what actions or interventions were needed for the resident and communicate the interventions to staff in response to repeated falls and injuries of unknown cause and failed to monitor service-planned interventions for effectiveness as follows:

* On 8/24/21 - skin tear on the left outer wrist;

* On 9/9/21 - wound on left calf;

* On 9/19/21 - staff documented alert monitoring for a fall; and

* On 9/22/21 - staff documented "heard [Resident] screaming for help, when I entered [his/her] room [s/he] was on the bathroom floor and had a bruise on the right knee."

There was no documented evidence the facility communicated instructions to staff on what to monitor or what care was needed for the resident's injuries and there was no documented evidence the facility reviewed fall interventions for effectiveness.

The need to ensure interventions were developed in response to changes of condition, the interventions were communicated to staff on all shifts, and were monitored for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

1. All resident records will be reviewed to ensure all change of condition is identified with appropriate action (evaluation, intervention, service plan update, and resident monitoring).

2.  The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Change of Condition policy. All direct care staff will receive additional training on the Stop and Watch early warning tool procedure.

3.  The Executive Director, Wellness Director(s), and Wellness Nurse will review this area daily per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

2 Resident 6 was admitted to the facility in March of 2020 with diagnoses including dementia and chronic kidney disease.

a. The resident's clinical records, dated 12/20/21 through 01/19/22, indicated the following:

* 12/31/21 "According to the patient, sustained an injury to [her/his] hand [s/he] stated a cut ... Pt. [patient] was examined and it was determined hands were free from cuts /abrasions";

* On 01/05/22 a home health note documented "please continue to re-dress left top of hand as needed for bleeding and for healing process as well as to keep covered and protected, wound care supplies are in brown box in pt's [patient's] room...wound left top of hand/wrist area ½ inch length, skin tear"; and

* On 01/08/22 the MAR was updated to include "monitor top of left hand".

The facility lacked documented evidence the resident's skin tear was evaluated, consistently monitored, and interventions identified from the incident until 01/08/22 when monitoring of the wound was initiated.

The need to ensure the facility evaluated and monitored the resident's wound was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Service) on 01/20/22. They acknowledged the findings.

b. The resident's clinical records, dated 12/20/21 through 01/19/22, indicated the following:

* Resident 6's weight was monitored with weekly weights. On 01/04/22 Resident 6 was weighed and documented as 97 lbs (pounds);

* On 01/11/22 his/her weight was documented as 86.4, a loss of 10.6 lbs (10% of body weight in one week);

* On 01/14/22 a home health note documented "weight 86.4 lbs eating small amounts"; and

* On 01/18/22 Resident 6's weight was recorded as 92 lbs, a loss of five lbs (5%) from 01/04/22.

Resident 6 was observed eating lunch independently on 01/19/22 and again on 01/20/22, with less than 50% of the meal eaten on both days. On 01/20/22 Resident 6's weight was confirmed as 92 lbs.

The loss of over 10 lbs between weekly weights constituted a change of condition. The facility lacked documented evidence the resident's change of condition related to weight loss and weight fluctuation was evaluated.

The need to ensure the facility evaluated the resident's changes of condition and referred significant changes to the RN was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Service) on 01/20/22. No further information was provided.

3. Resident 4 was admitted to the facility in 2015 with diagnoses including diabetes.

The resident's clinical records, dated 12/01/21 through 01/18/22, indicated the following:

a. On 12/29/21 staff documented on a facility progress note that the resident had a fall. Review of the incident report, dated 12/29/21 stated "Resident was found on the floor during the breakfast...found lying on the floor on [his/her] left side ..."

There was no documented evidence the facility thoroughly reviewed the incident to determine the circumstance of the fall and development of interventions to prevent further falls. There was also no documented evidence the resident's short-term change of condition related to the fall was monitored and progress documented weekly through resolution.

The need to ensure short term changes were evaluated, specific resident interventions determined and documented, and monitored until resolution was discussed with Staff 1 (Executive Director) on 01/20/22. She acknowledged the findings.

b. Staff documented on a facility progress note on 12/29/21 that the resident had "a big scratch mark on [his/her] back" from a fall.

On 12/30/21 staff documented the "scratch" on the back was "more a redness..."

There was no documented evidence the resident's short-term change of condition related to the skin injury was monitored and progress documented weekly through resolution.

The need to ensure the facility monitored the resident's changes of condition weekly through resolution was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Service) on 01/20/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed ensure changes of condition were evaluated, referred to the facility RN when appropriate, monitored through resolution, and interventions identified and implemented for 3 of 4 sampled residents (#s 4, 6 and 8) reviewed for changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 2018 with diagnoses including hypertension and macular degeneration.

The resident's clinical record, dated 12/20/21 through 01/19/22, indicated the following:

* 12/26/21: The resident experienced symptoms of constipation and became non-responsive.  S/he was sent to the emergency department and was diagnosed with constipation and syncope, and returned to the facility on 12/26/21.

* An after visit summary from the emergency department, dated 12/26/21, was reviewed and instructed the facility to have the resident follow-up with his/her primary care physician (PCP) within a week. The resident was seen by the PCP on 01/14/22. The PCP ordered Colace (stool softener) to be given as needed twice per day for constipation - no bowel movement within two days.

* The 12/27/21 through 01/20/22 MAR was reviewed. The resident received Colace per MD order once on 01/18/22 and staff marked it as "not effective".

* A review of facility communication logs from 12/27/21 through 01/19/22 revealed staff were inconsistently documenting the resident's bowel pattern. Direct care staff interviewed on 01/19/22 and 01/20/22 stated they did not document bowel monitoring but would sometimes write down whether the resident had a bowel movement or not. Staff 6 (MT) stated there was no documentation of the resident's last bowel movement and was unsure when to give the PRN Colace.

During interviews with Staff 1 (Executive Director), Staff 3 (RN) and Staff 18 (Director of Health Services) on 01/19/22 and 01/20/22, staff stated the facility did not do bowel monitoring, had not identified other interventions to address the constipation, nor provided clear direction to staff on how and when to administer the PRN Colace.

The facility lacked documented evidence the resident's short-term change of condition related to constipation was consistently monitored, and interventions identified and implemented.

The need to ensure the facility monitored the resident's change of condition, identified and implemented interventions, and documented at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 3 (Regional RN) and Staff 18 (Director of Health Services) on 01/20/22.  Staff 3 stated she would contact the resident's PCP to discuss the PRN medication and provide additional direction to direct care staff. Staff 18 completed an Interim Service Plan instructing staff on signs and symptoms to be monitored.

1. A change of condition assessment will be completed for resident #4, 6, and 8.

2. The Wellness Director(s) and Wellness Nurse will receive additional training on the Change of Condition policy.

3.  The Executive Director, Wellness Director(s), and Wellness Nurse will review this area daily per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

2. Resident 3 was admitted to the facility in June of 2019 with diagnoses including Parkinson's Disease and dysphagia (difficulty swallowing).

A review of Resident 3's clinical records revealed the following:

* 05/01/21 weight recorded was 168 lbs.;

* 06/01/21 weight recorded was 156 lbs., (a loss of 12 lbs. or 7% weight loss in 30 days);

* 07/01/21 weight recorded was 157 lbs.;

* 07/26/21 weight recorded as 145 lbs.  (a loss of 12 lb. or 7.5% weight loss in 25 days); and

* 07/27/21 Resident 3's quarterly service plan was developed with no mention of the weight loss.

Resident 3 experienced a significant weight loss from 5/1/21 to 6/1/21, when s/he lost 7% of body weight. There was no RN assessment to address the weight loss.

The resident continued to lose weight, an additional 7.5% of body weight from 7/1/21 to 7/26/21 with no RN assessment of the weight loss.  

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 (Executive Director) and Staff 2 (Operational Specialist) on 10/21/21. Staff 1 and Staff 2 confirmed the lack of an RN assessment of Resident 3's significant weight loss.

Refer to C270, example 1 a.

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 3 and 5) who experienced significant changes of condition related to weight loss. Resident's 3 and 5 continued to experience weight loss over several months. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in December 2020 with diagnoses including dementia with behavioral disturbance.

Weight records, dated 5/1/21 - 10/18/21, indicated Resident 5 experienced a 18-pound weight loss from 6/1/21 to 8/24/21. This constituted a 12.8% total body weight loss in three months and represented a significant change of condition. The facility failed to ensure an RN assessment was completed for the weight loss which documented findings, resident status and interventions made as a result of the assessment.

The record indicated Resident 5 continued to lose weight as follows:

* Between 8/24/21 and 9/23/21, Resident 5 lost 14 pounds or 11.4% body weight over one month;

* Resulting in a total of 33.2 pounds or 23.85% over six months.

An RN assessment, completed 7/29/21 related to a change of condition and return to the facility, did not address the weight loss. An RN progress note, dated 8/20/21, documents the need for staff to escort Resident 5 to the dining room and encourage him/her to eat.  During an interview on 10/19/21, Staff 3 (Regional RN) confirmed there was no RN assessment completed and no interventions (with the exception of adding finger foods) were implemented related to Resident 5's weight loss.

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 (Executive Director) and Staff 2 (Operational Specialist) on 10/21/21. They acknowledged the findings.

Refer to C270, example 2a.

1. All resident records will be reviewed to ensure a change of condition assessment has been completed by the Wellness Nurse.

2.  The Executive Director and Wellness Nurse will  receive additional training on the Change in Condition policy and procedure.  

3.  The Wellness Nurse will review this area daily when in the community per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

Based on observations, interviews and record review, it was determined the facility failed to ensure an RN assessment was performed for residents who had significant changes of condition for 1 of 3 sampled residents (#6) who experienced a significant change. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in March 2020 with diagnoses including dementia with behavioral disturbance and kidney disease.

Review of the resident's record showed Resident 6 was weighed once a week to monitor weight.

The weekly weight record showed a severe weight loss between weekly weights on 01/04/22 (97 lbs) and 01/11/22 (86.4 lbs) of 10.6 lbs or 10% of his/her total body weight.  

A hospice note dated 01/14/22 documented "weight 86.4, eating small amounts".

On 01/18/22, Resident 6's weight was recorded as 92 lbs, a five lb (5.2%) loss from 01/04/22 (97 lbs). The weight loss constituted a significant change of condition.

There was no documented evidence of an RN assessment of the weight loss.

Resident 6 was observed eating lunch on 01/19/22 and again on 01/20/22, with less than 50% of the meal consumed on both days.

On 01/19/22, Staff confirmed Resident 6's weight as 92 lbs.

The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 01/20/22. No further information was provided.

1. A significant change of condition assessment was completed for resident #6 and confirmed that there was not any weight loss so there was not a significant change of condition. The 10.6 pound weight loss was a data entry error.

2. The Care Staff will  receive additional training on obtaining and documenting weights in the EHR.  

3.  The Wellness Director and Wellness Nurse will review this area monthly per the Quality Assurance - Health Services and Clinical Review Schedules.

4.  The Executive Director will ensure the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure outside service providers left written information in the facility that addressed on-site services being provided to the resident, and followed recommendations from home health and hospice providers for 2 of 3 sampled residents (#s 3 and 5) who received outside services. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and Parkinson's Disease.

During the survey, Resident 3 required assistance with toileting, grooming and bathing. S/he was unable to use utensils and required meals prepared as finger food to eat independently.

Review of Resident 3's record revealed outside provider notes were not consistently documented as reviewed and/or recommendations were not implemented as follows:

* Outside provider visit notes were not consistently left in the facility - hospice provided service twice a week, however, only two notes were left onsite between 7/1/21 and 10/15/21, other notes were faxed to the facility up to four weeks after the service was provided.

* Hospice recommended all meals served as finger food to allow independent eating on 7/20/21, however, progress notes dated 9/22/21 indicated the hospice nurse observed Resident 3 being served mashed potatoes and soup.

* Hospice note dated 10/14/21 documented "concerned with heavy blood during bms [bowel movement]", and requested the facility to monitor for blood during bowel movements. There was no documented evidence this was done.  

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/21. They acknowledged the findings.

2. Resident 5 was admitted to the facility in January 2020 with diagnoses including dementia.  

During the acuity interview on 10/18/21, Resident 5 was identified as receiving outside provider services previously of physical therapy and currently of hospice.  

Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 07/28/21 through 10/18/21 were completed.

The resident received physical therapy visits and notes were reviewed from 8/3/21 through 8/31/21. The resident was then admitted to hospice services on 08/31/21. Hospice nursing visits were to occur at least weekly and as needed for comfort and general care.

Outside provider visit notes were not consistently documented as reviewed and/or recommendations were not implemented as follows:

* Physical therapy recommendations on 08/03/21 instructed staff to provide frequently scheduled toileting and a lowered bed height. The resident was not put on scheduled toileting and the bed height was not lowered until 10/11/21;

* Nursing recommendations on 09/13/21 instructed staff to educate staff on a scheduled toileting regimen and to remove all breakable items for the resident's room to prevent injuries. Items were not removed until after 9/29/21 ; and

* Nursing recommendations on 09/21/21 documented hospice provided music therapy, a weighted blanket and a thera-bear to use. However, the facility did not obtain information for staff to follow on how/when to use these interventions.

During interviews with caregiving staff on 10/21/21, staff were not aware of where to locate some of the items provided and how/when to use them.

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/21. They acknowledged the findings.

1. All resident records will be reviewed to ensure coordination of outside services for identified needs have been received and reviewed.  

2.  The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Outside Agency Policy.

3.  The Wellness Director(s) will review this area daily per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place for residents and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:

1.  Resident 4 was admitted to the facility in 2015 with diagnoses including Type II Diabetes.

Resident 4's current physician orders, dated 4/14/21, included:

* Check CBG (blood sugar level) four times daily; and

* To administer Humalog insulin before each meal based on the resident's CBGs;

: 141 - 180 = 8 units

: 181 - 220 = 12 units

: 221 - 260 = 16 units

: 261 - 300= 20 units

: 301 - 340 = 25 units

: 341 - 380 = 30 units

: 381 - 420 = 35 units

: Greater than 420 = 40 units

* To administer Humalog insulin before bedtime based on the resident's CBGs;

: 141 - 180 = 4 units

: 181 - 220 = 6 units

: 221 - 260 = 8 units

: 261 - 300= 10 units

: 301 - 340 = 12 units

: 341 - 380 = 15 units

: 381 - 420 = 18 units

: Greater than 420 = 20 units

Resident 4's CBGs (blood sugar level) record from 9/01/21 through 10/18/21 indicated the resident's CBGs were between 145 and 381 except on two occasions, on 9/9/21 before breakfast, CBG of 114 and on 9/25/21 before breakfast, CBG of 112.

The 09/01/21 - 10/18/21 MAR revealed there was no documentation for the administered insulin amount when CBGs were greater than 141.

In an interview on 10/18/21 at 3:35 pm, Staff 12 (MT) stated the facility switched their electronic medication record system in July of 2021. Staff 12 further stated there was no section to document administered insulin amounts when CBGs were greater than 141 with the current electronic record system and therefore, did not document it.

This represented an unsafe medication administration system because it did not address documentation of the correct amount of insulin when unlicensed staff administered, which may result in substantially lower or higher blood sugar levels.

The need to ensure the facility had a safe medication administration system and oversight of the overall medication and treatment administration systems was reviewed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings.

On 10/21/21, during the exit interview, Staff 2 stated facility addressed the above issue and provided evidence of the corrected system prior to exiting the facility.

2. Resident 6 was admitted to the facility in 3/2020 with diagnoses including dementia with behavioral disturbance.

A review of current physician orders and 10/1/21 through 10/18/21 MAR was reviewed during the survey.

Resident 6 had physician orders, dated 9/24/21, that prescribed acetaminophen 325 mg tablet, PRN every six hours and acetaminophen 650 mg suppository, PRN every six hours. The clinical record indicated the resident had a drug allergy to acetaminophen.

Resident 6's MAR also identified a drug allergy to acetaminophen. According to the MAR, the Resident was not administered either of the PRN acetaminophen orders.

During an interview on 10/19/21, Staff 4 (Health Service Specialist), reported she was unaware of the drug allergy or that the resident was prescribed a medication that s/he was allergic to. Staff 4 stated that the pharmacy should have caught the issue and consulted with the prescriber.

On 10/20/21, the findings were reviewed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). On 10/21/21, Staff 4 stated she discussed the drug allergy with the prescriber and provided an order to discontinue both acetaminophen medications.

3. During the survey, administrative oversight of the medication and treatment administration system was found to be ineffective based on deficiencies in the following areas:

* C 303: Medication and Treatment Orders;

* C 310: Accuracy of Medication Administration Records;

* C 315: Accuracy of Treatment Administration Records;

* C 325: Self Administration of medications ; and    

* C 330: Psychotropic Medication Administration.

1. All resident records have been reviewed to ensure sliding scale insulin has been scheduled per the emar adjustment allow documentation of units within the order. All resident records have been reviewed for medications prescribed by physicians that are listed as allergies.

2. The Executive Director, Wellness Director(s), and Wellness Nurse received training on entering sliding scale orders into the emar.

3. The Wellness Director(s) and Wellness Nurse will review this area daily per the Quality Assurance - Health Services and Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure physician's orders were followed for 3 of 5 sampled residents (#s 2,  3 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and difficulty moving due to Parkinson's Disease.

Resident 3's most current physician orders, dated 10/15/20, included the direction to "obtain monthly vitals and weight," and "notify RN for weight loss/gain of greater than 3 lbs in a month."

Resident 3's record documented no weights taken in August, September, or October of 2021.  Resident 3's record also documented weight loss of more than 3 lbs for the months of June and July, however, there was no documentation the RN was notified per the physician order.

On 10/20/21, the physician orders and current MARs were reviewed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

2. Resident 2, who had diagnoses including hypertension, had physician orders, dated 7/27/21, to obtain monthly vitals and weight on "Day 2 of every month" and notify RN for blood pressure greater than 160/80 or less than 80/60, heart rate greater than 100 or less than 55 per minute, respiratory greater than 20 or less than 10 per minute and weight loss/gain greater than 3 pounds in a month.

Resident 2's 10/1/21 through 10/20/21 MAR revealed there was no documented evidence facility staff obtained the vital signs and weight on 10/2/21 as prescribed.

3. Resident 4 was admitted to the facility in 2015 with diagnoses including essential hypertension and edema.

a. Resident 4 had physician orders, dated 4/14/21, to obtain blood pressure daily.

Resident 4's 09/01/21 through 10/18/21 MAR revealed eight occasions, on 09/04/21, 09/17/21, 09/18/21, 09/19/21, 10/02/21, 10/03/21, 10/06/21 and 10/08/21, the blood pressure was not obtained as prescribed.

b. Resident 4 had physician orders, dated 4/14/21, to obtain the resident's weight weekly and notify physician if weight gain of five pounds in one week.

Resident 4's 09/01/21 through 10/18/21 MAR revealed five occasions, on 09/04/21, 09/11/21, 09/18/21, 10/02/21 and 10/09/21, the weight was not obtained as prescribed.

On 10/20/21, the need to ensure staff followed physician orders was reviewed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

1. All Medication Administration Records will be reviewed to ensure signed physician orders are in place and medication or treatment orders are followed.    

2.  The Executive Director, Wellness Director(s), and Wellness Nurse and all Med Tech's will receive additional training on the Medication/Treatment Administration Policy and Procedure.

3. The Wellness Director(s) will review weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

2. Resident 8 had physician orders, dated 01/14/22, to administer "Colace 50 mg twice daily as needed for constipation, give if no bowel movement for 2 days."

Resident 8's 01/01/22 through 01/20/22 MAR revealed the Colace was administered once on 01/18/22 and documented as "not effective".

During an interview with Staff 6 (MT) on 01/20/22, the electronic MAR system was viewed. Staff 6 stated the resident did not receive a second dose of Colace after the initial dose on 01/18/22 despite not having had a bowel movement (bm). Staff 6 administered one dose of the Colace on 01/20/22 at 9:26 am "because [s/he] still had not had a bm". Staff 6 stated it appeared the resident had gone at least four days without a bm (01/17/22 through 01/20/22).

The facility failed to follow physician order's on 01/18/22 and 01/19/22 when the resident had gone more than two days without a bowel movement.

On 01/20/22, the need to ensure staff followed physician orders was reviewed with Staff 1 (Executive Director) and Staff 3 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician's orders were followed for 2 of 4 sampled residents (#s 4 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 2015 with diagnoses including diabetes and edema.

a. Resident 4 had physician orders, dated 12/09/21, to obtain the resident's blood sugar level before bedtime daily and to administer insulin as needed.

Resident 4's 01/01/22 through 01/18/22 MAR revealed eight occasions that the blood sugar level was not obtained as prescribed.

b. Resident 4 had orders, dated 12/09/21, to obtain the resident's weight weekly and notify physician if there was a weight gain of five pounds in one week.

Resident 4's 12/01/21 through 01/19/22 weight record and 01/01/22 through 01/18/22 MAR revealed two occasions, on 01/01/22 and 01/15/22, that the weight was not obtained as prescribed.

On 01/20/22, the need to ensure staff followed physician orders was reviewed with Staff 1 (Executive Director) and Staff 18 (Director of Health Service). They acknowledged the findings.

1. All sliding scale insulin administration records will be reviewed to ensure the emar requires documentation of the obtained CBG when documenting insulin administration.

2.  The Med Tech's will receive additional training on proper documentation of blood sugars and insulin, and obtaining weights and vital signs per physician orders as indicated in the emar.

3. The Wellness Director(s) will review weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

4. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia.

A review of Resident 5's 10/1/21 through 10/18/21 MAR revealed the administration record contained blanks for the following medications:

* Asmanex (inhaler for asthma) on two occasions;

* Diclofenac gel (for pain management) on one occasion; and

* Lantanoprost drops (for glaucoma) on five occasions.

On 10/20/21, the need to ensure accurate documentation on the MAR was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility, for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1.  Resident 6 was admitted to the facility in 3/2020 with diagnosis including dementia with behavioral disturbance.

Resident 6's 10/1/21 through 10/18/21 MAR was reviewed during the survey. The following inaccuracies were identified:

a. Resident 6's MAR noted Haldol PRN every four hours. There were no orders in the facility to administer Haldol; and

b. Resident 6 was prescribed lorazepam PRN every four hours. The MAR indicated to give lorazepam PRN every two hours. The medication was inaccurately transcribed to the MAR. The MAR indicated the lorazepam had not been administered from 10/1/21 through 10/18/21.

The need to ensure MARs were reviewed for accuracy was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and difficulty moving due to Parkinson's Disease.

Resident 3 was prescribed Carbidopa/Levidopa for Parkinson's Disease.

Review of Resident 3's MAR between October 1st and October 19, 2021 showed the administration record of the Carbidopa/Levidopa was left blank six times.

On 10/20/21, the need to ensure accurate documentation on the MAR was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

3. Resident 4 was admitted to the facility in 2015 with diagnoses including Type II diabetes mellitus and edema.

a. Resident 4 was prescribed Humalog insulin 20 units to administer every day before lunch and dinner for diabetes mellitus.

Review of Resident 4's 10/1/21 through 10/18/21 MAR revealed one occasion on 10/06/21, the administration record of the insulin was left blank.

b. Resident 4 was prescribed Nystatin powder three times daily to treat a rash.

Review of Resident 4's 10/1/21 through 10/18/21 MAR revealed five occasions the administration record was left blank on 10/01/21, 10/05/21, 10/06/21, 10/07/21 and 10/08/21.

On 10/20/21, the need to ensure accurate documentation of the MAR was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

1. All Medication Administration Records will be reviewed to ensure accurate medication records.  

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Orders Policy and Procedure.

3.  The Wellness Director(s) and Wellness Nurse will review daily per the Quality Assurance - Health Services and Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

3. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and difficulty moving, due to Parkinson's Disease.

A progress note dated 10/10/21 revealed Resident 3 had a fall with injury, including skin abrasions on head and right arm,treated and bandaged by facility staff.  The TAR for October 2021 did not document that treatment was provided.

The lack of a documented treatment record for Resident 4's treatments was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 2015 with diagnoses including a diabetic ulcer and edema.

Resident 4's progress notes, reviewed from 07/23/21 through 10/18/21, staff documented they provided skin care and applied cream to Resident 4 including on 09/25/21, 09/26/21 and 09/28/21.

The 09/01/21 through 10/18/21 TARs were reviewed. House orders for wound care (cuts, abrasions and skin tears) and treatments were listed on the TAR. However, there was no documentation on the TAR by staff that any of the treatments were provided or cream was applied.

The lack of a documented treatment record for Resident 4's treatments was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

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 3 of 3 sampled residents (#3, 4 and 5) who received wound care. Findings include, but are not limited to:

1. Resident 5 was admitted to the memory care unit in 2020 with diagnoses including dementia and had a history of frequent falls.

Resident 5's progress notes, reviewed from 7/28/21 through 10/18/21, documented wound care was provided to various skin injuries including on 07/29/21, 07/30/21, 08/20/21, 09/10/21, 09/17/21, 09/29/21 and 10/18/21.  

The 09/01/21 through 10/18/21 MARs were reviewed. House orders for wound care (cuts, abrasions and skin tears) and treatments were listed on the TAR. However, there was no documentation by staff of any of the treatments provided on the TAR.

The lack of a documented treatment record for Resident 5's wound care was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/21 at 12:40 pm. They acknowledged the findings.

1. All Treatment Administration Records will be reviewed to ensure accurate medication records.  

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Orders Policy and Procedure.

3.  The Wellness Director(s) and Wellness Nurse will review daily per the Quality Assurance - Health Services and Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, the facility failed to ensure residents had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 2) who self-administered medications. Findings include, but are not limited to:

During the facility acuity review on 10/18/21, Resident 2 was identified to self-administer his/her medications.

Review of the resident's signed physician orders and an evaluation related to self-administration revealed the following:

* Physician order, dated 7/27/21, indicated there was no order to self-administer medications on multiple scheduled prescription eye drops, scheduled prescription oral regimen including potassium, seroquel (an antipsychotic medication) and as needed ventolin (to treat bronchospasm) inhaler; and

* There was no current documented evidence the facility evaluated Resident 2's ability to safely self-administer the medications. The last evaluation for self-administration of medication was on 4/27/21.

On 10/19/21 Staff 1 (Executive Director) confirmed there was no current evaluation related to self-administration for Resident 2. Staff 1 stated the most recent self-administration of medication for Resident 2 was in 4/2021 and had not been updated quarterly as required.

The need for residents to have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and quarterly evaluation of the residents' ability to safely self-administer the medications was discussed with Staff 1 and Staff 2 (Operational Specialist) on 10/20/21. They acknowledged the findings.

1. All resident records will be reviewed to identify self-administration of medication and ensure that there are orders from the primary care provider as well as a self-medication assessment.

2. The Executive Director and Wellness Nurse will receive additional training on the Self-Administration of Medication section of the Evaluation and Service Plan.

3. The Wellness Nurse will review quarterly and with each new order per the Quality Assurance - Clinical Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 1 of 1 sampled resident (#2) who self-administered medications. This is a repeat citation. Findings include, but are not limited to:

During the facility acuity review on 01/19/22, Resident 2 was identified to self-administer his/her medications.

Review of the resident's clinical record revealed no current documented evidence the facility evaluated Resident 2's ability to safely self-administer the medications.

On 01/20/22, Staff 18 (Director of Health Service) confirmed there was no current evaluation related to self-administration for Resident 2.

The need for a quarterly evaluation of the resident's ability to safely self-administer medications was discussed with Staff 1 (Executive Director) and Staff 18 on 01/20/22. They acknowledged the findings.  

1. A self-medication assessment was completed for resident #2 on 1/20/22 with the Quarterly RN assessment.                                                                       

2. The Wellness Nurse will receive additional training on the timing of Self-Administration of Medication Assessments.

3. The Wellness Nurse will review quarterly and with each new order per the Quality Assurance - Clinical Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been attempted with ineffective results prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (#5) who was administered a PRN psychoactive medication for aggression. Findings include, but are not limited to:

Resident 5's MAR, dated 10/1/21 - 10/18/21, was reviewed and indicated the resident was administered PRN lorazepam (an anti-anxiety medication) on 10/2/21. There was no documented evidence non-pharmacological interventions had been attempted with ineffective results prior to administering the PRN psychotropic medication.  

An interview with Staff 6 (Life Enrichment Director/MT) and Staff 7 (MT) on 10/21/21 revealed there was no place on the eMAR to document when/which interventions were attempted and may be ineffective prior to administering PRN medications. A discussion with Staff 4 (Health Services Specialist) verified the eMAR system required some additional information be entered into the system and Med Techs trained on how to enter the information accurately.  

The need to ensure staff documented non-pharmacological interventions had been attempted with ineffective results prior to administering a PRN psychoactive medication was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/20. They acknowledged the findings. Staff 4 entered the required information into the eMAR system for Resident 5 and other residents with a PRN psychotropic medication order and stated staff will be trained on entering the information accurately.

1. All resident Medication Administration Records will be reviewed to ensure resident specific parameters and non-pharmacological interventions are in place for PRN psychotropic medications.

2.  The Executive Director, Wellness Director(s), Wellness Nurse, and Med-Tech's will receive additional training on the Yardi Psychotropic Medications job-aid.   

3. The Wellness Director(s) will review this area weekly and with each new order per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potential restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (# 4) who had a half-length side rail on their bed. Findings include, but are not limited to:

Resident 4 was observed to use a half-length side rail to the right side of the bed.

Review of the resident's clinical record revealed, there was no documented evidence of an assessment completed by a RN, Physical Therapist or Occupational Therapist for the use of the side rail.

On 10/20/21, the lack of documented assessment and requirements for the use of the side rail was reviewed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

1. All resident records will be reviewed to ensure physicain order and nurse assessments are completed on all devices with restraining qulaities.

2. The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on Devices with Restraining Qulaities.

3. The Wellness Nurse will review quarterly and with a Change of Condition per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident.  Findings include, but are not limited to:

The facility was licensed as a Residential Care Facility (RCF). The RCF portion of the building housed 28 residents (with a capacity for 39 residents) on two floors. The memory care unit housed 16 residents (with the capacity for 20) on one floor of the building.

1. During the entrance conference on 10/18/21, the following was identified regarding resident care needs:

* The facility had a total census of 44 residents;

* Five residents needed two-person assist with transfers or Hoyer;

* Five residents were on hospice; and

* Four residents were identified as needing meal assistance.

2. The staffing plan provided by the facility was as follows:

* Dayshift - 2 MTs and 4 CGs;

* Evening shift - 2 MT and 4 CGs; and

* Night shift - 1 MT and 2 CGs.

During an interview on 10/18/21 at approximately 10:00 am, Staff 9 (Wellness Director) stated she has worked nearly full time as Med Tech on the memory care unit due to difficulty scheduling staff for the memory care unit and acknowledged the facility had been running short staffed.

3. The facility staffing schedule from 10/1/21 through 10/17/21 was reviewed. Multiple scheduling vacancies were reflected on the schedule. Staff from other positions such as Wellness Director and Life Enrichment Director were used to fill the vacancies.

4. Observations and interviews conducted between 10/18/21 and 10/21/21 showed the following:

* Multiple residents in the memory care needed cuing or full meal assistance;

* Two residents on the memory care required the assistance of two staff for transfer and mobility;

* During interviews, several staff confirmed the facility was often short staffed;

* Several newly hired staff stated they had "not really been trained" because of staffing shortages;

* On 10/18/21 at approximately 12:00 noon, one of two caregivers on the memory care unit left the facility for an appointment, leaving one caregiver and one MT providing care on the unit for the remainder of the shift;

* On 10/19/21 at 10:10 am, a resident was observed walking slowly in one of the hallways in the memory care unit. The resident was removing and replacing his/her clothing and periodically stood without clothes on. At 10:17 am, a caregiver approached and assisted the resident to their room;

* On 10/20/21 and 10/21/21 day shifts, two caregivers and one MT were observed working on the floor. A resident on the memory care required close supervision and assistance. The care staff working on the unit were unable to provide the 1:1 care and a staff person from the RCF section of the facility was called to provide the care;

* On day shift 10/19/21 and 10/20/21, two caregivers and one MT were working on the memory care unit. A resident was observed pacing rapidly through the hallways and into the common areas. The resident approached the door to the outdoor courtyard and went outside. A caregiver passing by went out into the courtyard and brought the resident back inside the unit. When interviewed on 10/20/21, the caregiver reported they were providing care to other residents and could not supervise the resident outside, so they brought him/her inside; and

* In an interview on 10/21/21, Staff 6 (Life Enrichment Director) was asked about the calendar of scheduled activities. Staff 6 stated some of the activities did not occur because she was assigned to provide MT duties and/or drive residents to appointments and other tasks of direct care in the facility.

The facility's failure to ensure adequate staffing in order to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 and Staff 2 (Operations Specialist) on 10/21/21. No additional information was provided.

1. The community will continue to recruit for open positions and will maintain current agency staffing contracts to assist with providing shift coverage as available.

2. The Executive Director, Wellness Director(s), and other department managers will cover open shifts as needed during the recruitment process to meet the scheduled and unscheduled needs of the residents.

3. The Executive Director will review weekly and as needed.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. This is a repeat citation. Findings include, but are not limited to:

The facility was licensed as a Residential Care Facility (RCF). The RCF portion of the building housed 27 residents (with a capacity for 39 residents) on two floors. The memory care unit housed 15 residents (with the capacity for 20) on one floor of the building.

During the entrance conference on 01/19/22, the following was identified regarding resident care needs:

* The facility had a total census of 42 residents;

* Three residents needed two-person assists with transfers or Hoyer lift;

* Three residents were on hospice; and

* Three residents were identified as needing meal assistance.

The staffing plan provided by the facility was as follows:

* Day shift - 2 MTs and 4 CGs;

* Evening shift - 2 MT and 4 CGs; and

* Night shift - 1 MT and 2 CGs.

The facility staffing schedule, from 01/16/22 through 01/20/22, was reviewed. Multiple scheduling vacancies were filled using staff from other positions, such as Wellness Director. On 01/20/22 at 2:17 pm, Staff 1 (Executive Director) stated Wellness Directors, who usually filled the vacancies, were currently not working due to illness. She further stated there were three staff persons who were not on the schedule due to illness.

Observations and interviews conducted between 01/19/22 and 01/20/22 showed the following:

* Multiple residents in the memory care needed cuing or full meal assistance;

* Two residents in the memory care required the assistance of two staff for transfers and mobility;

* During interviews, several staff confirmed the facility was often short staffed;

* On 01/20/22 at approximately 9:30 am the memory care unit had one MT and one caregiver on duty. Staff reported a second caregiver had been re-assigned to the "assisted living" area of the facility;

* On 01/20/22 at 9:45 am, Resident 4 was observed in the bathroom alone. Resident 4 stated s/he was stuck in the bathroom and needed help. The surveyor was looking for staff to provide assistance but was not able to find caregiving staff. The MT was informed and s/he left med-tech duties to assist the resident;  

* On 01/20/22 at 11:30 am, approximately eight residents were observed in the memory care unit dining room for lunch without a staff person present;

* On day shift on 01/20/22, one caregiver and one MT were working on the memory care unit. A resident was observed approaching the door to the outdoor courtyard and went outside. A caregiver went out into the courtyard and brought the resident back inside the unit. When interviewed, the caregiver stated they could not supervise the resident outside, so they brought him/her inside; and

* In an interview on 01/20/22, Staff 6 (MT) and Staff 8 (CG) were asked about the calendar of scheduled activities. They stated some of the activities did not occur because there was only one staff that provided activities on both the memory care and the assisted living areas.

The facility's failure to ensure adequate staffing in order to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Executive Director) on 01/20/22. No additional information was provided.

1. The community will continue to recruit for open positions. A new Wellness Coordintor (staffing position) has been added to manage the schedule and cover open shifts as needed.

2. The Executive Director, Wellness Director(s), and other department managers will cover open shifts as needed during the recruitment process to meet the scheduled and unscheduled needs of the residents.

3. The Executive Director will review weekly and as needed.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 8, 11 and 12) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/19/21 and revealed Staff 8 (CG), Staff 11 (CG) and Staff 12 (MT), hired on 04/29/21, 08/03/21 and 08/04/21, lacked documented evidence they had completed First Aid certification and abdominal thrust training.

The need for staff to complete all required training was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings.

1. All employee records will be reviewed to ensure documented evidence of completion of first aid and abdominal thrust are present.

2. The Executive Director and Business Office Director will receive additional training on Training within 30 days for Direct Care Staff.  

3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule.

4.The Executive Director will ensure the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 14, 15 and 21) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/20/22 and revealed Staff 14 (MA), Staff 15 (CG) and Staff 21 (CG), hired on 11/23/21, 09/28/21 and 12/16/21, respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Executive Director) on 01/20/22. She acknowledged the findings.

1. All employee records will be reviewed to ensure documented evidence of completion of first aid and abdominal thrust are present.

2. The new Business Office Director will receive training on the Staff Records Checklist that includes documentation of training completed within the first 30 days.

3. The Business Office Director will review monthly per the Quality Assurance - Business Office Review Schedule.

4.The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented all required components in accordance with Oregon Fire Code every other month, and Life Safety instruction was provided to staff on alternating months. Findings include, but are not limited to:

Review of Fire and Life safety records on 10/19/21 for April 2021 through September 2021 lacked documentation of the following:

* Fire and life safety instruction to staff on alternate months on different topics;

* Fire drills conducted and recorded every other month at different times of the day;

* The facility was not consistently relocating or evacuating residents during fire drills; and

* Documentation was lacking or incomplete regarding:

- Escape route used;

- Evacuation time-period needed;

- Resident evacuation problems encountered; and

- Number of occupants evacuated.

On 10/20/21, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drills included required components according to the Oregon Fire Code was reviewed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist). They acknowledged the findings.

1. The community will complete fire drills life safety instruction at least every other month.

2. The Executive Director and Mainteance Director will receive additional training on the Fire Life Safety Training & Drill Flow Chart and the Fire Drill Checklist.

3. The Maintenance Director will review monthly per the Quality Assurance - Maintenance Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

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 were requested during the survey. The following deficiencies were identified:

* Documentation that fire and life safety training was provided to residents within 24 hours of move-in;

* Documentation that annual fire and life safety training was provided to residents, including evacuation methods, responsibilities during fire drills and designated meeting place outside of the building; and

* Alternate exit routes were used during fire drills.

The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, alternate exit routes were used during fire drills, and all staff were aware of the designated point of safety was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings. No further information was provided.

1. All resident records will be reviewed to ensure completion of the new resident safety orientation checklist has been completed.

2. The Executive Director and Mainteance Director will receive additional training on the New Resident Safety Orientation Checklist and the Fire Life Safety Training & Drill Flowchart.

3. The Maintenance Director will review with each new move-in and annually per the New Resident Checklist and Quality Assurance - Maintenance Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

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

Refer to Z 142, Z 155, Z 162, Z 164, C 231, C 242, C 260, C 262, C 270, C 280, C 303, C 325, C 360 and C 372.

Refer to Z142, Z155, Z162, Z164, C231, C242, C260, C262, C270, C280, C303, C325, C360, and C372.

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 360, C 420 and C 422.  

Refer to C 231, C 360, C 420, and C 422

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 160, C 231, C 360, C 372 and C 455.

Refer to C160, C231, C360, C372, and C455.

Based on interview and record review, it was determined the facility failed to ensure all required pre-service orientation for 3 of 4 newly hired staff (#s 8, 11 and 13) and pre-service dementia training for 4 of 4 newly hired staff (#s 8, 11, 12 and 13) was completed prior to beginning job responsibilities.  The facility failed to ensure 30-day competency demonstration was completed for 3 of 3 newly hired staff  (#s 8, 11 and 12), and failed to ensure documented evidence of the required 12 hours of annual in-service, including six hours of dementia care training for 1 of 2 long-term staff (# 6) whose training records were reviewed. Findings include, but are not limited to:

Training records were reviewed with Staff 2 (Operations Specialist) on 10/19/21. The following deficiencies were identified:

1. Staff 8 (CG), Staff 11 (CG) and Staff 13 (Cook), hired on 4/29/21, 8/3/21 and 5/25/21, did not have documented evidence that pre-service orientation had been completed in the following required areas:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Food handler's certification (for Staff 13);

* Fire safety and emergency procedures; and

* Evidence Staff 8 and Staff 13 were provided a written job description.

2. Staff 8 (CG), Staff 11 (CG), Staff 12 (MT), and Staff 13 (Cook), were hired on 04/29/21, 08/03/21, 08/04/21 and 05/25/21 respectively, did not have documented evidence of the required six hours of department approved pre-service dementia training in the following required areas:

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

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

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

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

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

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

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

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

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

3. Staff 8 (CG), Staff 11 (CG) and Staff 12 (MT), hired on 4/29/21, 8/3/21 and 8/4/21 respectively, did not have documented evidence of competency demonstration in the following:  

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

4. Staff 7 (MT), hired 04/09/2019, did not have documented evidence of completing the required 12 hours of annual training including six hours related to dementia care between 4/2020 and 4/2021.

The need to ensure newly-hired direct care staff completed all required training prior to beginning their job duties and prior to working independently, documented methods to determine competency of direct care staff and on-going required 12 hours of annual training including six hours related to dementia care training was reviewed with Staff 1 (Executive Director) and Staff 2 on 10/20/21. They acknowledged the findings.

1. All employee records will be reviewed to ensure documented completion of pre-service orientation, pre-service dementia training, competency demonstration, and annual continuing education are completed.

2. The Executive Director and Business Office Director will receive additional training on General & Memory Care Orientation, Training Checklists, and skills Observations.

3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to ensure 2 of 6 sampled newly hired staff (#s 14 and 15) completed all required pre-service training prior to performing any job duties, and completed competency training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Executive Director) on 01/20/22. The following deficiencies were identified:

1. Staff 14 (MT) was hired 11/23/21.

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

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures;

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

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

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

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

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

* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.)

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

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

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

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

b. There was no documented evidence Staff 14 demonstrated competency in her job duties within 30 days of hire and prior to working independently in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation, and reporting;

* General food safety, serving and sanitation; and

* Medication Administration.

The surveyor informed Staff 1 that Staff 14 could not administer medications until documented training was completed. She acknowledged and stated documented medication training would be completed for Staff 14 before she administered medications.

2. Staff 15 (CG) was hired 09/28/21.

a. There was no documented evidence he had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures;

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

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

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

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

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

* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.)

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

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

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

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

b. There was no documented evidence Staff 14 demonstrated competency in his job duties within 30 days of hire and prior to working independently in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation, and reporting; and

* General food safety, serving and sanitation.

The facility's failure to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 1 on 01/20/22. She acknowledged the findings. No further information was provided.

1. All employee records will be reviewed to ensure documented completion of pre-service orientation, pre-service dementia training, and competency demonstration is completed.

2. The Executive Director, Wellness Director(s), and Business Office Director will receive additional training on General & Memory Care Orientation, Training Checklists, and skills Observations.

3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

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 242, C 260, C 262, C270, C 280, C 290, C 300, C 303, C 310, C 315, C 325, C 330 and C 340.

Refer to C 242, C 260, C 262, C 270, C 280, C 290,

C 300, C 303, C 310, C 315, C 325, C 330, and C 340.

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 242, C 260, C 262, C 270, C 280, C 303 and C 325.

Refer to C242, C260, C262, C270, C280, C303, C325.

4. Resident 5 was admitted to the facility in July 2020 with diagnoses including dementia. The current service plan was reviewed during the survey and lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

Observations made between 10/18/21 and 10/21/21 revealed the resident attended some meals in the dining room and slept through others. The resident required care staff to provide cueing, encouragement and physical assistance to eat. An entree was frequently provided that required staff to provide physical assistance as it was not a "finger food". On 10/19, 10/20 and 10/21, the resident slept through breakfast and was up with staff assistance at around 11:30 am each day.   

During an interview on 10/18/21, Staff 9 (Wellness Director) stated Resident 5 often would not get up for breakfast and would eat meals inconsistently, but usually ate better at lunch and dinner and was doing better at eating with finger foods. Staff 9 stated finger foods were not consistently being provided.

The service plan, dated 8/3/21, stated the resident often wandered away from meals, does well with finger foods and having food cut up into bite sized pieces. The service plan lacked any information on the resident's preferred meal times, food and liquid preferences and need for staff intervention to ensure adequate nutrition and hydration was provided.

The need to provide a daily meal program for nutrition and hydration based upon the resident's preferences and needs, available throughout each resident's waking hours and documented in the resident's service plan was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the residents' service plans and were followed for 3 of 3 sampled residents (#s 5, 6, and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 3/2020 with diagnoses including dementia with behavioral disturbance.

Resident 6's current service plan, dated 7/13/21, indicated s/he was at risk for dehydration and had a history of weight loss. The service plan directed staff to provide fluids four times per shift in addition to mealtimes, a full glass of water at med pass and noted staff should check to ensure fluids were within reach and encourage resident to drink the fluids.

During observations from 10/19/21 through 10/21/21, Resident 6 was only offered fluids at mealtimes. Observations of Resident 6 while s/he was in their room on 10/19/21 and 10/20/21 identified the resident was not provided fluid within reach at bedside.

There was no resident specific nutrition and hydration information within the service plan that addressed the weight loss or to provide the resident snacks throughout the day.

2. Resident 7 was admitted to the facility in 12/2018 with diagnoses including Lewy body dementia.

Resident 7's current service plan, dated 07/30/21, indicated s/he was at risk for dehydration and had a history of weight loss. The service plan and MAR directed staff to do the following:

* Provide fluids four times per shift in addition to mealtimes;

* Provide a full glass of water at med pass;

* Check to ensure fluids were within reach, encourage resident to drink them;

* Refill cup as needed to ensure there was fluids within reach at all times;

* Provide organic protein powder once per day; and

* Provide snacks four times per day.

Resident 7's 10/1/21 through 10/20/21 MAR identified the following:  

* Organic protein powder was not administered on 10/2/21 and 10/3/21;

* Snacks were not provided on 10/1/21 and 10/8/21 at 7:30 pm; and

* On six occasions, meal consumption was not recorded on the MAR.

During observations from 10/19/21 through 10/20/21, Resident 7 was only offered fluids at mealtimes and there were no observed snacks being offered throughout the day.

3. During observations on 10/21/21 at 10:37 am, multiple non-sampled residents were heard making the following comments:

* " I'm waiting for something to eat ";

* " Where is everyone, I guess we don't get coffee today "; and

* A group of three non-sampled residents were observed to ask a direct care staff for coffee. The coffee was not provided.

The need to ensure individualized nutrition and hydration plans were included in the resident service plans and were being followed by staff was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

1. All resident service plans will be reviewed and updated with an individualized nutrition and hydration plan.    

2.  The Executive Director, Wellness Director(s), Wellness Nurse will receive additional training on the Service Plan Policy and Procedure.

3.  The Wellness Director will review weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.   

2. Resident 5's service plan was reviewed during the survey.  The service plan stated the resident "does better with one on one activities or a small group with low stimulation". The service plan contained some historical information on previous music preferences and current sleep patterns, however did not contain any information on the resident's current preferences; abilities and skills; emotional/social needs and patterns. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

On 10/21/21, the lack of an individualized activity plan was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

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

1. Residents 6's service plan was reviewed during the survey. The facility did not consistently document a quarterly activity evaluation. The evaluation lacked one or more of the following required components and was not included on the residents' service plan:

* Abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

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

The current service plan identified preferred activities of sing alongs, coffee hour, travel films. Observations on 10/19/21 through 10/21/21, showed Resident 6 was wheelchair bound and unable to successfully propel the wheelchair for long distances without staff assistance. Staff did not assist the resident to attend a singing activity occurring on the unit. The only activity offered to the resident was reading a newspaper in his/her room, alone.

On 10/20/2021 the need to evaluate and develop individualized activity plans including all required components for each memory care resident was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

1. An Activity Assessment will be completed for all residents and the individualized plan will be updated in the resident service plan.

2.  The Executive Director and Life Enrichment Director will receive additional training on the Activities Guide.   

3.  The Life Enrichment Director will review this area weekly per the Quality Assurance - Activities Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.   

2. Residents 6's service plan was reviewed during the survey. The activity plan, located in the resident's 07/13/2021 service plan, lacked the following components:

* Current abilities and skills;

* Sensory stimulation activities;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.  

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

The July 2021 service plan identified preferred activities of playing golf, bridge and the stock market, and that Resident 6 was able to self propel using a manual wheelchair.

Observations on 01/19/22 through 01/20/22, showed Resident 6 required staff assistance to propel a wheelchair, and was not encouraged to participate in the activities offered.

On 01/20/2022 the need to evaluate and update individualized activity plans quarterly and as needed for each memory care resident was discussed with Staff 1 (Executive Director). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 2 of 2 sampled residents (#s 6 and 8) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Residents 8's service plan was reviewed during the survey. The activity evaluation, dated Feb 2020, documented some historical information about the resident's activity preferences. The activity plan, located in the resident's 11/16/21 service plan, lacked the following components:

* Current abilities and skills;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

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

The current service plan identified preferred activities of listening to country music, playing bunco and socializing with other residents. Observations on 01/19/22 through 01/20/22, showed Resident 8 required staff assistance with walking and impaired vision. Staff did not encourage, invite or assist the resident to attend any activities on the unit.

On 01/20/2022 the need to evaluate and update individualized activity plans quarterly and as needed for each memory care resident was discussed with Staff 1 (Executive Director). She acknowledged the findings.

1. An Activity Assessment will be completed for all residents and the individualized plan will be updated in the resident service plan.

2.  The Life Enrichment Director will receive additional training on the Activities Guide.   

3.  The Life Enrichment Director will review this area weekly per the Quality Assurance - Activities Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.