Print Inspection: BND2

The findings of the re-licensure survey, conducted 02/13/23 through 02/15/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 02/15/23, conducted 06/22/23 through 06/23/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 02/15/23, conducted 10/02/23 through 10/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third revisit to the re-licensure survey of 02/15/23, conducted 01/22/24 through 01/24/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the fourth revisit to the re-licensure survey of 02/15/23, conducted on 04/01/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

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

The licensee is responsible for the operation of the facility and the quality of services rendered in the facility, including the supervision and training of staff.

During the second revisit to the re-licensure survey of 02/15/23, conducted 10/02/23 through 10/05/23, administrative oversight to ensure correction of previously identified deficiencies, including ensuring a sufficient number of trained caregivers to meet the care and supervision needs of each resident, and the development, implementation, and monitoring of systems for responding to resident changes of condition, was found to be ineffective based on the severity and number of citations.

Refer to deficiencies in this report.

1) Memory care staff files will be audited, and any incomplete training will be completed. Any assisted living staff that cover shifts in Memory Care will have additional Dementia training completed in advance of covering any shifts. RN consultant will be hired to ensure oversight of change of condition monitoring.

2) New staff will complete all orientation requirements within 30 days of hire. RN will receive additional training through OHCA course.AL staff without MC training will not be allowed to cover shifts in Memory Care

3) Weekly meeting will be help with MC administrator and Operations Manager to review COC and staff training. Business Office Manager will audit employee files quarterly to ensure training compliance records.

4)Memory Care Administrator will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure injuries of unknown cause, falls, resident-to-resident physical altercations, and potential sexual incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office as required for 4 of 5 sampled residents (#s 2, 3, 4, and 6) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in August 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 11/19/22 service plan, 12/02/22 through 02/03/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be confused, required one staff assistance for ADL care, and needed frequent redirection by staff throughout the day. The resident wandered the memory care unit in and out of resident apartments and common areas. The resident required frequent reminders to use his/her walker.

a. A temporary service plan dated 01/23/23 indicated Resident 2 had "two residents interested" in him/her. A progress note dated 01/24/23 indicated Resident 2 had "been involved with two peers." No other information on the specifics of the incident were noted, and no additional incidents were identified in the progress notes or alert charting.

In an interview on 02/13/23, Staff 5 (Health & Wellness Coordinator) indicated Resident 2 had two incidents within the last month with Resident 6. On one occasion the two residents were found naked in Resident 6's apartment; the second occurrence was soon after when the residents were both again found in Resident 6's apartment, undressed down to underwear. Staff 5 stated he found the residents during the first incident and reported the information to management. He was not directly involved with the second incident.

There was no investigation completed for either incident, no additional progress notes, and no reports were made to the local SPD office at the time of the incidents.

The facility was asked to report the potential sexual incidents to the local SPD office, and confirmation of the report was received prior to exit.

b. A progress note dated 12/02/22 indicated Resident 2 was hit in the face by another resident.

A temporary service plan dated 12/05/22 indicated the resident experienced a fall while outside in the courtyard. The resident sustained an abrasion, a lost tooth, and a bloody nose. There were no progress notes regarding the incident.  

No investigations were completed regarding the resident-to-resident altercation or fall with injury, and no reports were made to the local SPD office at the time of either of the incidents.

The facility was asked to report the fall with injury and the resident-to-resident altercation to the local SPD office, and confirmation of the report was received prior to exit.

The need to ensure all sexual incidents, resident-to-resident altercations, and falls with injury were promptly investigated to rule out abuse and/or neglect, and reported to the local SPD as needed was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

2. Resident 6 was admitted to the facility in August 2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 11/13/22 service plan, 01/23/23 through 02/08/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to have hallucinations, confusion, and short- and long-term memory impairments. The resident was noted to be independent with a majority of his/her ADLs and ambulated without assistance around the facility.

* A progress note dated 01/22/23 indicated a behavior incident occurred on 01/21/23. The note indicated staff were searching for Resident 2 and discovered him/her in only a brief, inside Resident 6's apartment. Resident 6 was also undressed, only in underwear, and denied the presence of Resident 2 in his/her apartment. Resident 6 attempted to shut the staff out of the apartment. Staff assisted Resident 2 to get dressed and removed him/her from the apartment.

In an interview on 02/13/23, Staff 5 (Health & Wellness Coordinator) indicated Resident 6 had two incidents within the last month with Resident 2. On one occasion the two residents were found naked in Resident 6's apartment; the second occurrence was soon after when the residents were both again found in Resident 6's apartment, undressed down to underwear. Staff 5 stated he found the residents during the first incident and reported the information to management. He was not directly involved with the second incident.

There was no investigation completed for either incident, no additional progress notes, and no reports were made to the local SPD office at the time of the incidents.

The facility was asked to report the potential sexual incidents to the local SPD office, and confirmation of the report was received prior to exit.

The need to ensure all sexual incidents, resident-to-resident altercations, and falls with injury were promptly investigated to rule out abuse and/or neglect and reported to the local SPD as needed was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

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

The resident's facility record, including progress notes, temporary service plans (TSPs), and incident reports, was reviewed, and interviews were conducted. The following was identified:

a. A TSP dated 11/27/22 referred to the resident having "Skin tears on left forearm and hand."

There was no documented evidence the injuries were investigated or reported to the local SPD office if abuse and/or neglect could not be ruled out.

The facility was asked to report the injuries, and confirmation of the report was received prior to exit.

b. A TSP and an incident report, both dated 02/11/23, indicated staff discovered "a large bruise" on the resident's right forearm. The incident report stated the resident was unable to say how or when the bruise occurred.

There was no documented evidence the injury of unknown cause had been reported to the local SPD office.

The facility was asked to report the injury, and confirmation of the report was received prior to exit.

c. An alert charting note dated 12/10/22 indicated the resident was found "topless" in another resident's room, possibly having "wondered [sic] over from [a different resident's] room."

There was no documented evidence the potential sexual incident had been investigated or reported to the local SPD office.

The facility was asked to report the incidents, and confirmation of the report was received prior to exit.

The need to investigate all injuries and incidents to determine whether or not abuse and/or neglect could be ruled out, and to report to the local SPD office when needed, was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/14/23 and 02/15/23. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 10/2021 with diagnoses including dementia with behavioral disturbance.

The resident's record, including progress notes, TSPs, and incident reports was reviewed, and interviews were conducted. The following was identified:

a. A TSP dated 12/06/22 indicated the resident had sustained a "quarter sized bruise circling around [his/her] left elbow."

b. An incident report dated 02/10/23 revealed Resident 4 had an altercation with another resident in which s/he "grabbed" the other resident's wrists and yelled at them.

There was no documented evidence the injury of unknown cause had been investigated and no documented evidence either incident had been reported to the local SPD office.

The facility was asked to report both incidents, and confirmation of the report was received prior to exit.

The need to investigate all injuries and incidents to determine whether or not abuse and/or neglect could be reasonably ruled out, and to report to the local SPD office when needed, was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/14/23 and 02/15/23. They acknowledged the findings.

1. All incidents listed for residents 2, 3, 4, and 6 were appropriately reported, investigated, and documented. This includes reporting to Resident's legal representatives and HCP.

2. Staff was educated on how to report sexual/resident-resident altercations/falls with injury. A staff training was conducted to review the policies in place for reporting/investigating abuse and a paper form of the policies is easily accessible in both the medication room and the manager's office. Opal's manager and coordinator were educated on investigation strategies along with when to self-report incidents to the appropriate parties. GM will ensure that all new hire employees participate in New Employee Orientaion where they will receive the apropriate training in the following areas:

R-31 Suspected Resident Abuse

oForm R-31 Sexual Abuse Investigation Instruction Form AL Opal

oPR R-31 Resident Intimacy Guidelines

oPR R-31 Suspected Abuse Reporting Agency List

oRM-5 Non Employee Incident Report Policy (includes QM provsions)

oPR RM-5 Reportable Incident Guidelines

oPR RM 2 Workplace Investigation Guidelines, GM is responsible for the completion of New Employee Orientation.

3. Reportable incidents are to be evaluated on an ongoing basis as they occur by the General Manger (GM) and Health and Wellness Manager (HWM). Additionally, on a monthly basis, the GM and HWM are to review "dashboard" reports that may indicate inconsistent reporting that may warrant additional evaluation as part of the community's Quality Management (QM) program.

4.The GM is responsible to see that the corrections are completed/monitored.  

2. Resident 7 moved to the facility December 2021 with diagnoses including Alzheimer's dementia and a recent diagnosis of hip fracture.

Observations of the resident, interviews with staff, and review of the resident's 05/16/23 service plan, temporary service plans, progress notes, and incident investigations were completed and revealed s/he required staff assistance for several ADL care needs and was on hospice services.

An incident report dated 06/12/23 was reviewed and revealed Resident 7 had a "bloody lip from biting [his/her] lip accidentally". Review of the incident report indicated the resident "had no comment" as to what had happened.

In an interview with Staff 7 (Wellness Nurse/LPN) and Staff 21 (Lead Health and Wellness Coordinator) on 06/23/23 at 11:00 am additional information was provided to the survey team which had not been included in the incident report dated 06/12/23. On 06/12/23 Staff 7 had observed Resident 7 breathing in and out of his/her mouth causing the lips to become dried and cracked. Following the observation by Staff 7 on 06/12/23, interventions were put in place to alleviate the cracked lips. The facility failed to document information in order to reasonably conclude that the physical injury was not the result of abuse or neglect.

The need to document information necessary in order to reasonably conclude that the physical injury was not the result of abuse was discussed with Staff 7 and Staff 21 on 06/23/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office as required for 2 of 2 sampled residents (#s 7 and 8) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in May 2023 with diagnoses including anxiety disorder and a recent diagnosis of lung cancer.

Observations of the resident, interviews with staff, and review of the resident's 05/06/23 service plan, temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be confused, restless, required one to two staff assistance for ADL care, and needed frequent redirection by staff throughout the day. The resident had experienced frequent falls since May 2023.

Six incident reports were reviewed for falls that occurred between 06/01/23 through 06/17/23, including injuries of bruising and a hematoma. The incident reports failed to include information obtained, as part of the facility investigation, used to reasonably conclude that the repeated falls and resulting physical injuries were not the result of abuse or neglect. Incident reports included information to "see fall risk reduction plan in service plan". Upon review, the 05/06/23 service plan did not include resident specific interventions for fall reduction. In addition, the incident reports identified interventions including "one hour safety checks, use of a one-on-one caregiver and use of a walker" that were not included on the service plan.

In an interview on 06/23/23, Staff 7 (Wellness Nurse / LPN) and Staff 21 (Lead Health and Wellness Coordinator) acknowledged a review of current fall interventions were not included when performing investigations in order to assist in determining whether abuse and/or neglect had been ruled out.

The need to ensure resident incidents were thoroughly investigated in order to rule out abuse and/or neglect was discussed with Staff 7 and Staff 21 on 06/23/23. They acknowledged the findings.

1) Copy of SOD was placed in Residents 7 and 8's chart to acknowledge the violation.

All incidents occurring in Opal Memory Care will be thoroughly investigated by the facility LPN or a designated person. This will include the investigation of how the incident may have occurred as well as specific interventions that have been put in place to prevent further incidents of the same nature. For all incidents, the GM and HWM or Opal manager will investigate within 24 hours to rule out abuse or neglect and protect the at risk resident.  

2) Health Services staff will be educated on how to report resident-resident altercations, falls with injury, and injuries of unknown cause by 8/7/23 or before their next shift. Training will review the policies in place for reporting/investigating abuse and a paper form of the policies are available for all staff members in the Opal Manager office as well as the medication room. On or before 8/7/23 the Health and Wellness Coordinator and all Medication Aides were educated on investigation strategies along with when to self-report incidents to the appropriate parties.

3) Reportable incidents are to be evaluated on a daily and on an ongoing basis as they occur by General Manager (GM) and Health and Wellness Manager (HWM).  

4) The GM is responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to report physical injuries of unknown cause to the local Seniors and People with Disabilities (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse, and failed to notify the local SPD office immediately of any incident of suspected abuse for 2 of 4 sampled residents (#s 9 and 12) with injuries of unknown cause and physical altercations. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 07/2022 with diagnoses including dementia with behavioral disturbance, chronic diastolic (congestive) heart failure, restlessness, and agitation.

A review of the resident's clinical record between 08/07/23 and 10/02/23 and family and staff interviews identified the following:

* Service Plan dated 09/14/23 indicated the resident "has dementia and has moments that [s/he] will be confused.";

* According to a Resident Incident Report dated 08/27/23, Resident 9 stated [s/he] was hit by another resident on the shoulder and " ...it was hard and hurt.";

* According to a Resident Incident Report dated 09/13/23, Resident 9 "punched another resident three times in the right shoulder after the resident refused to take off the jacket."; and

* A Resident Incident Report dated 09/30/23 noted: "I [MT] saw a large, dark gray/purple in color bruise on the resident's left forearm.  ...it was not tender or painful to the touch and does not appear swollen," and "Resident was unable to tell me [MT] what caused the bruise. [S/he] stated, 'well, it wasn't there yesterday.'"

These incidents on 08/27/23, 09/13/23, and 09/30/23 represented injuries of unknown cause and suspected abuse of the resident. There was no documented evidence the facility reported them immediately to the local SPD office as injuries of unknown cause or suspected abuse.

In an interview with Staff 21 (Lead Health and Wellness Coordinator) on 10/03/23, she acknowledged two resident-to-resident altercations and one incident of injury of unknown cause were not reported immediately to the local SPD office. On 10/04/23, Staff 21 provided documentation that she self-reported the incidents to the local SPD office.

The need to ensure resident incidents were reported immediately to the local SPD office as needed was discussed with Staff 42 (Senior Vice President, Operations), Staff 3 (Health and Wellness Manager), Staff 37 (Interim General Manager), and Staff 21 on 10/05/23. They acknowledged the findings. No further information was provided.

2. Review of Resident 12's progress notes, dated 08/18/23 through 09/29/23, temporary service plans (TSP's), and incident reports identified three altercations between Resident 12 and other residents. These were listed as:

* On 08/17/23 Resident 12 was in the common area and was helping a housemate get out of his/her wheelchair and into a chair. Another housemate asked Resident 12 to stop and Resident 12 "rammed [his/her] walker into" the housemate who was telling Resident 12 to stop.

* On 08/20/23 Resident 12 saw two housemates argue and "went up to defend" one of the housemates. The resident began to insult one of the housemates and "call [him/her] names...then pushed" the housemate.

* On 09/16/23 an alert charting note stated that Resident 12 "had another episode of being aggressive towards" another housemate and grabbed the housemate "by both of [his/her] wrists" until a caregiver intervened.

There was no documented evidence the facility reported the 08/16/23 and 09/16/23 resident-to-resident altercations to the local SPD. The 08/20/23 incident was reported by the facility, but not in a timely manner.

On 10/04/23, the surveyor requested Staff 3 (Health and Wellness Manager) report the 08/17/23 and 09/16/23 incidents to SPD. Verification the incidents had been reported was provided on 10/04/23.

On 10/05/23, the need to immediately report incidents of abuse to the local SPD office was discussed with Staff 3, Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

1) Copy of SOD was placed in Residents 9 and 12's chart to acknowledge the violation.

All incidents occurring in Opal Memory Care will be thoroughly investigated by the facility LPN or a designated person. This will include the investigation of how the incident may have occurred as well as specific interventions that have been put in place to prevent further incidents of the same nature. For all incidents, Memory Care Administrator will investigate within 24 hours to rule out abuse or neglect an and will report any incidents that have potential of abuse or neglect to APS.

2) Memory Care Administrator educated on company policy related to Suspected Abuse.

Incident reports and notes will be reviewed daily by MC administrator and Operations Manager to determination of reporting to APS.

3) Reportable incidents are to be evaluated on a daily by Memory Care Administrator and Operations Manager.

4) The Memory Care Administrator is responsible to see that the corrections are completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear direction to staff for 2 of 6 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in March 2021 with diagnoses including Alzheimer's disease.  

Observations of the resident, interviews with staff, and review of the service plan, dated 01/14/23, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff, and/or did not provide clear direction to staff in the following areas:

* Aggression with and refusals of ADL care;

* Standby assistance when walking;

* Side rail use;

* Fluid type and amounts at meals; and

* Hallucinations and fear of "kids beating" him/her up;

The need to ensure resident service plans were reflective of current care needs, were consistently followed by staff, and provided direction to staff was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

2. Resident 2 was admitted to the facility in August 2021 with diagnoses including dementia.  

Observations of the resident, interviews with staff, and review of the service plan, dated 11/19/22, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff, and/or did not provide clear direction to staff in the following areas:

* Found undressed with another resident;

* Straw use and fluids between meals;

* Cues to slow down when eating and take a drink every 2-3 bites;

* Wandering into others' apartments;

* Walker use;

* Exit-seeking and shaking exit doors; and

* Mechanically soft/cut up food items and resident taking items from other residents' plates.

The need to ensure resident service plans were reflective of current care needs, were consistently followed by staff, and provided direction to staff was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

1. 1.Residents 1 and 2 have been evaluated and service plans have been updated and are now reflective of the resident's current status. The service plans provide clear direction to staff on how to appropriately manage the concerns listed in the C260 section of the Statement of Deficiencies.

2. A staff training was conducted to review service plans, Opal Manager will provide trainings as needed depending on assesments and evaluations.

3. Opal Manager will provide Quarterly assesements and update services as needed.

4. The GM is responsible to see that the corrections are completed/monitored  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear direction to staff for 1 of 2 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 05/2023 with diagnoses including anxiety disorder and a recent diagnosis of lung cancer.  

Observations of the resident, interviews with staff, and review of the service plan, dated 05/06/23, and temporary service plans (TSPs) showed the service plan was not reflective of the resident's current care needs, and/or did not provide clear direction to staff in the following areas:

* Emergency evacuation assistance;

* Independence with the call system;

* Bathing assistance;

* Orientation;

* Dining escort;

* Level of assistance needed for dressing, grooming and nail care assistance;

* Assistance with glasses;

* Level of assistance needed for bed mobility and transfer assistance;

* Safety checks for fall risk;

* Positioning legs with pillows while in bed; and  

* Toileting assistance and incontinence of bowel and bladder.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 21 (Lead Health and Wellness Coordinator) and Staff 7 (Wellness Nurse/LPN) on 06/23/23. They acknowledged the findings.

1) Resident 8's service agreement was updated and put into place to reflect the guidelines of person-centered care prior to her date of passing, 07/01/2023. Resident 7 was evaluated and his service agreement has been updated to reflect his current status and preferences. The service plans to provide clear direction to staff on how to provide patient-centered care to all Opal residents with individualized needs and preferences.

2) In-Service Training was completed with HWM, HWC, and GM to review service plans. The Health and Wellness Manager will routinely provide training as needed depending on the assessments and evaluations.

3) HWM or Designee will audit evaluations and service plans of existing residents on or before 8/7/23. Additional monitoring will be done every 90 days as outlined by company policy. The GM and HWM or Opal Manager will review evaluations and change of condition evaluations as a part of their weekly 1:1 meeting.

4) The General Manager is responsible to see that quarterly assessments, updates, and corrections are completed and monitored.  

3. Resident 11 was admitted to the facility in 01/2021 with diagnoses including dementia, chronic pain, and restlessness and agitation. The resident was receiving hospice services at the time of the survey.

The current service plan, created on 09/14/23, was not reflective of Resident 10's current status and care needs and/or was not implemented in these areas:

* Weekly weights after significant weight loss;

* Updated fall risk interventions; and

* Instructions for side rail use and staff side rail safety monitoring.

The need to ensure resident service plans were accurate and were implemented was discussed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

2. Resident 10 was admitted to the facility in 10/2019 with diagnoses including dementia with behavioral disturbance, chronic pain, and history of urinary tract infections (UTIs).

The current service plan, provided by the facility on 10/04/23, was not reflective of Resident 10's current status and care needs and/or was not implemented in the following areas:

* Use of a call pendant as specified;

* Use of hearing aid as specified;

* Provision of apple juice mixed with cranberry juice;

* Lighting preferences;

* Supplemental nutritional beverages; and

* Use of barrier cream with toileting changes.

The need to ensure resident service plans were accurate and were implemented was discussed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear directions to staff regarding the delivery of services, and/or were implemented for 4 of 4 sampled residents (#s 9, 10, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 07/2022 with diagnoses including dementia with behavioral disturbance, chronic diastolic (congestive) heart failure, restlessness, and agitation.

The resident's current service plan, dated 09/14/23, was reviewed, and the resident and staff were interviewed. The service plan was not reflective of the resident's current status and care needs and/or did not provide clear instructions to staff in the following areas:

* Hearing and use of assistive devices;

* Physician Orders for Life Sustaining Treatment status;

* How side rails were to be used and monitored for safety;

* Behavioral problems and effective non-drug interventions;

* Bed alarm; and

* Instructions for bleeding precautions and interventions while on anticoagulation therapy.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was discussed with Staff 42 (Senior Vice President, Operations), Staff 3 (Health and Wellness Manager), Staff 37 (Interim General Manager), and Staff 21 (Lead Health and Wellness Coordinator) on 10/05/23. They acknowledged the findings. No further information was provided.

4. Resident 12 was admitted to the facility in 05/2023 with diagnoses including dementia with behavioral disturbance.

The current service plan, dated 09/29/23, was not reflective of Resident 12's current status and care needs and/or was not implemented in the following areas:

* Routine nail care from an outside podiatrist;

* Weekly weights;

* Incontinence assistance required;

* Elevating lower extremities;

* Home health services;

* Use of a walker for ambulation and the need for reminders to use it; and

* Assistance needed for shaving.

The need to ensure resident service plans were accurate and were implemented was discussed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

1) All four residents service plans have been updated to reflect residents' current needs along with specific instruction to staff.. Resident 9's service plan currently reflects hearing and use of devices, POLST form, side-rail assessment, behavioral and non-pharmaceutical interventions, the use of a bed alarm, instructions for bleeding and interventions. Resident 10 service

agreement was updated to reflect current needs prior to her date of passing on 10/13/2023. Resident 11's plan of care is now reflective of weekly weights, fall risk interventions and instructions for bed rail use. For resident 12, the service plan has been updated to directly reflect his change of condition and will be monitored quarterly.

2) In-Service Training was completed with Memory Care administrator, and Ops Manager related to evaluation and service plans being accurate and reflective of residents' current needs.

3) Memory Care Administrator, HWM or Designee will audit. review and update evaluations and service plans every 90 days and when there is a resident with a short term/significant change of condition.

2. Resident 2 was admitted to the facility in August 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 11/19/22 service plan, 12/02/22 through 02/03/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to be confused, required one staff assistance for ADL care, and needed frequent redirection by staff throughout the day. The resident wandered the memory care unit in and out of resident apartments and common areas. The resident required frequent reminders to use his/her walker.

a. On 11/11/22 the resident experienced a non-injury fall in the patio area. An additional non-injury fall occurred on 01/28/23 in the dining room.

Investigations of the incidents were incomplete. As a result, the facility failed to determine actions needed, develop and implement resident-specific interventions, and to re-evaluate existing interventions for appropriateness and effectiveness.  

b. Resident 2 experienced two potential sexual incidents with Resident 6, one when found naked together and a second incident when found undressed down to underwear, both in Resident 6's apartment. Monitoring was initiated along with interventions for the second incident, but interventions were not monitored for effectiveness and re-evaluated as needed. The monitoring in place was not resident- or incident-specific. No monitoring was documented for the first incident.

The need to ensure short-term changes of condition had resident-specific interventions developed, implemented, and communicated to staff and were re-evaluated for effectiveness was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

3. Resident 6 was admitted to the facility in August 2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 11/13/22 service plan, 01/14/213 through 02/08/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was noted to have short- and long-term memory impairment and was independent with ADLs.

Resident 6 experienced two potential sexual incidents with Resident 2: one incident when found naked together and a second incident when found undressed down to underwear, both in Resident 6's apartment. Monitoring was initiated along with interventions for the second incident. The interventions were not monitored for effectiveness and re-evaluated as needed. The monitoring in place was not resident- or incident-specific. No monitoring was documented for the first incident.

The need to ensure short-term changes of condition had resident-specific interventions developed, implemented, and communicated to staff and were re-evaluated for effectiveness was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, actions or interventions were determined and communicated with staff, and changes were monitored through resolution, with at least weekly documentation, for 3 of 5 sampled residents (#s 2, 3, and 6). Findings include, but are not limited to:

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

The resident's clinical record, including progress notes, temporary service plans, and incident reports, was reviewed, and interviews were conducted. The following was identified:

A 12/06/22 temporary service plan (TSP) noted the resident was "off [his/her] baseline tonight." A 12/10/22 monitoring entry on the TSP stated the resident "was topless in [Resident 2's] room, but I think it was from wondering [sic] over from [another resident's] room."

There was no documented evidence this incident had been evaluated, actions or interventions had been determined and implemented, or interventions monitored for effectiveness.

The need to evaluate, determine actions or interventions for, and monitor interventions for effectiveness was reviewed with Staff 2 (ED), Staff 3 (Health & Wellness Manager), and Staff 4 (Health & Wellness Coordinator) on 02/15/23. They acknowledged the findings.

1. Facility will evaluate the residents who experience short term change of condition or significant change of condition, refering to the facility nurse for assesment, documenting the change in condition and updating the service plan as needed.

2.Facility has provided written policies regarding resident monitoring and reporting to caregivers and made them accessible to the facility. Residents will be monitored consistent with individual evaluated needs pertinent to service plan. Staff have been trained to identify changes in the residents physical, emotional and mental status and have been trained on the reporting protocol.

3. On an ongoing basis, the GM and HWM will have a weekly 1:1 meeting to review assessments and service plans.

4. The GM is responsible to see that the corrections are completed/monitored.  

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for the resident, communicate the interventions to staff, and monitor the conditions to resolution for 2 of 2 sampled residents (#s 7 and 8) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved into the facility in 12/2021 with diagnoses including Alzheimer's dementia disorder and a recent diagnosis of hip fracture.

The resident's clinical record, including progress notes, temporary service plans, and incident reports, were reviewed and interviews were conducted. The following was identified:

a. A 05/06/23 temporary service plan (TSP) noted the resident had a new behavior of "legs dangling over side of bed". Alert monitoring notes from 05/07/23 through 05/09/23 documented staff monitoring if Resident 7 had legs dangling over the side of the bed. Staff were instructed to "be aware that this is a thing that is now happening". However, there was no further instruction provided to staff of what to do if the behavior occurred.

b. A 05/28/23 temporary service plan (TSP) noted the resident had "an episode that was seizure-like activity that lasted 15-20 seconds". Staff were instructed to "monitor for any changes or concerns". Alert monitoring notes from 05/28/23 through 05/31/23 documented whether any seizure-like activity had occurred. However, there was no further instruction provided to staff of what to do should seizure-like activity occurred.

The conditions above lacked documented evidence actions or interventions had been determined and communicated to staff.

The need to evaluate, determine actions or interventions and monitor interventions for effectiveness was reviewed with Staff 7 (Wellness Nurse/LPN) and Staff 21 (Lead Health & Wellness Coordinator) on 06/23/23. They acknowledged the findings.

2. Resident 8 moved into the facility in 05/2023 with diagnoses including anxiety disorder and was recently diagnosed with lung cancer.

The resident's clinical record, including progress notes, temporary service plans and incident reports, were reviewed and interviews were conducted. The following was identified:

a. A 06/11/23 temporary service plan (TSP) noted the resident was having dark colored urine with odor. Alert monitoring notes from 06/11/23 through 06/14/23 documented increased confusion and dark colored urine. On 06/15/23, Staff 7 (Wellness Nurse/LPN) ended alert monitoring and documented "resident started new medication to treat UTI" and ended the alert monitoring for dark colored urine, stating a new TSP was initiated. On 06/13/23 a TSP for a new medication for UTI was started and staff were instructed to monitor for any adverse side effects of the new medication. However, there was no further documentation of monitoring of the dark colored urine.

b. A 06/11/23 temporary service plan (TSP) noted the resident had a "rash starting to form [on his/her] backside". Alert monitoring notes from 06/11/23 through 06/14/23 documented the status of the rash and that a cream was being applied. On 06/15/23, Staff 7 ended alert monitoring without an update on the status of the rash. There was no further documentation of monitoring of the rash. In an interview on 06/23/23, Staff 24 (Resident Assistant II/MT) confirmed the resident continued to have a rash and barrier cream was being applied.

c. Resident 8 experienced six falls between 05/06/23 and 06/20/23. Progress notes and temporary service plans (TSPs) documented monitoring for pain and injuries via alert charting following each fall. However, there was no documented evidence fall interventions were identified or implemented and monitored for effectiveness. Incident reports completed after each fall included some interventions including: providing safety checks every hour and every two hours and providing a one-on-one caregiver. There was no evidence the interventions were communicated to staff to follow. The current service plan, dated 05/06/23, did not include the fall interventions identified on incident reports for staff to follow.

The conditions above lacked documented evidence the conditions had been evaluated, actions or interventions determined and communicated to staff on all shifts, and interventions monitored for effectiveness.

The need to evaluate, determine actions or interventions, and monitor interventions for effectiveness was reviewed with Staff 20 (General Manager), Staff 21 (Lead Health & Wellness Coordinator), and Staff 7 on 06/23/23. They acknowledged the findings.

1) Resident 7's service agreement has since been updated and Resident 8 is deceased.

2) Health Services Staff have completed training related to monitoring and documenting resident changes of condition by 8/7/23 or before the beginning of their next shift. Reportable conditions will generate incident reports and Temporary Service plans that will be reviewed by the HWM. Temporary service plans will include instruction for staff on what to monitor and facility designee/LN will document resolution of incident. The HWM or designee will ensure that the RN is notified of any needed Change in Condition assessments and service plans are updated as needed.

3) The GM and HWM or Designee will review incident reports, Short Term monitoring Plans, and significant change of conditions weekly, to ensure continued compliance.

4) The GM is responsible to see that the corrections are completed/monitored.

3. Resident 11 moved into the facility in 05/2023 with diagnoses including dementia without behavioral disturbance.

The resident's clinical record, including progress notes dated 08/07/23 through 10/02/23, temporary service plans (TSPs), and weight records were reviewed, and interviews were conducted. The following was identified:

a. Resident 11's weight records from 06/2023 through 09/2023 were reviewed and indicated the following:

* 07/11/23 - 130 pounds;

* 08/02/23 - 121.8 pounds;

* No weights were taken in September 2023;

* 10/01/23 - 142.0 pounds; and

* Re-weighed on 10/02/23 - 141.0 pounds.

Between 07/2023 and 08/2023, Resident 11 had a weight loss of 8.2 pounds in one month, or 6.3% of his/her total body weight. This constituted a significant change of condition. There was no documented evidence the facility determined, documented, and communicated to staff what actions or interventions were needed for the resident. The weight loss was not referred to the facility RN for assessment.

Resident 11 was not weighed in September 2023, and there was no monitoring of the weight loss.

Between 08/2023 and 10/02/2023 Resident 11 gained 20 pounds in two months, or 17% of his/her total body weight.

On 10/04/23 an interview with Staff 28 (Contract RN) revealed she had not been notified that Resident 11 had a significant weight loss, and she did not address the resident's weight until her progress note on 09/19/23. The note indicated "Weight monitoring weekly," but on 10/04/23 Staff 21 (Lead Health and Wellness Coordinator) acknowledged that Resident 11 was not being weighed weekly.

The need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift, and conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 3 (Health and Wellness Manager) and Staff 21 on 10/05/23. They acknowledged the findings.

2. Resident 10 was admitted to the facility in 10/2019 with diagnoses including dementia with behavioral disturbance, chronic pain, and history of urinary tract infections (UTIs).

Documentation from a physician at Resident 10's primary care clinic dated 06/14/23, discussing the resident's ongoing UTIs, noted, "Suggest urine culture to be done if with symptoms because of high risk status for complications is [sic] if UTI is truly present."

The record indicated Resident 10 experienced the following changes of condition:

a. On 08/11/23, staff documented in a Progress Note: " ...resident has painful urination and urine has a strong, foul odor." The med tech documented she contacted hospice and was told "their visitation schedules are packed at the moment" but hospice would send a nurse as soon as possible.

There was no documented evidence the facility determined, documented, and communicated to staff what actions or interventions were needed for the resident. There was no documented evidence the facility monitored the resident's condition. A hospice nurse did not evaluate the resident until 09/08/23 and, though they noted a concentrated odor, did not indicate the resident had a UTI.

b. On 09/12/23, staff documented in a Progress Note: "[resident's] urine is smelling more strongly, suggesting possible UTI but staff have not seen any behavioral changes."

There was no documented evidence the facility determined, documented, and communicated to staff what actions or interventions were needed for the resident. There was no documented evidence the facility monitored the resident's condition.

c. On 09/21/23, a med tech documented in a Progress Note that a hospice aide reported the resident had "some mucus in [his/her] urine" and complained of "mild back pain." The med tech wrote that the facility would monitor the resident's urine for three days "to see if it is an ongoing issue."

There was no documented evidence the facility determined, documented, and communicated to staff what actions or interventions were needed for the resident. There was no documented evidence the facility monitored the resident's condition. A hospice nurse met with the resident on 09/23/23 and documented, "No indication of UTI at this time."

On 09/27/23, a caregiver reported the resident had "a thick yellowish/brown discharge in [his/her] underwear. The med tech documented she notified hospice, who stated it could be a sign of a yeast infection. The resident was placed on monitoring, and treatment for a yeast infection was initiated by hospice on 09/30/23.

The facility's failure to monitor Resident 10's symptoms, given the resident's documented history of infections, was discussed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the lack of monitoring.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for the resident, communicate the interventions to staff, and monitor the conditions to resolution for 3 of 4 sampled residents (#s 10, 11 and 12) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 moved into the facility in 05/2023 with diagnoses including dementia with behavioral disturbance.

The resident's clinical record, including progress notes dated 08/18/23 through 09/29/23, temporary service plans (TSP), and incident reports, were reviewed, and interviews were conducted. The following was identified:

a. Resident 12 experienced three resident-to-resident altercations:

* On 08/17/23 Resident 12 had a resident-to-resident physical altercation. The incident report completed after the altercation included some interventions, including providing safety checks every two hours for 72 hours for every change of condition, encouraging resident to use his/her call pendant and ask for help, educating staff "to keep close monitor of resident's interaction with [the housemate]," and keeping the two residents "separated when agitation is apparent."  There was no documented evidence the interventions identified on the incident report were added to the resident's service plan and communicated to staff;

* On 08/20/23 Resident 12 was involved in another resident-to-resident physical altercation. The service plan, updated 08/24/23, stated "staff are to check on [Resident 12] every two hours and as needed to ensure that [s/he] is in a safe position and not causing harm to [him/herself] or others." The facility failed to inform staff  as to which housemates Resident 12 was involved with, how to limit the contact between them, and how to keep Resident 12 and housemates safe;

* On 09/13/23 a TSP was created that which identified Resident 12 "has been aggressive with carestaff and residents" and included what to monitor. There were no interventions identified regarding what to do when staff observed these behaviors; and

* On 09/16/23 staff documented Resident 12 had an altercation with another housemate, and Resident 12 grabbed the housemate "by both of his/her wrist[sic]." There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident and communicated the actions or interventions to staff on each shift.

Resident 12 was involved in multiple altercations with peers. The facility failed to develop interventions to prevent further incidents and protect other residents on the MCC.

b. Resident 12's weight records from June 2023 to Sept 2023 were reviewed and indicated the following:

* 06/02/23 - 198.2 pounds;

* 07/22/23 - 195.4 pounds;

* 08/01/23 - 186.2 pounds; and

* 09/09/23 - 180 pounds.

Between 06/2023 and 09/2023, Resident 12 had a significant weight loss of 18.2 pounds in three months, or 9.2% of his/her total body weight. This represented a significant change of condition.

On 10/12/23 at 8:50 am Resident 12 was weighed at the request of this surveyor and was 197.2 pounds. Resident 12 was one pound away from his/her initial weight of 198.2 pounds.

In an interview on 10/04/23, Staff 28 (Contract RN) reported she had not been notified that Resident 12 had a significant weight loss and his/her weight was not addressed until her assessment on 09/29/23. The assessment noted "Weight monitoring weekly," but on 10/04/23 Staff 21 (Lead Health and Wellness Coordinator) acknowledged that Resident 12 was not being weighed weekly.

The need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift, and conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 3 (Health & Wellness Manager), Staff 21, Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

1) For residents 10, 11 and 12, interventions were established for change of condition assessments and will continue to be monitored by facility RN.

2) Memory Care Staff received in-service on change of condition assessment process to include notification to RN, intervention and monitoring requirements and documentation.

3) Memory Care administrator and Operations manager will review COC assessments weekly and ensure service plans are reflective of RN recommendations and monitoring care plan documents effectiveness of interventions through resolution.

4) The GM is responsible to see that the corrections are completed/monitored.

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

Resident 5 was admitted to the facility in March 2021 with diagnoses including Alzheimer's disease.

Weight records, dated 08/06/23 through 02/06/23, and progress notes, dated 01/27/23 through 02/10/23, indicated the resident experienced the following:

* An 11.6 pound loss between 01/02/23 and 01/09/23, which constituted an 11.21% severe loss in one week;

* A 6.8 pound gain between 01/09/23 and 01/16/23, which constituted a 7.40% severe gain in one week;

* A 3.6 pound loss between 01/16/23 and 01/30/23, which constituted a 3.65% loss and was not significant for the resident; and

* A 6.6 pound weight gain between 01/30/23 and 02/05/23, which constituted a 6.94% severe weight gain in less than one week.

The resident's last weight was noted as 98 pounds on 02/06/23. This was a 3.6 pound loss from the 02/05/23 weight. A more current weight was not provided prior to exit.

Progress notes, temporary service plans, and physician communications dated 12/07/22 through 02/06/23 indicated the resident had experienced an ongoing decline in cognition and ADL abilities, as well as an increase in confusion and behaviors with care. The resident was admitted to hospice on 01/13/23 for a decline in condition.

Multiple observations of the resident between 02/13/23 and 02/15/23 showed the resident attended only two of the six meal opportunities observed. The resident could ambulate to the dining room and eat independently once served. The resident was observed to be easily distracted from the meal and required frequent cues to continue to eat.

The resident ate 75-100% of the meals observed. Intake amounts were unknown by staff for any meal items delivered to the resident's room when s/he declined to come to the dining room. The resident was able to request food and fluids but was inconsistent with his/her requests.

In interviews between 02/13/23 and 02/15/23, Staff 14 and 15 (CGs) indicated the resident's intake varied and that s/he ate better when in the dining room. The staff further indicated the resident required a lot of cueing to keep eating the meal, as s/he was very easily distracted. The staff were unsure if the resident had a health shake with breakfast or how much the resident might have eaten when in his/her apartment.

Interviews with Staff 4 (Health & Wellness Coordinator) and Staff 6 (RN) on 02/14/23 indicated an assessment was completed at the time the resident was admitted to hospice services on 01/14/23. Staff 6 acknowledged the assessment mentioned weight loss but did not address the ongoing weight changes, interventions in place, or additional plans for the resident. Staff 6 indicated hospice was their main intervention. Staff 4 indicated hospice had been in process for a few months, as the resident was on a steady decline. Staff 4 stated there was a swallow evaluation completed in November 2022 to ensure there were no swallow or diet texture concerns, with no issues found. Both staff indicated the resident received health shakes in in the morning for the last several months. The staff denied any concerns regarding acute medical conditions or edema.

The facility failed to ensure an RN assessment was completed for the weight losses and gains from January 2023 to February 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

1. Resident 1 was reassessed for Significant Change of Condition by RN, and service plan was updated to reflect this.

2. The HWM provided training to staff regarding "change of condition" incident reporting requirements, including weight variances and notifications to the resident's health care practitioner for potential intake monitoring orders or other orders. To ensure the violation will not happen again,- HWM, RN and Opal Manager who are responsible for these functions will be oriented to these practices and such training will be documented.

3. HWD/Opal Manager will review "dashboards" and incident reports daily.  Any significant changes in condition will have assessments and service plan updates completed within 48 hours. The ongoing, weekly GM1:1 meetings with the HWM and Opal Manager will include a review of incident reports, assessments and service plans. IR would be generated, resulting in HWM/GM review within 24 hours and notification of RN to complete assessment.

4. The GM is responsible to see that the corrections are completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#8) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 8 moved into the facility in 05/2023 with diagnoses including anxiety disorder and a recent diagnosis of lung cancer.

a. Weight records, dated 04/13/23 (obtained from move-in record) through 06/06/23, and progress notes for the same time period indicated the resident experienced the following:

* A 13 pound loss between 04/13/23 and 05/15/23, which constituted an 8.02% significant loss in one month; and

* The resident lost an additional five pounds, or 3.95% loss, between 05/15/23 and 06/06/23.

Progress notes, temporary service plans, and physician communications from 05/06/23 through 06/22/23 indicated the resident had experienced ongoing decline in cognition and ADL abilities, as well as an increase in confusion. The resident was admitted to hospice on 06/01/23 for a decline in condition related to lung cancer.

An RN assessment was provided. The assessment had been completed by Staff 7 (Wellness Nurse/LPN) and was dated 05/31/23. The assessment was later signed by Staff 26 (Health and Wellness Director/RN), dated 06/13/23.  The assessment mentions the resident "lost 9 pounds in the last 3 months". However, the assessment did not include information of findings and interventions made as a result of the assessment.  Additionally, the review by the RN was not completed timely.

Multiple observations of the resident on 06/22/23 and 06/23/23 showed the resident attended lunch meal in the dining room on 06/22/23 and in bed 06/23/23. The resident needed to use a wheelchair and was assisted to the dining room by staff on 06/22/23. Lunch on 06/22/23 consisted of diced vegetable soup. Resident 8 was not able to feed him/her self and care staff provided full meal assistance. Resident 8 would turn his/her head away when presented with a spoon of soup. Staff provided cueing and encouragement. Staff offered an alternative of yogurt. The resident refused all but one bite of food. Staff reported the resident had eaten "well" at breakfast earlier that day. Juice was offered, using both a cup and a straw, however the resident had difficulty with both. Staff were able to assist the resident with taking several sips of juice.

b. The resident was diagnosed with lung cancer at the end of 05/2023. Observations of the resident and interviews with care staff on 06/22/23 and 06/23/23 revealed the resident to be confused, was unable to verbalize sentences, was non-ambulatory, required two person assistance for transfers and dressing and extensive assistance of one with all other ADL's.  S/he required meal assistance with meals and was losing weight. The overall decline in cognition and ADL functioning constituted a significant change in condition.

A review of the resident's clinical record, including physician communication, progress notes and TSPs from 05/06/23 through 06/22/23 showed staff were aware of the decline.

An RN assessment, completed by the LPN on 05/31/23 and signed by the RN on 06/13/23, documented the resident had experienced some significant weight loss, was using a walker for ambulation, was independent with transfers and getting in/out of bed, required cueing for toileting, was oriented to person and place, had some wandering behaviors and was independent with use of the call system. The 05/06/23 service plan indicated the resident was ambulatory with a walker and sometimes needed a wheelchair, was independent with using a call pendant and required cueing and stand by assist with ADL's such as grooming and dressing.

Interviews with Staff 21 (Lead Health & Wellness Coordinator) and Staff 7 on 06/23/23 indicated an RN assessment was completed at the time the resident was being assessed for admission to hospice services on 06/01/23. Staff 7 acknowledged the resident had experienced significant decline since 05/31/23 and another RN assessment had not been performed to address the ongoing changes.  

The facility failed to ensure an RN assessment was completed for the weight loss and overall significant decline which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed timely and included all required information was discussed with Staff 20 (General Manager), Staff 7 and Staff 21 on 06/23/23. They acknowledged the findings.

1) Resident 8 passed away on 07/01/2023.

2) Corporate RN to provide Significant Change of Condition training to HWM, LN, and Opal Coordinator on or before 8/7/23. Training to include indentifying signs of decline, documentation standards and timely involvement of RN assessment and notification to physician. Community will have an RN in the building 24 hours weekly to ensure that significant COC's are being completed in a timely manner as of 8/7/23

3) The GM and HWM or Designee will review chart notes at the 1:1 meeting weekly to ensure ongoing compliance.

4) The GM is responsible to see that the corrections listed above are completed and monitored.  

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#12) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 12 moved into the facility in 05/2023 with diagnoses including dementia with behavioral disturbance.

A review of Resident 12's record revealed on 09/20/23 the resident fell and hit their head. They were sent to the hospital and diagnosed with a subdural hematoma. They were started on anti-seizure medications and taken off anti-hypertensive medications (for high blood pressure).  Resident 12 returned to the facility on 09/22/23 using a walker for ambulation. On 10/02/23, an interview with Resident 12's spouse indicated the resident was discharged from the hospital with the walker and had been using it since. On 10/02/03, an interview with Resident 12's HH PT indicated that s/he needed verbal cues to be reminded to use the walker, but could walk around the facility without physical assist. A review of Resident 12's 09/2023 MAR confirmed the resident was no longer taking hypertensive medications and was currently taking levetiracetam twice daily for seizures.

The fall with a subdural hematoma and need for anti-seizure medication represented a significant change of condition, requiring an assessment by the facility RN. The facility failed to ensure an RN assessment was completed in a timely manner. The change of condition assessment was not completed until 09/29/23. The RN assessment was not reflective of the resident's change in status in the following areas:

* Fall assessment failed to indicate the resident had a recent fall which required medical attention, since the fall required a walker to ambulate, and was no longer taking anti-hypertensive medication;

* Resident 12 required reminders to use the walker, but could use it independently; and

* The resident started taking anti-seizure medication.

There was no documented evidence the service plan was updated to reflect Resident 12's change in status and care needs.

The need ensure to RN assessments were completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

1) For resident 12, community RN assessment has been completed for significant change of condition, evaluation and service plan were updated to include RN assessment finding and recommendations.

2) Corporate RN to provide Significant Change of Condition training to Memory Care administrator and community RN. Community RN to also attend OHCA role of RN training.

3) The Operations Manager and GM will review significant change of condition weekly and ensure timely completion and that service plans are reflective resident status and care needs.

4) The Memory Care Administrator is responsible for ongoing monitoring and compliance.

Based on observation, interview, and record review, it was determined the facility failed to carry out medication and treatment orders as prescribed and ensure written, signed physician orders were documented in the resident's facility record for all medications that the facility was responsible to administer for 1 of 4 sampled residents (#10) whose orders were reviewed. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 10/2019 with diagnoses including dementia with behavioral disturbance, chronic pain, and history of urinary tract infections (UTIs).

Review of the most recent signed orders from the resident's primary care physician, dated 09/12/23, and other recent orders from the hospice provider identified the following deficiencies:

* Calmoseptine ointment was ordered to be administered topically to the coccyx area at every brief change. The order was entered on the MAR as "PRN" and facility staff reported they were not applying the ointment regularly as ordered.

* The resident had orders for acetaminophen - administer 650 mg every four hours as needed for pain and morphine sulfate solution  - give 0.5 ml every hour as needed for pain unrelieved by acetaminophen. Instructions on the MAR directed staff to administer the acetaminophen before administering the morphine. Between 09/01/23 and 09/30/23, the facility documented it administered the morphine on 10 occasions without first administering the acetaminophen.

* The resident had an order for the facility to give 237 ml of Ensure (a nutritional supplement beverage) as needed if the resident requested it or did not eat a meal. The supplement was not documented as administered between 09/01/23 and 09/30/23. In an interview on 10/04/23, Staff 9 and Staff 14 (CGs) stated there were times during that period when the resident did not eat his/her meal and should have been provided the supplement, but it was not available. They reported a family member had just brought in the supplements on 10/02/23.

* The resident had an order for the facility to assist the resident in donning compression stockings each morning and removing them each evening. On 09/02/23 and 09/03/23, the resident was observed not wearing the stockings. In an interview on 10/03/23, Staff 33 and Staff 36 (CGs) stated there were days when staff did not put the resident's compression stockings on for him/her because staff could not find them.

* The MAR included instructions for the facility to administer lorazepam (to treat anxiety) as needed for anxiety, shortness of breath, or dangerous behavior. The facility did not have a copy of the order for the lorazepam in the resident's facility record.

The need to ensure there were orders in the resident's record for all medications being administered and orders were followed as prescribed was reviewed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

1) Medication orders were obtained for resident 10 prior to her passing on 10/13/23.

2) Memory Care Administrator, facility Nurse and RAII trained on medication policy by Corporate Nurse. All resident MARs will be audited to ensure it matches physician orders.

3) All MARs will be reviewed quarterly to ensure accuracy and missed meds and treatment will be reviewed daily for compliance.

4) The Memory Care Administrator is responsible to see that the corrections listed above are completed and monitored.

2. Resident 14 was admitted to the facility on 12/13/23 with diagnoses including dementia and Stage 3 kidney disease.

Review of the Physician's orders dated 11/21/23 and the December MAR showed the following medications were not given as ordered from admission on 12/13/21 until 12/21/23:

* Omeprazole 20 mg (antacid):

* Biotin 5,000 MCG (vitamin supplement);

* Calcium Carbonate (antacid, calcium supplement);

* Multivitamin (supplement);

* Vitamin C (supplement);

* Vitamin D (supplement);

* Acetaminophen PRN 500 mg (analgesic); and

* Docusate sodium 250 mg (laxative).

A fax was sent to the pharmacy on 12/19/23 ordering the medications, however, there was no documented evidence the physician was notified Resident 14 had not received their medications from 12/13/23 to 12/21/23.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 46 (Opal Manager MCC) and Staff 47 (RN Consultant Elderwise) on 01/23/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure that physician's orders were carried out as prescribed and written, signed practitioner's orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 3 sampled residents (#s 13 and 14) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 was admitted to the facility in 11/2023 with diagnoses including Type II diabetes and unspecified dementia without behavioral disturbance.

An interview with Staff 46 (Opal Manager MCC) and Staff 47 (RN Consultant Elderwise) on 01/23/24 at 3:30 pm revealed there was no documented evidence that written, signed physician or other legally recognized practitioner orders were documented in the resident record for the following 17 medications the facility was responsible to administer:

* Allopurinol 300 mg (for gout);

* Atorvastatin 20 mg (for high cholesterol);

* BD Nano 2 Gen Pen NDL 32gx4mm (for insulin injection);

* Calcitriol 0.25 MCG (for kidney disease);

* Donepezil HCL 10 mg (for dementia);

* Farxiga 5 mg (for Type II diabetes);

* Ferrous sulfate 325 mg (supplement);

* Furosemide 40 mg (for edema);

* Lantus Solostar 100 UN/ML pen (for Type 2 diabetes);

* Levothyroxine 25 MCG (hypothyroidism);

* Metoprolol tartrate 25 mg (for blood pressure);

* Tamulosin HCL 0.4 mg (for nocturia);

* Trulicity 1.5 mg/0.5 ML pen (for Type II diabetes);

* Vitamin B-12 1000 MCG (for Vitamin B-12 deficiency);

* Acetaminophen PRN 500 mg (for pain);

* Fluticasone PRN 50 MCG (for allergies); and

* Guaifenesin PRN 100 mg/5ml syrup (for cough).

On 01/24/24 at 10:15 am, the surveyor confirmed with Staff 46 a request had been made to the provider to obtain signed physician orders for the resident.

The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record was discussed with Staff 46 on 01/24/24. The findings were acknowledged.

C 303 - Following the visit on 1/24/24 the Memory Care Team corrected the following items. We will require all medictions to be avaible or ordered at the time of move in for new resident. Signed ordered will be documented in ElderMark.

Opal Manager and community RN will review ElderMark for signed ordered and monitor MAR for proper administration.  First, Second and Third Checks will be implemented to ensure compliance. Medications are monitored daily.  

Complainace by 3/7/24

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included parameters for administration of PRN medications for 1 of 2 sampled residents (#8) whose MARs were reviewed. Findings include, but are not limited to:

Resident 8 moved into the facility in 05/2023, had diagnoses including lung cancer and was receiving Hospice services.

Resident 8's physician orders and 06/01/23 through 06/22/23 MARs were reviewed and revealed the following:

The following medications lacked resident specific parameters or instructions to direct staff which PRN medication should be administered and in what order:

* Lorazepam "every 2 hours as needed for anxiety/agitation"; and

* Haloperidol "every 4 hours as needed for increased agitation/restlessness."

In an interview on 06/23/23, Staff 24 (Resident Assistant II/MT) confirmed the resident had been receiving both medications as needed and it was not clear which should be given first.  Staff 7 (Wellness Nurse/LPN) acknowledged the lack of parameters and clear instructions to staff for PRN medications.

The need to ensure an accurate MAR that included resident specific parameters and clear instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 20 (General Manager) and Staff 7 on 06/23/23. They acknowledged the findings.

1) Medication administration orders for Resident 7 have been received outlining what pain medication is to be given first along with time parameters of which indicate the amount of time that the medication aide's should wait prior to administering the higher strength pain medication. Resident 8 has passed away.

2) Corporate RN to provide training for HWM, Opal Coordinator and LN on accurate MAR records and company medication policy on or before 8/7/23.

3) HWM to review medication records monthly for an ongoing period of time to ensure all MARs included resident specific parameters and clear instructions for staff when more than one PRN

medication was prescribed for the same condition.

4) The HWM and GM are responsible for seeing that these corrections are being completed and monitored.  

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

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

Observations of the resident and interviews with staff showed the resident had a half side rail on the left side of his/her bed. The resident's service plan, dated 01/14/23, had no information regarding the side rail.

Review of the resident's record showed a thorough assessment had not been completed for the use of the side rail.

In an interview on 02/15/23, Staff 5 (Health & Wellness Coordinator) indicated a hospital bed with the side rail was delivered on 01/13/23, when the resident was admitted to hospice.

The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

1. Resident 1's service plan was updated to reflect the supportive device use and precautions. An assessment was conducted by RN and orders for supportive devices were received.

2. A community audit has been performed to ensure knowledge of all assistive devices and implementation of Physician's orders for devices, RN assessments, and updated service plans that list uses/precautions. The GM, Opal Manager and HWM have received training related to the outside provider coordination of care requirements requiring orders and service agreement provisions for residents admitted to a hospice program.

3.The ongoing, weekly GM1:1 meetings with the HWM and Opal Manager will include a review of service plans/coordination with third party providers.

4. The GM is responsible to see that the corrections are completed/monitored.  

2. Resident 7 was admitted to the facility in 12/2021 with diagnoses including Alzheimer's dementia disorder and a recent diagnosis of hip fracture.

An observation was made of Resident 7 on 06/22/23 at 11:00 am, Resident 7's hospital bed was observed to have half-length side rails on both sides of the bed. The side rails were in the up position and securely fastened to the bed.

In an interview with Staff 21 (Lead Health and Wellness Coordinator) on 06/22/23 at 12:05 pm, side rail assessment documentation was requested. A side rail assessment was provided dated 05/03/23 that lacked the following required information:

*The facility had not documented other less restrictive alternatives evaluated prior to the use of the device; and

*A thorough assessment had not been conducted by the facility RN, a PT or OT.

The need to ensure supportive devices with potentially restraining qualities was assessed prior to use, and that the facility evaluated other less restrictive alternatives was discussed with Staff 7 (Wellness Nurse/LPN) and Staff 21 on 06/23/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT, or OT prior to use for 2 of 2 sampled residents (#'s 7 and 8) who had side rails. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in May 2023 with diagnoses including anxiety disorder.

Observations of the resident and interviews with staff showed the resident had half side rails on the left and right sides of his/her bed. The resident's service plan, dated 05/06/23, had no information regarding the side rails. Staff reported the resident was frequently restless in bed and had experienced frequent falls.

A review of the resident's record showed a thorough assessment had not been completed for the use of the side rails.

In an interview on 06/22/23, Staff 21 (Lead Health & Wellness Coordinator) indicated the hospital bed with the side rails was delivered on 06/16/23. On 06/23/23, Staff 21 provided a side rail assessment, completed on 06/22/23 (during the survey). Upon review, the assessment had not been completed by the facility RN, OT or PT.

The clinical record did not have documented evidence that other, less restrictive alternatives were evaluated prior to the use of the device.

The need for the facility RN, or a PT or OT to complete an assessment and the need to have less restrictive alternatives tried prior to the use of devices with restraining qualities was discussed with Staff 20 (General Manager), Staff 7 (Wellness Nurse/LPN), and Staff 21 on 06/23/23. They acknowledged the findings.

1) Resident 8 passed away prior to an updated bed rail assessment being performed. For Resident 7, the service agreement has been updated to include less restraining alternatives attempted prior to the implementation of bed rails. Additionally, an updated bed rail assessment has been completed by the facility RN.   

2) HWM, HWC, and GM retrained on company assessment policy to include bed bars and transfer aids. Prior to the addition of bed rails for any resident, individualized, less restraining interventions will be documented in the resident's evaluation and service agreement. When these interventions show to be ineffective, bed rails may then be ordered and a comprehensive bed rail assessment will be completed by the facility RN or by the third-party PT/OT.  

3) The Opal Coordinator will be responsible for recommending to the HWM/LN when a resident may require a transfer aid. Transfer aids assessment will be reviewed quarterly as part of a 90-day evaluation or significant change of condition assessment.  Audit of current residents requiring use of transfer aids to be completed by 8/7/23. 90 day reviews of bed rail evaluations will be reviewed on an ongoing basis or as needed with significant COC or quarterly evaluations.

4) The HWM and GM are responsible for seeing that these corrections are being completed and monitored.   

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, document other less restrictive alternatives were evaluated prior to the use, and inform the individual of the risks and benefits associated with the device for 3 of 3 sampled residents (#s 9, 10, and 11) who used a supportive device with restraining qualities. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 01/2021 with diagnoses including dementia, chronic pain, and restlessness and agitation. The resident was receiving hospice services at the time of the survey.

The resident was observed to have a side rail on the right side of the bed.

The facility was unable to provide documentation of the following:

* The resident specifically requested or approved of the device and the facility had informed the individual of the risks and benefits associated with the device;

* The facility registered nurse, a physical therapist, or occupational therapist had conducted a thorough assessment; and

* The facility had documented other less restrictive alternatives were evaluated prior to the use of the device.

The lack of documentation regarding the resident's supportive device was reviewed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the lack of documentation.

3. Resident 10 was admitted to the facility in 10/2019 with diagnoses including dementia with behavioral disturbance, chronic pain, and history of urinary tract infections (UTIs). The resident was receiving hospice services at the time of the survey.

The resident was observed to have a hospital bed with semi-circular bed handle devices on both sides of the bed, positioned toward the resident's upper body.

The facility was unable to provide documentation of the following:

* The resident specifically requested or approved of the device and the facility had informed the individual of the risks and benefits associated with the device;

* The facility RN, a PT, or an OT had conducted a thorough assessment; and

* The facility had documented other less restrictive alternatives evaluated prior to the use of the device.

The lack of documentation regarding the resident's bed device was reviewed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the lack of documentation.

2. Resident 9 was admitted to the facility in 07/2022 with diagnoses including dementia with behavioral disturbance, chronic diastolic (congestive) heart failure, restlessness, and agitation.

During the acuity interview on 10/02/23, Resident 9 was identified as having a side rail.

Observation of Resident 9's hospital bed on 10/02/23 revealed no side rail was attached. During an interview and joint investigation with Staff 31 (CG), one half-length side rail was found under the resident's bed. Staff 31 confirmed the side rail was "usually on" the bed.

During an interview with Staff 21 (Lead Health and Wellness Coordinator) on 10/03/23, she confirmed the side rail was located under the bed.

Resident's Bed Bar and Transfer Aid Consent form, dated 07/24/22, was reviewed. There was no documentation the facility RN,  PT, or OT had conducted a thorough assessment or other less restrictive alternatives were evaluated prior to the use of the device.

The resident's service plan, dated 09/14/23, was reviewed. There was no information relating to the side rail and it's correct use included.

The need to ensure the facility RN, PT, or OT had conducted a thorough assessment, other less restrictive alternatives were evaluated prior to the use of a supportive device with restraining qualities, direct care staff were instructed on the correct use of the device, and i'ts use was included in the resident's service plan was discussed with Staff 42 (Senior Vice President, Operations), Staff 3 (Health and Wellness Manager), Staff 37 (Interim General Manager), and Staff 21 on 10/05/23. They acknowledged the findings.

1) Updated bed rail assessments have been completed by facility RN for residents 9 and 11 and service plans have been updated to include lesser restraining alternatives attempted prior to the implementation of bed rails. Resident 10 passed away prior to updated bed rail assessment being performed.

2) Memory Care Administrator and Nurse retrained on company assessment policy to include bed bars and transfer aids. Prior to the addition of bed rails for any resident, individualized, less restraining interventions will be documented in the resident's evaluation and service agreement. When these interventions show to be ineffective, bed rails may then be ordered, and a comprehensive bed rail assessment will be completed by the facility RN or by the third-party PT/OT.

3) The Memory Care Administrator will be responsible for recommending to the RN when a resident may require a transfer aid. Transfer aids assessment will be reviewed quarterly as part of a

90-day evaluation or significant change of condition assessment. Audit of current residents requiring use of transfer aids to be completed by 10/24/23. 90-day reviews of bed rail evaluations will be reviewed on an ongoing basis or as needed with significant COC or quarterly evaluations.

4) The HWM and GM are responsible for seeing that these corrections are being completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 direct care staff (#s 12 and 13) reviewed for staff training had completed 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 02/14/23 and revealed there was no documented evidence Staff 12 (Lead Medication Tech), hired on 10/19/22, and Staff 13 (Caregiver), hired on 09/30/22, 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 19 (Business Office Manager) on 02/14/23, and with Staff 2 (ED) on 02/15/23. They acknowledged the findings.

1. Staff 12 and 13 have completed the required training; a note has been made in the respective files that is was after the required 30-day period. All staff records have been audited for the required training. Should other records be found in violation, the GM will document the deficient practice and ensure training is obtained if it has not been completed.

2. The GM and hiring managers (Department Heads) will use the Onboarding Checklist to ensure employees receive required training within the specified time frames.

3. The GM and hiring managers will review onboarding records at their respective weekly 1:1 meetings.

4. Hiring managers are responsible for ensuring new employees meet the conditions of employment or are removed from the work schedule. The GM is responsible for ensuring employees who have not met the conditions of employment are removed from the schedule and/or terminated.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 direct care staff (# 25) reviewed for staff training had completed 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 06/22/23 and revealed there was no documented evidence Staff 25 (Resident Assistant II/MT), hired on 04/19/23, 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 20 (General Manager) and Staff 8 (Business Office Manager) on 06/23/2023. They acknowledged the findings.

1) Staff 25 has completed the required training and a note has been made in the respective file that it was after the required 30-day period. All staff records to be audited by 8/7/23 and deficiencies will be corrected and training completed by 8/7/23.

2) The GM and hiring managers (Department Heads) will use the Onboarding Checklist to ensure that employees receive the required training within the specified time frames.

3) GM and Hiring Managers to review all new employee hires monthly on an ongoing basis at the 1:1 meeting between the GM and HWM.

4) The Department Heads/Hiring Managers are responsible for ensuring new employees meet the conditions of the employment or are removed from the work schedule. The GM is responsible for ensuring employees who have not met the conditions of employment are removed from the schedule and/or terminated.

Based on record review and interview, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 32 and 33) completed First Aid and Abdominal Thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 10/04/23. The following deficiencies were identified:

Staff 32 (MT) was hired 08/07/23 and Staff 33 (MT) was hired 07/14/23. There was no documented evidence Staff 32 or Staff 33 completed First Aid and abdominal thrust training within 30 days of hire.

The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 42 (Senior Vice President, Operations), Staff 3 (Health and Wellness Manager), Staff 37 (Interim General Manager), and Staff 21 (Lead Health and Wellness Coordinator) on 10/05/23. They acknowledged the findings. No additional information was provided.

1) Staff 32 and staff 33 have completed the required training, and a note has been made in the respective file that it was after the required 30-day period. All staff records to be audited by 10/31/23 and deficiencies will be corrected, and training completed by 10/31/23.

2) Training provided to Business Office Manager on employee records policy.

3) Business Office Manager and Memory Care Administrator to review all new employee hires monthly to ensure compliance.

4) Memory Care administrator is responsible for monitoring ongoing compliance.

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

Review of fire drill and fire and life safety records for September 2022 through February 2023 identified the following:

* There was no documented evidence fire and life safety instruction for staff had been conducted and documented on alternate months; and

* The facility had not documented residents being relocated or evacuated during fire drills, so there was no documentation of the escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, the evacuation time period needed, and number of occupants evacuated.

The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 2 (ED) on 02/15/22 at 11:10 am. She acknowledged the findings.

1. The violation cannot be corrected as it occurred in the past.

2. The GM and Plant Operations Supervisor have been re-oriented to the requirements of this regulation, the policy established for the community and the community's fire drill documentation tool.

3. The Plant Operations Supervisor will ensure fire drills are scheduled using TELS, the community's electronic building systems management platform. The system sends notifications to both the Plant Operations Supervisor and GM to ensure they are aware the drills and training are due. The GM and Plant Operations Supervisor will review the required documentation after each drill to ensure the required elements are included.

4. The GM is responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and fire and life safety instruction to staff was provided and documented on alternate months. This is a repeat citation. Findings include, but are not limited to:

Review of fire drill and fire and life safety records for April 2023 through June 2023 identified the following:

* Fire drills were not conducted in the memory care facility and recorded every other month;

* There was no documented evidence fire and life safety instruction for staff had been conducted and documented on alternate months; and

* The facility had not documented residents being relocated or evacuated during fire drills, there was no documentation of the escape route used, problems encountered, and comments relating to residents who resisted or failed to participate in the drills.

The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 22 (Guest Services)  and Staff 20 (General Manager) on 06/23/23. They acknowledged the findings.

1) General Manager provided fire drill process and documentation education no later than 8/7/23 to Plant Operation Supervisor. The documentation format has been updated to reflect the escape route used, problems or comments related to residents who resisted or failed drill, evacuation time, number of occupants, and alternative routes used.

2) Resident's will have the right to participate in relocation or evacuation and will be provided with information including escape routes and education. Resident's that participated or refused are documented and will maintain documentation compliance with monthly drills rotating times of day, and shifts.

3) Monthly fire drill records will be reviewed with Plant Operations during their 1:1 meeting and with HWM/Opal Manager after each drill.  

4)The General Manager is responsible to see that the corrections are completed and monitored.         

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills for the memory care community according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Fire drill records for the previous three months were reviewed. All fire drills were conducted in the ALF setting, and MC staff participated in one of three drills. The following deficiencies were identified:

* Staff did not evacuate or relocate MC residents during the fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, and the number of occupants evacuated.

The requirements regarding fire drills were discussed with Staff 42 (Senior Vice President, Operations), Staff 3 (Health and Wellness Manager), Staff 37 (Interim General Manager), and Staff 21 (Lead Health and Wellness Coordinator) on 10/05/23. They acknowledged the findings. No further information was provided.

1) Staff re-educated on fire drill and education procedure. Operations Manager attended fire drill on 10/18/23 to ensure in-person training to Plant Operations Supervisor.

2) Operations Manager provided fire drill process and documentation education no Plant Operation Supervisor. The documentation will reflect the escape route used, problems or comments related to residents who resisted or failed drill, evacuation time, number of occupants, and alternative routes used. Resident's will have the right to participate in relocation or evacuation and will be provided with information including escape routes and education. Resident's that participated or refused are documented and will maintain documentation compliance with monthly drills rotating times of day, and shifts.

3) Monthly fire drill records will be reviewed with Plant Operations during their 1:1 meeting and with HWM/Opal Manager after each drill.

4)The General Manager is responsible to see that the corrections are completed and monitored

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills for the memory care community according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Fire drill records for the previous two months were reviewed. All fire drills were conducted in the ALF setting, and MCC staff participated in two of two drills. The following deficiencies were identified:

* Staff did not evacuate or relocate MCC residents during the fire drills; therefore, the facility's fire drill documentation did not include information on escape routes used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, evacuation time-period needed, and the number of occupants evacuated.

The requirements regarding fire drills were discussed with Staff 2 (Operations Manager), Staff 45 (Plant Operations Manager), and Staff 46 (Opal Manager) on 1/23/24. They acknowledged the findings. No further information was provided.

C 420-

This voilation will be corrected by having dedicasted evacuation zones for residents during fire drills as well as having a separate memory care fire drill apart from AL.

Fire drills will be properly executed during the next drill and reviewed by Opal Manager, Plant Ops and General Manager.

Fire Drills and fire safety will occur monthly.

Compliance by 3/7/24

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

Refer to Z142, Z155, Z162, Z163, Z164, C231, C260, C270, C280, C340, C372 and C420.

1) Training was conducted for HWM, Opal Coordinator, and GM by the Operations Director. A RN will be present in the building for 24 hours a week, effective by 8/7/23.

2) See POC for tag Z142, Z155, Z162, Z163, Z164,

C231, C260, C270, C280, C340, C372

and C420.

3) All systems related to tags Z142, Z155, Z162, Z163, Z164,C231, C260, C270, C280, C340, C372

and C420 will be audited monthly to ensure compliance.

4) The GM is responsible to see that the corrections are completed and monitored.  

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include but are not limited to:

Refer to Z 142, Z 155, Z 162, Z 164, C 150, C 231, C 260, C 270, C 280, C 340, C 372, and C 420.

1) Training was conducted for HWM, Opal Coordinator, and GM by the Operations Director. A RN will be present in the building for 24 hours a week, effective immediately.

2) See POC for tag Z142, Z155, Z162, Z164,

C231, C260, C270, C280, C340, C372

and C420.

3) All systems related to tags Z142, Z155, Z162, Z164, C231, C260, C270, C280, C340, C372

and C420 will be audited monthly to ensure compliance.

4) The Memory Care administrator is responsible to see that the corrections are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include but are not limited to:

Refer to C 303 and C 420.

C 455-

The facity will be in compliance at the time of resurvey corrective measures are to be overseen by Opal Manager, RN and General Manager.

Opal Manager and General Manager will review compliance at weekly 1:1 meetings and documented useding establied meeting agenda template.  

Compliance by 3/7/24

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 372, and C 420.

1. All staff that will be conducting, monitoring, and reviewing the oreceeding tags: C231, C372, and C420

have been instructed and trained on proper protocols. This was done to ensure that resident evaluations, service plans, coordination of care, staff training, significant changes in condition, and fire drill safety meet the licensing requirements for the facility.

2. GM, HWM and Opal Manager have been re-oriented to the requirements of this rule.

3. 1:1 weekly meeting with HWM, GM and Opal manager.

4.The GM is responsible to see that the corrections are completed/monitored.

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

Refer to C 231, C372 and C420.

1) All staff that will be conducting, monitoring, and reviewing the previous tags: C231, C372, and C420, have been trained on proper protocol. This was done to ensure that residents evaluations, service plans, coordination of care, staff training, significant changes in condition, and fire drill safety meet the licensing requirements for the facility.

2) GM and HWM have been re-oriented to the requirements of this rule.

3) 1:1 weekly meeting with the HWM and GM.

4) The GM is responsible to see that these corrections are completed and monitored.  

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

Refer to C 150, C 231, C 372, C 420, and C 455.

1) See POC for Tag C150, C231, C372 and C420

2) Memory Care Administrator, Coordinator and facility nurse has been retrained on company policy and processes per the plant of correction by Operations Manager.

3) Operations Manager will audit processes outlined in plan of correction related to tag C150, 231, 372 and 420 with Memory Care Administrator weekly.

4) The Memory Care Administrator is responsible to see that these corrections are completed and monitored.

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

Refer to C 420.

C 142-

This voilation will be corrected by having dedicasted evacuation zones for residents during fire drills as well as having a separate memory care fire drill apart from AL.

Fire drills will be properly executed during the next drill and reviewed by Opal Manager, Plant Ops and General Manager.

Fire Drills and fire safety will occur monthly.

Compliance by 3/7/24

Based on interview and record review, it was determined the facility failed to provide residents with dementia-trained staff who had received training as required in OAR 411-057-0155. Findings include, but are not limited to:

Refer to Z 155 example 2.

1) All direct care staff serving memory care training records will be audited to ensure appropriate pre-service orientation and Relias trainings are assigned and are completed prior by 11/4/2023.

2) Memory Care Administrator trained on emergency situation staffing documentation requirements which will include nature of emergency, length of emergency period and names and positions of staff that provided coverage.

3) Business Office Manager will audit Staff training records monthly to ensure compliance.

4)The Memory Care Administrator is responsible to see that the corrections are completed, and ongoing compliance monitored.

Based on interview and record review, it was determined the facility failed to have documented evidence 2 of 3 sampled newly-hired direct care staff (#s 11 and 18) completed all required pre-service orientation and dementia training, 2 of 2 new staff (#s 12 and 13) demonstrated competency in assigned duties within required timelines, and 2 of 2 sampled long-term direct care staff (#s 17 and 18) completed a total of 16 hours of in-service training annually, including six hours related to dementia care. Findings include, but are not limited to:

Training records were reviewed with Staff 19 (Business Office Manager) on 02/14/23 and Staff 2 (ED) on 02/15/23. The following deficiencies were identified:

a. There was no documented evidence Staff 11 (Caregiver), hired on 12/02/22, and Staff 18 (Caregiver), hired on 10/04/22, completed the following pre-service orientation and dementia training topics before providing care and services independently:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures;

* Written job description;

* Dementia disease process including progression of the disease;

* Communication and responding to behavioral symptoms;

* Addressing social needs and activities for dementia;

* Care and safety including food, fluids, and wandering;

* Environmental factors that are important for dementia;

* How to provide personal care for a person with dementia; and

* Use of supportive devices with restraining qualities.

b. Staff 12 (Caregiver), hired 10/19/22, and Staff 13 (Caregiver), hired 09/30/22, failed to demonstrate competency within 30 days of hire in the following areas:

* Providing assistance with ADL;

* Role of service plans in providing individualized care;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

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

* General food safety, serving, and sanitation.

c. Staff 17 (CG), hired 09/10/20, and Staff 18 (CG), hired 09/30/20, were reviewed for annual training based on hire date. There was no documented evidence they completed the required 16 hours of annual in-service training (which included at least six hours of dementia care training) in the year from 09/2021 to 09/2022.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 2 (ED) and Staff 19 (Business Office Manager) on 02/15/23. They acknowledged the findings.

1. Staff numbers 11, 12, 13, 17, and 18 have completed the required trainings  and have also been observed by the memory care manager or the coordinator for competency of caring for the residents.

2. Management will conduct continued education training throughout the year to meet the required 16 hours of training annually. The Opal Manager and Health and Wellness Coordinator will ensure proper training and documentation is conducted and files for each new staff member show the staff members' competency of caring for a memory care community resident.

3. 1:1 weekly meeting with GM to review onboarding checklist and continuing education training needs.

4. The GM is responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to have documented evidence 3 of 3 sampled newly-hired direct care staff (#s 23, 24 and 25) completed all required pre-service orientation training and 2 of 2 new staff (#s 24 and 25) completed preservice dementia training and demonstrated competency in assigned duties within required timelines. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed on 06/22/23 and 06/23/23. The following deficiencies were identified:

a. There was no documented evidence Staff 23 (Resident Assistant I/CG), hired 05/24/23, Staff 24 (Resident Assistant II/MT), hired 04/21/23, and Staff 25 (Resident Assistant II/MT), hired 04/19/23 and completed the following pre-service orientation training topics before performing any job duties:   

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures; and

* Written job description.

b. There was no documented evidence Staff 24 and Staff 25 completed the following pre-service dementia training before providing care and services independently:

* Care and safety including food and fluids, use of person-centered approach and addressing pain;

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

* Recognizing and reporting behaviors that indicate a change in condition.

c. There was no documented evidence Staff 24 and Staff 25 demonstrated competency, within 30 days of hire, in the following areas:

* Providing assistance with ADLs;

* Identification, documentation, and reporting of changes of condition;

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

* Other duties as applicable including Med pass and treatments.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 8 (Business Office Manager) and Staff 20 (General Manager) on 06/23/23. They acknowledged the findings.

1) Staff numbers 23, 24, and 25 will complete the required training on or before 7/14/23 and have been observed by the Opal Coordinator or designee for competency in caring for the residents.

2) Management-level staff will conduct continued education training throughout the year to meet the required 16 hours annually. The HWM and Opal Coordinator will ensure proper training and documentation are conducted and filed in the designated employee file for each new staff member to demonstrate the competency of caring for an Opal resident.

3) The GM and HWM or Designee will audit onboarding checklists and continuing education training needs weekly for a total of 8 weeks, ending 9/6/23 to ensure continued compliance.

4) The GM is responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly-hired staff (#s 32 and 33) completed orientation and pre-service training topics prior to beginning job duties and demonstrated competency within 30 days of hire. This is a repeat citation.  Findings include, but are not limited to:

Training records were reviewed on 10/04/23, and the following was identified:

1. Staff 32 (MT) was hired 08/07/23, and Staff 33 (MT) was hired 07/14/23.

a. There was no documented evidence the following orientation topics were completed:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention; and

* Fire safety and emergency procedures.

b. There was no documented evidence the required pre-service training was completed prior to providing personal care in:

* 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 ongoing 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.

c. There was no documented evidence competency was demonstrated within 30 days of hire in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Changes of condition and changes that require reporting;

* General food safety, serving and sanitation; and

* Medication administration.

2. Staff 40, 41, and 43 were caregivers at a sister facility which was not a MCC. Review of staffing records showed they were scheduled to work multiple shifts in September 2023 in this MCC. The facility was asked to provide documentation the staff had received the required training in dementia topics.

Review of the records provided by the facility indicated Staff 40, 41, and 43 lacked any of the pre-service dementia training required prior to working with residents on the MCC.

The need to ensure newly-hired direct care staff completed all orientation and pre-service training topics prior to beginning any job duties and demonstrated required competencies within 30 days of hire was discussed with Staff 42 (Senior Vice President, Operations), Staff 3 (Health and Wellness Manager), Staff 37 (Interim General Manager), and Staff 21 (Lead Health and Wellness Coordinator) on 10/05/23. They acknowledged the findings. No further information was provided.

Staff Training

1) Staff 32 and 33 will complete the required training on or before 10/31/23 and have been observed by the Opal Coordinator or designee for competency in caring for the residents. Competency is documented using skills checklist.

2) Staff will be required to complete pre-service orientation during new hire paperwork to ensure pre-service requirements are met. Additionally, staff will be required to complete Relias training and demonstrate competency within 30 days of hire. Competency will be documented use the skills checklist within 30 days of hire. Business Office Manager will audit employee training records each month for compliance.

3) Memory Care Administrator and Business office manager will week monthly to audit employee training records.

4) The Memory Care Administrator is responsible to see that 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 260, C 270, C 280, and C 340.

1. Opal Manager as well as HWM, LPN, RN and GM will ensure all updates have been made related to sections C260, C270, C280, C340

2. Management will conduct continued education training throughout the year to meet the requirements.

3. 1:1 weekly meeting with HWM and GM.

4. The GM is responsible to see that the corrections are completed/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 C260, C 270, C 280, C 310 and C 340.

1) Training was conducted for HWM, Opal Coordinator, and GM by Operations Director. A full time RN is bieng recruited for the community.

2) See POC for tag C260, C 270, C 280, C 310 and

C 340.

3) All systems related to tags C260, C 270, C 280, C 310 and C 340.will be audited weekly and monthly to ensure compliance for a total of 3 months ending 10/14/23. Facility will be in compliance by 8/7/23.

4) The GM is responsible to see that 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 260, C 270, C 280, C 303, and C 340.

1) See POC for tag C260, C270, C280, C303 and C340

2) Memory Care Administrator, Coordinator and facility nurse will receive training form Operations Manager on policies and processes outlined in POC for tag C260, C270, C280, C303 and

C340

3) Memory Care Administrator and Operations will meet weekly to conduct audit and ensure plan of correction is being followed.

4) The Memory Care Administrator is responsible to see that the corrections are completed and monitored.

Based on 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 303.

Z 162 - Following the visit on 1/24/24 the Memory Care Team corrected the following items. We will require all medictions to be avaible or ordered at the time of move in for new resident. Signed ordered will be documented in ElderMark.

Opal Manager and community RN will review ElderMark for signed ordered and monitor MAR for proper administration.  First, Second and Third Checks will be implemented to ensure compliance. Medications are monitored daily.  

Complainace by 3/7/24

Based on interview and record review, it was determined the facility failed to ensure an individualized nutritional plan for each resident was developed and included in residents' service plans for 3 of 6 sampled residents (#s 1, 3, and 4). Findings include, but are not limited to:

Service plans for Residents 1, 3, and 4 were reviewed during survey. Each of the service plans included some food preferences, but lacked individualized hydration information and staff instructions related to meeting resident-specific nutrition and hydration needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/14/23 and 02/15/23. They acknowledged the findings and agreed more individualized nutrition and hydration information was needed on service plans.

1. Resident 1, 3, and 4's service plans have been and reviewed and updated in order to reflect individualized hydration and nutrition information under the "Hydration Reminder" and "Nutrition Reminder" services.

2. Opal Manager and Health and Wellness Coordinator will ensure that each resident's service plans reflect individual preferences that reflect all current needs of the residents nutrition and hydration preferences.

3. Quarterly as part of the service planning process.

4. The GM is responsible to see that the corrections are completed/monitored.   

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in residents' service plans for 1 of 2 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

A review of Resident 8's progress notes and hospice communication notes provided between 05/31/23 and 06/22/23 showed the following:

* The resident was experiencing physical and cognitive decline and significant weight loss;

* On 06/13/23, hospice recommended to "push/encourage fluids";

* On 06/17/23, hospice recommended finger foods be provided to aid the resident in eating; and

* An interview with Staff 14 (Resident Assistant I/CG) and observations of meals showed Resident 8 required meal assistance in order to eat.

The record showed evidence the hospice recommendations had been reviewed by facility staff. Resident 8's service plan, dated 05/06/23, was reviewed. The service plan did not include the interventions stated above and lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to ensure individualized nutrition and hydration plans were developed and included in residents' service plans was discussed with Staff 20 (General Manager), Staff 21 (Lead Health and Wellness Coordinator) and Staff 7 (Wellness Nurse/LPN) on 06/23/23. They acknowledged the findings.

1) Resident 8 has since passed away.

2) HWM and Opal Health and Wellness Coordinator will ensure that each resident's service plans reflect individual preferences that reflect all current needs of the resident's hydration and nutrition preferences by 8/7/23.

3) Audits are to be completed quarterly ending 12/31/23 to ensure compliance.

4) The GM is responsible to see that the corrections are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 5 of 6 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3, 4, and 5's service plans offered some information about the residents' interests, but the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and/or

* Activities that could be used as behavioral interventions, if necessary.

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

Observations between 02/13/23 and 02/15/23 showed multiple small group activities being led by facility staff. Residents 1, 2, 3, and 4 were not consistently invited to activities or provided adaptations to participate in the activity.

The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Memory Care Manager), Staff 2 (ED), and Staff 3 (Health & Wellness Manager) on 02/15/23. The staff acknowledged the findings.

1. Resident 1, 2, 3, 4, and 5's service plans have been updated to include an individualized activity plan.

2. Opal Manager and Health and Wellness Coordinator will ensure all service plans are updated in order to reflect individualized activity plans reflecting "54 things about me" and "my life story".

Quarterly as part of the service planning process or as needed depending on changes in condition.

4. The GM is responsible to see that the corrections are completed/monitored.   

2. Residents 8 moved to the memory care facility in 05/2023 with diagnoses including dementia and anxiety disorder and was recently diagnosed with lung cancer. Resident 8's service plan offered some information about the residents' historical interests, however, the facility had not fully evaluated the resident's current abilities and activity needs, including:

* Current abilities and skills;

* Emotional and social needs;

* Physical abilities and limitations;

* Adaptations necessary for the resident.  

There was no specific activity plan that detailed what, when, how and how often staff should offer and assist the resident with individualized activities s/he would benefit from.

Observations and interviews indicated the resident had experienced recent decline and was dependent on staff to provide all activities.

On 06/23/23 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 20 (General Manager) and Staff 21 (Lead Health and Wellness Coordinator) who acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation for 2 of 2 sampled residents (#s 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved to the memory care facility in 12/2021 with diagnoses including Alzheimer's dementia and a recent diagnosis of hip fracture. Resident 7's service plan dated 05/16/23 lacked documentation pertaining to activities. The facility had not evaluated the resident's current abilities and activity needs, including:

* Past and current interests;  

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate.  

An individualized activity plan had not been developed based on an activity evaluation that detailed what, when, how and how often staff should offer and assist the resident with individualized activities s/he would benefit from.

Observations and interviews indicated the resident had experienced a recent decline and was dependent on staff to provide all activities.

On 06/23/23 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plans for each resident was discussed with Staff 7 (Wellness Nurse/LPN) and Staff 21 (Lead Health and Wellness Coordinator) who acknowledged the findings.

1) Resident 8 has passed away as of 07/01/2023. Resident 7's service plan has been updated to include an individualized activity plan.

2) HWM and Opal Coordinator will ensure that all service plans are updated in order to reflect indivualized activity plans from the individual "54 things about me," and "My Life Story." by 8/7/23.  

3) This will be reviewed quarterly ending 12/31/23 as a part of the service planning process or as needed depending on changes in condition.

4) The HWM and GM are responsible to see that the corrections are completed and monitored.  

Based on observation, interview, and record review, it was determined the facility failed to evaluate for activities and develop an individualized activity plan based on the activity evaluation for 3 of 4 sampled residents (#s 10, 11 and 12) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend, and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms, walked around the facility, or fell asleep in the common areas. All residents were diagnosed with some type of dementia.

Resident 10 was receiving hospice services, was very hard of hearing, and needed intermittent assistance from staff for mobility in a manual wheelchair. The activity plan noted Resident 10 enjoyed socializing with others, knitting, reading, and watching TV and directed staff to remind the resident to attend activities of choice. During the survey, Resident 10 was not invited to multiple group activities and was not provided with any one-on-one activities.

Resident 11 was receiving hospice services, was hard of hearing, needed assistance from staff to get in and out of bed, and used a manual wheelchair. Resident 11's activity plan noted "likes to travel, enjoys gardening, and loves fishing" and "staff is to encourage resident as much as possible to partake of any activities and outings." During the survey, Resident 11 was not invited to multiple group activities and was not provided with any one-on-one activities.

Resident 12 was receiving Home Health PT and OT services, ambulated around the facility with a walker (but needed reminders to use), and needed verbal encouragement to remain in activities. In the past two months, the resident had been involved in several physical altercations with peers. The activity plan noted Resident 12 enjoyed playing golf when sunny outside, watching sports on TV, doing word searches, and coloring and that the resident was very social and "loves to participate in activities with others."  The activity plan also stated Resident 12 was "independent with activities." During the survey, Resident 12 was not provided with any one-on-one activities, and when s/he did participate in an exercise class, the resident needed encouragement to stay and not get up and leave.

Resident 10, 11 and 12's activity section of the service plans were reviewed. Though the service plans included some information about the residents' past and current interests, the facility had not fully evaluated and documented the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for participation; and

* Activities that could be used as behavioral interventions.

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

The need to develop individualized activity plans which were based on a thorough evaluation of the resident's interests, abilities and needs was discussed Staff 30 (Opal Program Supervisor), Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health & Wellness Coordinator), Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

1) Resident 10 has passed away as of 10/13/23. Resident 11 and 12 activity plans has been updated to include an individualized activity plan.

2) Memory Care administrator will audit service plans to ensure service plan is detailed with activity plan based on evaluation of residents, interests, abilities and needs. Resident activity plan will include details regarding resident abilities, skills, emotional and social needs, address physical abilities, limitation, adaptations and when activities can be used as behavioral interventions. Memory Care Administrator will provide training Memory Care Activity staff on evaluation process and use of service plan to ensure individualized activity plan is followed and updated when resident changes occur.

3) This will be reviewed quarterly ending 1/31/24 as a part of the service planning process or as needed depending on changes in condition.

4) The HWM and GM are responsible to see that the corrections are completed and monitored.

2. Resident 9 was admitted to the facility in 07/2022 with diagnoses including dementia with behavioral disturbance, chronic diastolic (congestive) heart failure, restlessness, and agitation.

During the acuity interview on 10/02/23, Resident 9 was identified as having a history of disruptive behaviors.

A review of the resident's clinical record dated 08/07/23 through 10/02/23, including the service plan, dated 09/14/23 and temporary service plans (TSPs), as well as family and staff interviews, identified the following:

Between 08/17/23 and 09/13/23, Resident 9 had the following documented behaviors:

* 08/17/23: a peer-to-peer altercation where the resident was the aggressor;

* 08/27/23: a peer-to-peer altercation where the resident was hit on the shoulder;

* 08/30/23: a peer-to-peer altercation where the resident was found "shaking [another] resident and yelling for stealing [his/her] clothes." Resident became "violent and... struck care staff" when asked to leave the other resident room; and

* 09/13/23: a peer-to-peer altercation where the resident was the aggressor and "punched another resident three times in the right shoulder after the resident refused to take off the jacket."

Temporary service plans listed no interventions for staff to implement and in the section "Problem/Needs" noted the following:

* 08/17/23: "monitor for any behaviors or related concerns";

* 08/27/23: "monitor for pain and bruising";

* 08/30/23: "monitor for any behaviors and or wandering into other residents rooms"; and

* 09/13/23: "please monitor for any further behaviors."

There was no documented evidence the facility immediately put interventions in place and updated the care plan regarding the altercations, potential triggers for the altercations, or what individualized behavior interventions staff were to use following the incidents. The current service plan noted in the "Non-Pharmacological Intervention" section to "please redirect [him/her] and speak with [him/her] in a calm voice." There were no clear instructions provided to staff on how to manage individual behavioral symptoms.

The need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 42 (Senior VP of Operations), Staff 3 (Health and Wellness Manager), Staff 37 (Interim General Manager), and Staff 21 on 10/05/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service or care plan for 1 of 2 sampled residents (#12) who had challenging behaviors in the MCC. Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 05/2023 with diagnoses including dementia with behavioral disturbance.

Review of the record indicated Resident 12 had three physical altercations with different peers and ongoing verbal behaviors of  "constantly berating and being mean to several residents."

The service plan, dated 09/29/23, included the following information regarding the for resident's behavior and behavior interventions:

* The "non-pharmacological" section noted that Resident 12 "does not experience any anxiety, aggression or behaviors in general." This was not reflective of the resident's documented behaviors.

* Safety Checks: The "Frequent Wandering" section noted the resident had increased agitation and instructed staff to "check on [Resident 12] every two hours and as needed to ensure that [s/he] is in a safe position and not causing potential harm to ...others."

* Behavior: The "Frequent Redirection" section stated Resident 12 had been aggressive with care staff and residents and listed behaviors to monitor. The instructions to staff were to "refer to the behavior management to redirect [Resident 12] when s/he has outburst moments and notify ...manager and facility nurse."

* Behavior: The "Management Plan" directed staff to follow "responsive behavior plan to support resident to feel comfortable and safe in environment." There was no further instruction documented as to what the behavioral plan was and what staff  were to do for Resident 12 when the behaviors occurred.

In an interview on 10/02/23, Staff 13 (CG) stated, "[Resident 12] gets over protective of [his/her] roommate and tries to transfer [him/her] into a chair." When staff intervene to help his/her roommate, Resident 12 gets upset at staff and tells them to "go away." Resident 12 also "watches what other residents are doing and would say to the residents, 'Don't touch that, it's not yours' and will take matters into [his/her] own hands." Staff 13 stated that "the more we cue [him/her] the madder [s/he] gets. So I have learned to remove the resident [s/he] is going after because [Resident 12] just gets more upset if I try to redirect [him/her]. She also stated, "We will call [his/her spouse]."

In an interview on 10/03/23, Staff 14 (CG) stated that when Resident 12 is aggressive toward staff "I just give [him/her] space and come back a little later." She denied receiving any instruction on how to manage Resident 12's aggressive behavior but stated, "I just will lead the other residents away ..." rather than trying to move Resident 12.

There was no documented evidence the facility fully evaluated Resident 12's behavior and included specific information about the behavior in the service plan. The service plan lacked resident-specific interventions staff should implement to prevent or address the resident's behavior.

The need to ensure the facility evaluated and developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was discussed with Staff 3 (Health & Wellness Manager), Staff 21 (Lead Health and Wellness Coordinator) , Staff 37 (Interim General Manager), and Staff 42 (Senior Vice President, Operations) on 10/05/23. They acknowledged the findings.

Behavior

1) Resident 9 and 12 service plan has been updated to reflect current behavioral management plan including non-pharmaceutical interventions that are personalized to himself. Interventions have been updated to include specific instructions to community staff. Temporary plans of care will include specific behaviors related to each of the residents.

2) HWM and OPAL coordinator will ensure all services are updated in order to reflect all individualized behavioral management plans. Facility LPN will monitor temporary service plans every 72 hours for appropriate interventions.

3) This will be reviewed quarterly ending 1/31/24 as a part of the service planning process or as needed depending on changes in condition.

4) The HWM and GM are responsible to see that the corrections are completed and monitored.