Print Inspection: DTIM

The findings of the re-licensure survey, conducted 10/04/21 through 10/06/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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

A situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first re-visit to the re-licensure survey of 10/06/21, conducted 03/02/22 through 03/04/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 second re-visit to the re-licensure survey of 10/06/21, conducted 05/18/22 through 05/19/22, 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 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 develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 10/04/21 through 10/06/21, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.

Refer to the deficiencies in the report.

1. The facility will provide quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff

performance are being delivered.

2. Quality Iprovement training will be provided to the Memory Care Director. The quality improvement program will be reviewed and implemented with all staff. Weekly, monthly and quarterly audits will be completed and plan put in place to address deficiencies.

3. Weekly, Monthly and quarterly.

4. Memory Care Director

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

1. During the survey, conducted 10/04/21 through 10/06/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19, and made available to all facilities, were not being followed by the facility.

a. Facility staff were observed without face masks in place while preparing food for residents.

b. Staff were observed to enter through the back door of the memory care unit to begin their shift. They were not screened prior to entering the facility.

c. The screening process conducted at the front entrance of the building was not comprehensive or completed consistently.

2. Caregiving staff were observed on 10/04/21, 10/05/21 and 10/06/21, while serving meals, assisting residents to eat, and in the common areas.   

a. Staff donned gloves during the meal service. Staff touched doors, tables, resident clothing and wheelchairs. There was no removal of gloves or hand hygiene practiced.

b. Staff were observed with gloves on in common areas, entering and exiting resident rooms without removing gloves or practicing hand hygiene.

3. The morning medication pass was observed on 10/06/21. The Medication Aide failed to practice hand hygiene between residents.

Infection control practices were reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director) on 10/06/21. They acknowledged the need for increased oversight of infection control practices in the building.

1. Staff will properly don faceshield.  Staff will practice proper hand hygiene and store faceshields in designated area. Staff will use a comprehensive screening process when entering the facility.

2. Staff will be educated on the importance of

wearing PPE properly while in the facility;

Staff will be educated on the need to practice

hand hygiene every time they touched or

adjust their PPE; and

staff will be educated on proper storing of

disinfected reusable eye protection.

3. Daily observance of staff

4. RN, Memory Care Director.

Based on interview and record review, it was determined the facility failed to immediately notify the local SPD office, or the local AAA, of any incident of abuse or injury of unknown cause, for 2 of 2 sampled residents (#s 1 and 3) who had reportable incidents. Findings include, but are not limited to:

1. Resident 3 was admitted to the MCC in 2019 with diagnoses which included dementia.

Progress notes, incident investigations, temporary service plans and physician visit summaries reviewed between 07/01/21 and 10/04/21, revealed the following:

* Resident 3 fell on 08/15/21 and complained of pain in his/her left ankle. On 08/31/21, the resident was seen by the physician and was diagnosed with a "displaced fracture of the fifth metatarsal bone of the left foot" and a sprain of a "ligament of the left ankle."

* Progress notes, dated 09/09/21, indicated the resident had been placed on alert charting for an altercation with another resident that had occurred on 09/08/21.

There was no documented evidence the facility had conducted an immediate investigation of the incidents to include the time, date, description of the event, response of staff at the time of the event, follow up action, or administrator review. Additionally, there was no evidence the facility had ruled out abuse.

On 10/05/21, the surveyor requested the facility report the incidents to the local SPD. A fax confirmation of the report was received prior to survey exit.

The need ensure injuries of unknown cause or incidents of abuse or suspected abuse were immediately investigated, contained all required areas of documentation including administrator review, was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director) during the survey. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease. Review of the resident's 05/11/21 through 10/04/21 progress notes revealed the following:

On 08/27/21, a facility progress note showed the resident had a bruise to his/her right hip. There was no documentation as to how the injury occurred.

There was no documented evidence the facility immediately investigated the injury and documented it was not the result of abuse or neglect. The facility failed to report the injury to the local SPD office as suspected abuse/neglect.

The lack of a documented investigation and failure to report the injury to the local SPD office was discussed with Staff 2 (RN) and Staff 3 (Regional Director) on 10/05/21. They acknowledged the findings.

The surveyor directed Staff 2 and Staff 3 to report the injury of unknown cause to the local SPD office. Confirmation the report was received by the SPD office was received during the survey.

The need to ensure injuries of unknown cause were investigated promptly to rule out abuse and neglect or reported to the local SPD office as suspected abuse was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 on 10/6/21. They acknowledged the findings.  

1. For resident identified in the survey the facility completed an investigation and reported to Adult Protective Services on 10/6/2021

2. Staff will be trained on identifying and completing incident reports for injuries of unknown origin.  Incidents will be reviewed daily in daily clinical stand up meeting. The Adiministrator and facility RN will ensure resident incidents are thoroughly investigated in a timely manner and/or reported to the local

Seniors and People with Disability (SPD)

office.

3.Incidents and investigations will be reviewed daily.

4. Memory Care Director.

Based on interview and record review, it was determined the facility failed to promptly investigate incidents and document the required information to rule out abuse or neglect for 1 of 3 sampled residents (#12) who had falls and was involved in incidents with other residents. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 was admitted to the MCC in February 2022 with diagnoses including dementia.

Progress notes, incident investigations, temporary service plans and physician visit summaries reviewed between 02/17/22 and 03/04/22, revealed the following:

a. Resident 12 had an unwitnessed fall on 02/21/22 and sustained an abrasion to the spine. The abrasion was documented in progress notes on 02/22/22.

* An incident report, dated 02/28/22, indicated the investigation was "in process". There was no documented evidence the facility had conducted an immediate investigation of the incident to include the time, a full description of the event, response of staff at the time of the event, or follow up action. The administrator review indicated abuse or neglect could not be ruled out.

On 03/04/22, the surveyor requested the facility report the incident to the local SPD. A fax confirmation of the report was received prior to survey exit.

b. Resident 12 was involved in an incident on 02/19/22 when s/he was being yelled at by another resident.

* Progress notes, dated 02/19/22, documented that staff responded to the common area where yelling was heard and found Resident 12 had been sleeping on a couch and was being yelled at by another resident. There was no documented evidence the facility had conducted an immediate investigation of the incident to include the time, a full description of the event, response of staff at the time of the event, or follow up action. The record lacked evidence that abuse had been ruled out.

In an interview on 03/04/21, Staff 21 (Executive Director) stated no adverse effects were evident with either resident involved in the incident following the occurrence.

The need to ensure incidents of abuse or suspected abuse were promptly investigated and contained all required areas of documentation was discussed with Staff 1 (Administrator) and Staff 21 during the survey. They acknowledged the findings.

1. For the resident identified in the survey, the facility completed an investigation and reported to Adult Protective Services on 3/4/2022

2. Staff will be trained on identifying incidents and completing incidents.  Incidents will be reviewed daily in daily clinical stand up meeting. The Adiministrator and facility RN will ensure resident incidents are thoroughly investigated in a timely manner and/or reported to the local

Seniors and People with Disability (SPD)

office.

3.Incidents and investigations will be reviewed daily.

4. Administrator.

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

On 10/05/21 at 3:20 pm, the MCC kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:

* Tops of wall base boards;

* Walls;

* Interior of several drawers and cupboards;

* Underneath the sink;

* Interior of the refrigerator; and  

* Back and side of peninsula.

b. The following areas needed repair:

* Faucet nozzle and handle was not secured to sink;

* Base boards were scraped and gouged; and

* Several towels were observed in a cabinet underneath the sink. The towels were wet and catching water from a leak.

The areas that required cleaning and repair were observed and discussed with Staff 1 (Administrator) on 10/6/21 at 11:15 am. The findings were acknowledged.

1. The items identified in the deficiency: walls throughout the kitchen were cleaned

The faucet/ sink was repaired;

Shelves were cleaned.

2. A daily, weekly and monthly cleaning schedule will be implemented and utilized.

3. A formal weekly cleaning audit will be conducted.

4.The Dietary Service Director and the Memory Care Director.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were were accurate, used as the foundation to develop service plans, and updated each time a resident had a significant change in condition for 1 of 3 sampled residents (#1) whose evaluations were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease. The resident's 08/16/21 quarterly evaluation was reviewed and was identified as not reflective of the resident's status and needs in the following areas:

* Meal assistance;

* Emergency room visits;

* Skin issues;

* Assistive devices;

* Unexplained weight loss; and

* History of dehydration.

Resident 1 experienced the following significant changes of condition in July 2021:

* Severe weight loss; and

* A decline in ADL's.

The facility lacked documented evidence the evaluation was updated each time the resident experienced a significant change in condition.

On 10/05/21 the failure to ensure the evaluation was reflective of the resident's needs and updated after significant changes of condition was reviewed with Staff 2 (RN). She acknowledged the finding. No further information was provided.

The need to ensure quarterly evaluations were reflective of resident's current status, used as the basis for the service plan and were updated when residents experienced significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

1. For the residents identified in the deficiency a complete evaluation adressing all required elements has been completed to determine all the needs of the resident.

2. New evaluation forms have been devloped and implemented that address all areas identified in the rule.

3. At move in, 30 days and quarterly there after.

4. RCC/RN will be directly responsible and memory care director.  

2. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan dated 06/23/21, showed the care plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Transfer assistance;

* Bathing assistance;

* Incontinence and toileting needs;

* Eating assistance;

* Falls and safety interventions; and

* Outside provider services.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services, for 2 of 3 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 01/2021 with diagnoses including Alzheimer's disease.

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's 08/16/21 service plan, temporary service plans, and 05/11/21 through 10/04/21 progress notes were reviewed.

The resident's current service plan was not reflective and did not include clear instruction for staff in the following areas:

* Meals - regarding the need to assist the resident with meal intake;

* Transfers - regarding when staff should use the Hoyer lift for transfers;

* Toileting - regarding the resident's incontinence and toileting schedule;

* Outside provider services - regarding who was providing services, what services were provided, and how often services were provided; and

* Emergency evacuation - regarding clear instructions detailing how staff should assist the resident during an emergency evacuation.

The need to ensure service plans were reflective of the resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

1. For the residents identified in the deficiency, a complete audit of their service plan has occurred and service plan has been updated and are now reflective of the residents needs. Individualized detailed instruction to staff on intervention to try during periods of behavioral expression have been implemented on the service plan.

2. To assure that service plans are reflective of resident's needs, temporay service plans will be generated reflecting immediate changes an interventions and shared with staff during the daily shift meeting. Staff will initial service plan/ temporary service plan updates. Health and Wellness Director and designee will review service plan changes during a weekly meeting.

3. Daily and weekly

4. RN and Memory Care Director.

2. Resident 3 moved into the facility in 2019 and had diagnoses which included dementia.

Resident 3's clinical record, reviewed from 07/01/21 through 10/04/21, revealed s/he fell on 09/25/21 and sustained an abrasion to his/her right knee. No further documentation about the injury, including treatment and wound monitoring, was documented.  

During an interview with Staff 2 (RN) on 10/05/21, she stated she looked at the wound yesterday (10/04/21) and it had healed. She provided the surveyor with a wound update, documented in progress notes on 10/05/21.  

Failure to document the progress of short-term changes of condition at least weekly until resolution was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the facility RN as needed, determine and document interventions needed and monitored weekly through resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2021. The resident's progress notes, incident reports, 08/16/21 service plan, temporary service plans (TSP's), and incident reports were reviewed.

a. The resident experienced multiple short term changes in condition without documented monitoring of each condition at least weekly through resolution and interventions monitored for effectiveness in the following areas:

* Multiple injury falls within the community;

* Multiple non injury falls within the community; and

* Bruising to the skin, and an open wound.

b. The resident experienced the following significant changes in condition that lacked documented evidence staff evaluated the resident and made a referral to the facility RN regarding the resident's condition:

* Severe weight loss; and

* Decline in ADL's

The need to ensure short term changes in condition were monitored weekly through resolution, interventions monitored for effectiveness, and significant changes in condition evaluated and referred to the facility RN when necessary was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director) on 10/06/21.  They acknowledged the findings.

Refer to C 280, Example 2.

1. For the residents identified in the deficiency, a complete asssesment has been completed to determine any change in conditions that need monitored.  

2. Staff will be trained on the need to monitor the residents condition through resolution. To assure that change of conditions are evaluated, completed and monitored the  RN and Executive Director will review resident changes in condition at a weekly meeting.   

3. Daily and weekly

4. RN and Memory Care Director.

2. Resident 12 moved into the facility in 2022 with diagnoses including dementia and Parkinson's.

a. Resident 12's clinical record, reviewed from 02/17/22 through 03/04/22, revealed staff found bruising to his/her buttock area on 02/19/22. The record lacked any additional documentation of the bruising until 03/02/22 during the survey.

An interview with Staff 22 (RN) on 03/04/22 confirmed there had not been weekly documented monitoring of the bruises.

b. Resident 12 sustained an abrasion to the spine following a fall on 02/21/22. The record lacked documentation that the abrasion was monitored at least weekly, until resolved.

c. Resident 12 sustained a bump to the back of his/her head with redness following a fall on 02/22/22. The record lacked documentation that the bump and redness was monitored, at least weekly, until resolved.

d. Between 02/18/22 and 02/26/22, Resident 12 experienced five falls. Review of the resident's service plan, temporary service plans and incident reports revealed fall interventions had not been identified and monitored for effectiveness.

Failure to document the status of skin injuries at least weekly until resolution and the effectiveness of fall interventions was discussed with Staff 1 (Administrator), Staff 21 (Executive Director) and Staff 22 (RN) on 03/03/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident, communicate the interventions to staff, ensure interventions were resident-specific and monitor interventions for effectiveness, for 2 of 3 sampled residents (#s 3 and 12) who experienced changes of condition requiring monitoring. This is a repeat citation. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 8/2019 with diagnoses including dementia.

A review of the resident's clinical records, 02/04/22 through 03/02/22, indicated the following changes of condition:

* 02/07/22 Resident had swelling in the knee and went to the local hospital;

* 02/14/22 Resident had a follow up appointment with primary physician; and

* Physician ordered daily monitoring of resident's knee for "worsening of infection, increasing pain, redness, warmth or swelling".

There was no documented evidence the facility had provided written instructions to staff and/or monitored the above documented changes of condition to resolution.  

The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and monitored until resolution was updated was discussed with Staff 1 (Administrator) and Staff 21 (Executive Director) on 03/04/22. They acknowledged the findings.

1. For the two residents identified in the deficiency, a asssesment has been completed with specific actions, interventions and monitoring included. The implementation of the interventions and monitoring will be communicated to staff.  

2. Staff will be trained on the need to monitor the residents condition through resolution. To assure that change of conditions are evaluated, completed and monitored the  RN and Administrator will review resident changes at a weekly meeting.   

3. Daily and weekly

4. RN and Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes in condition. Residents 1 and 2 experienced ongoing severe weight loss. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia.

On all days of the survey, Resident 2 was assisted to eat meals and was provided a dietary supplement between meals.

It was documented Resident 2 weighed 107.4 lbs in 05/2021 and 06/2021.

In 07/2021 Resident 2 was noted to weigh 101.4 lbs, a 6 lb, or 5.6%, body weight loss in one month. This constituted a severe weight loss.

In 08/2021 Resident 2 was noted to weigh 95 lbs, an additional 6.4 lb, or 6.3 %, severe weight loss in one month.

Resident 2 had no documented weight for 09/2021.

Between 05/2021 and 08/2021, Resident 2 lost 12.4 lbs, 11.5% of his/her body weight in three months.  

A current weight for Resident 2 was requested during the survey. Resident 2's weight on 10/05/21 was noted to be 95.5 lbs.   

There was no documented RN assessment of Resident 2's ongoing severe weight loss.

The need for facility RN assessments of significant changes in condition was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease. The resident's 2021 weight records, 05/11/21 through 10/04/21 progress notes, incident reports, 08/16/21 service plan, and temporary service plans (TSP's) were reviewed.

a. Resident 1's April 2021 weight was recorded as 219.2 pounds. His/her July 2021 weight was recorded as 183 pounds, a loss of 36.2 pounds, or 16.51% of his/her body weight in three months. This represented a severe loss and was a significant change of condition which required an RN assessment. There was no evidence a facility RN assessment had been completed.

The resident's August 2021 weight was recorded as 161.1 pounds, a additional loss of 21.9 pounds or 12.79% of his/her total body weight in one month, which constituted a severe loss. There was no RN assessment documented.

The surveyor made a request for staff to obtain Resident 1's weight during the survey. Staff reported the resident's weight as 179.8 on 10/6/21.  

The lack of an RN assessment for Resident 1's severe weight loss was discussed with Staff 2 (RN) on 10/06/21. No further information was provided.

b. In 07/2021, Resident 1 experienced a significant change of condition related to a decline in ADL's in the following areas:

* Mobility;

* Transfers; and

* Eating.

The facility lacked documented evidence the RN assessed Resident 1 for the significant changes in condition.

The lack of an RN assessment for Resident 1's decline in ADL's was discussed with Staff 2 on 10/05/21. No further information was provided.

The requirement for the facility to ensure an RN assessed residents experiencing significant changes of condition, documented findings, resident status, interventions made as a result of the assessment, and communicated the actions or interventions to staff was discussed with Staff 1(Memory Care Director), Staff 2 and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.   

1.The RN completed a change of condition for the residents identified in the deficiency.  Interventions were implented 10/5/2021.  Education on interventions were completed with the driect care staff.

2.Care staff wil be trained to identify and communicate changes in care. A daily review of changes wil be completed in clinical stand up meeting. Any significant change will be assessed by the facility RN.

3.Changes will be reviewed daily in clinical stand up and monthly.

4.Facility RN and Memory Care Director.

2. On 02/28/22, Resident 12 experienced a significant change of condition related to overall decline in the following areas:

* Mobility;

* Behaviors; and

* Ability to eat independently and meal intake.

The resident was admitted to Hospice services on 02/28/22.

The facility RN documented a progress note and completed an "evaluation" form on 02/28/22. The assessment lacked the required information including findings, the overall status of the resident, and interventions identified as a result of the assessment.

The requirement for the facility to ensure an RN assessment of residents with significant changes including documented findings, resident status, interventions made as a result of the assessment, and communicated the actions or interventions to staff was discussed with Staff 1 (Administrator) and Staff 21 (Executive Director) on 03/04/22. They acknowledged the findings.   

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed in accordance with residents' condition for significant changes of condition for 2 of 2 sampled residents reviewed (#s 3 and 12). This is a repeat citation. Findings include, but are not limited to:

1. Resident 3 was admitted in 2019 with diagnoses which included dementia.

During the entrance conference on 3/10/21, Staff 1 (Administrator) stated the resident had a recent significant decline in health and returned from the emergency department on 02/07/22.

The decline in health constituted a significant change in condition for which an assessment by the facility RN was required.

The facility RN's assessment on 02/08/22, lacked information on findings, overall status of the resident and interventions as a result of the assessment.

The need to ensure the facility RN assessments included resident findings, overall status of resident and interventions was discussed with Staff 1 and Staff 21 (Executive Director) on 03/04/22 at 10:50 am. They acknowledged the findings.

1. For the two residents identified in the deficiency, the RN completed a change of condition for the residents that included: documented findings, resident status, interventions made as a result of the assessment, and communicated these actions or interventions to staff.  Education on interventions were completed with the direct care staff.

2. A daily review of changes wil be completed in clinical stand up meeting. Any significant change will be assessed by the facility RN. Administrator and RCC will review assessment to verify all required componets are refelected in the assessment.

3.Changes will be reviewed daily in clinical stand up and monthly.

4.Facility RN and Administrator.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 1 sampled resident (#1), who received home health services. Findings include, but are not limited to:

Resident 1 was re-admitted to the Memory Care Community on 07/12/21 following a hospital stay and treatment for a urinary tract infection (UTI) and decline in ADL's.

The resident's 05/11/21 through 10/04/21 progress notes, 07/12/21 hospital discharge records, and home health records were reviewed. The records indicated Resident 1 received home health PT services from an outside provider to monitor the resident's UTI and ADL decline and later, home health RN services to monitor and manage a wound to the resident's right second toe.

a. Review of the "Collaboration of Care" forms indicated home health providers left the following instructions for the facility:

* 07/14/21 - "Change [his/her] pants regularly, if incontinent"; and

* "Clean [his/her perineal area] to prevent another UTI. Keep clean and dry to keep skin from breaking down."

There was no documented evidence the facility updated the resident's service plan with these instructions or communicated the new instructions to staff.

The failure to update the service plan and communicate instructions to staff was discussed with Staff 1 (Administrator) on 10/06/21. She confirmed the findings.

b. The record indicated Resident 1 received an order for home health RN services to treat and monitor a wound to the resident's right second toe on 09/9/21.

There was no documented evidence facility management, or a licensed nurse was notified of the services provided by the outside provider, staff informed of new interventions, necessary service plans adjustments were made, or reporting protocols put in place.

The failure to review Resident 1's on-site health services, inform staff of new interventions, update the service plan, and implement reporting protocols was discussed with Staff 1 on 10/6/21. She confirmed the findings.

The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1, Staff 2 (RN) and Staff 3 (Regional Director) on 10/6/21. They acknowledged the findings.

1. The residents service plan identified in the deficiency were updated to reflect the coordination of service by home health including Home Healths suggestions.

2. The outside provider notes will be reviewed daily in clinical stand up and signed off weekly when implemented.

3. Daily, Weekly and monthly.

4. Resident Care Coordinator and RN and memory care director.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 2 sampled residents (#12), who received outside services. This is a repeat citation. Findings include, but are not limited to:

Resident 12 was admitted to the Memory Care Community in 02/2022.

The resident's clinical records were reviewed. The records indicated Resident 12 went to the emergency department on 02/25/22 and was receiving Hospice services since 02/28/22.

a. The "after visit summary", dated 02/25/22 obtained by the facility instructed staff to "hold magnesium until restarted by provider". Staff 23 (RN) wrote "noted 3/3/22" on the report. A review of the MAR showed the magnesium was administered on 02/25 though 02/28/22. On 03/04/22, Staff 2 (Regional RN) verified the recommendation to "hold" the magnesium should have been clarified and an order received from the prescriber.

b. On 03/02/22, a request was made for provider notes from Hospice services for Resident 12. Staff 25 (RCC) stated she would request Hospice fax the notes and that the Hospice service provider had not left notes with the facility upon recent visits on 02/28 and 03/02/22.

During an interview with Staff 21 (Executive Director) and Staff 25, staff reported the facility was working on a process to ensure outside providers would leave notes when they visited the facility, including any recommendations for staff to follow.

The need to ensure the facility had a process to obtain information from outside providers and ensure recommendation were followed was discussed with Staff 1 (Administrator), Staff 21 and Staff 25 on 03/04/22. They acknowledged the findings.

1. The resident identified in the deficiency, medication orders were verified and implemented.  The notes from the visits on 2/28 and 3/2 were reviewed and recommendations follwed.  The notes were added to the residents record.

2. A system for outside provider notes was implemented. The outside provider notes will be reviewed daily in clinical stand up and signed off weekly when implemented.

3. Daily, Weekly and monthly.

4. Resident Care Coordinator and RN and Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system, failed to have medication and treatment systems that were approved by a pharmacist consultant, registered nurse or a physician, and failed to ensure adequate professional oversight of the medication and treatment administration system. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:

1. During the survey, MARs for Residents 1, 2 and 3 were reviewed from 09/01/21 - 10/04/21. Initials for Staff 5 (MA) were present for numerous medications and administration times, including insulin administration.

In an interview with Staff 2 (RN) on 10/05/21 at 3:30 pm, she stated Staff 5 was not delegated to give insulin and was unsure why her initials were on the MAR.

Staff 9 (MA) was interviewed on 10/05/21 at 3:45 pm. She explained that her electronic MAR account and password "stopped working" several days ago so she logged into the system using Staff 5's password and gave medications and insulin using Staff 5's initials. She added that Staff 5's electronic MAR password was posted in the medication room in case passwords for other staff did not work. Staff 9 said she informed Staff 1 (Administrator) and the support system for the electronic MAR program of the issue.

The above information was shared with Staff 2 and Staff 3 (Regional Director) on 10/05/21 at 4:00 pm. They were unaware staff were not using their own passwords or initials when administering medications. Both stated they would investigate, contact the Electronic MAR Company to get the issue corrected, and provide additional education to the MAs regarding accurate MAR documentation.

On 10/06/21, Staff 3 informed the survey team that new pass codes had been assigned to medication staff and the issue had been resolved.

2. On 10/06/21 at 7:30 am, the survey team was informed the scheduled MA had called off work, Staff 5 (MA) would be staying from the overnight shift and covering as the MA.

On 10/06/21 between 8:10 am and 9:40 am, the RN surveyor observed Staff 5 administer medications. During the pass, the following was observed:

* Staff 5 gave pills to Resident 6 in the dining room. The pills had already been punched and the surveyor joined the medication pass in process. During the pass, Staff 5 dropped two pills onto the floor. She picked them up and returned to the cart.

Staff 5 proceeded to prepare pills for another resident. The surveyor intervened and asked why replacement pills would not be given. Staff 5 replied "I don't know, I guess I should" and proceeded to re-punch the dropped pills.

As the observation continued, the surveyor learned the following:

Resident 6 had an order for donepezil (medication for Alzheimer's) 10 mg two tablets at bedtime. In error, Staff 5 gave the resident one of the two tablets in the dining room at breakfast. She proceeded to give the second tablet when the surveyor intervened and asked Staff 5 to recheck the medication, administration time and MAR. Staff 5 acknowledged she gave the donepezil at breakfast when it should have been given at bedtime.

* Resident 7 had an order for Glipizide (diabetic medication) 5 mg 1.5 tablets before breakfast. As Staff 5 prepared the medication, she punched 1 tablet versus 1.5 as ordered. The surveyor brought the error to her attention and asked that the correct dose be administered. Additionally, the medication was administered after the resident had finished breakfast versus before as ordered.

* Resident 8 had an order for metoprolol (medication for hypertension 50 mg 1.5 tablets twice a day. As Staff 5 prepared the medication, she punched 1 tablet versus 1.5 as ordered. Before administering the medication, the surveyor asked Staff 5 to check the order with the medication dose. Staff 5 acknowledged the error, and the correct dose of metoprolol was administered.

* Resident 9 had an order for Synthroid (medication for hypothyroidism) 150 mcg one tablet daily before breakfast. Staff administered Resident 9 his/her Synthroid after s/he had eaten breakfast.

* Resident 10 had an order for Senexon-S 8.6-50 mg one tablet twice daily for constipation. As Staff 5 prepared Resident 10's medication, she stated she could not find the Senexon so could not give it. The surveyor asked her to double check the medication cards. Staff 5 rechecked the cards and found the medication.

* Two times during the medication pass observation, Staff 5 left medication cards and pill bottles on top of the cart and proceeded to leave. The surveyor intervened and asked her to secure the medications.

* During the medication pass, Staff 5 dropped a pill into a drawer that contained numerous medication cards. As Staff 5 pulled out the cards to retrieve the dropped pill, several random loose pills were discovered at the bottom of the drawer. Staff 5 stated she did not pass medications on this shift or in the MCC unit and was therefore unsure why there would be loose medications in the drawer.

During the pass, the surveyor asked Staff 5 about her medication training and experience. Staff 5 stated:

* She normally worked night shift on the ALF side;

* She had only passed medications on day shift "one other time";

* She had worked the night shift in the ALF "last night" and had to stay and pass medications in the MCC to cover a shift; and

* She had not passed medications in the MCC and was unfamiliar with the process. "I don't give medications on this side."

Between 8:10 am and 9:30 am, the RN surveyor observed Staff 5. During that time frame, Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director), and Staff 20 (ALF Executive Director) were informed that Staff 5 had made multiple medication errors, was unfamiliar with the medication administration system in the MCC, and needed to either be supervised for duration of pass or pulled from the task. At 9:40 am, no assistance or oversight had been provided to Staff 5. The RN surveyor immediately informed Staff 2 and Staff 3 that Staff 5 was unsafe giving medications independently and oversight was necessary. At that time, Staff 2 assisted Staff 5 with the remainder of the medication pass.

On 10/06/21 at 10:00 am, the survey team stopped survey activities and discussed the unsafe medication administration system and lack of oversight.

After a telephone consultation with the Community Based Care Supervisor, the survey team informed Staff 2 and Staff 3 on 10/06/21 at 10:30 am that the facility's failure to have safe medication administration system in place and lack of adequate professional oversight constituted a situation that required an immediate plan of correction.  

Staff 3 presented a plan of correction on 10/06/21 at 6:00 pm. The plan indicated corrections in the following areas:

* "Oversight and monitoring of staff administering medication";

* "Medication administration records not being accurate and not following physician orders for medication"; and

* "Facility Administration."

The survey team directed Staff 3 to contact her assigned Policy Analyst and Corrective Action Coordinator. The plan was accepted by the survey team and the immediate jeopardy was abated at 6:00 pm.

3. During an interview on 10/06/21 at 10:30 am, Staff 2 (RN) and Staff 3 (Regional Director) were asked to provide documentation that their medication system was approved by pharmacist consultant, registered nurse, or physician. Neither was aware of an approval.

In an interview at 6:00 pm the same day, Staff 3 verified the facility did not have medication and treatment systems in place that were approved by a consultant pharmacist, registered nurse or physician.

4. Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:

C 303: Systems: Medication and Treatment Orders;

C 304: Systems: Medication and Treatment Review; and

C 310: Systems: Medication Administration.

The requirement to ensure a safe medication system and adequate professional oversight of the medication administration system was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

1.  A plan of correction was submitted on 10/6 to address the: Oversight and monitoring of staff

administering medication";

* "Medication administration records not

being accurate and not following

physician orders for medication"; and

*"Facility Administration."

2.The medication system was approved by a registered nurse.  A pharmacy review of the medication administraion will be conducted every 90 days.Weekly audits of the MARS will be conducted.  All medication techs will be proven competent by an RN.

3.Weekly, monthly and quarterly.

4.Facility RN and Memory Care Director

Based on observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3), and 5 unsampled residents (#s 6, 7, 8, 9 and 10) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia and depression.

Resident 2's 09/2021 and 10/01-04/21 MARs and current physician's orders were reviewed.

There was no documented evidence Resident 2 was administered his/her am medications on 09/17/21 including:

* Aspirin 81 mg for chronic pain at 7:00 am;

* Ensure Nutritional supplement for weight loss at 8:30 am and 11:30 am;

* Levothyroxine Sodium 100 mcg for high blood pressure at 7:00 am; and

* Sertraline 25 mg for depression at 7:00 am.

The need to ensure medications were administered as ordered was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director). They acknowledged the findings.

2. Resident 3 moved into the facility in 2019. As of the survey, s/he had diagnoses which included dementia and insulin dependent diabetes.

MARs for Resident 3, reviewed from 09/01/21 - 10/04/21, and observation of the morning medication administration pass on 10/06/21 revealed the following orders were not followed:

* Lantus insulin 10 units once a day at 7:00 am.

- Resident 3 did not receive the insulin from 09/03/21 to 09/07/21 (five days).

- On 10/06/21, Resident 3 ate breakfast at 8:00 am. However, staff did not administer the insulin until after 9:00 am.

* Resident 3 had an order for Metformin 500 mg 1 tablet twice a day with meals for diabetes. According to the MAR, staff gave the second dose at 8:00 pm, not with a meal as ordered.

In interviews on 10/05/21 and 10/06/21, the surveyor and Staff 2 (RN) reviewed the MARs and orders. She acknowledged the insulin and Metformin had not been administered as ordered. She stated she would notify the PCP of the errors and change the administration time for the Metformin.

The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director) on 10/06/21 at 4:15 pm. They acknowledged the findings.

3. On 10/06/21 between 8:10 am and 9:40 am, the RN surveyor observed Staff 5 (MA) administer medications to unsampled residents #s 6, 7, 8, 9, and 10 . During the pass, Staff 5 failed to administer medications as ordered.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director) on 10/6/21. They acknowledged the findings.

Refer to C 300, Example 2.

1. For the residents identified in the deficiency, a complete audit of their physician orders and MAR's has been conducted and the MAR's are reflective of all orders. Staff have been educated to check and initial all orders from doctors to compare with the MAR.

2. RN or designee will audit all physician orders and initial and date that they have been added to the MAR's.

3. Weekly

4. RCC / RN will be directly responsible to assure systems are working and overseen by Memory care director.  

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (# 12), whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 12 was admitted to the facility in 02/2022 with diagnoses including dementia and Parkinson's.

Resident 12's 02/17/2022 though 03/04/22 MARs and current physician's orders were reviewed.

The following physician ordered medications were missing from the MAR:

* Rivastigmine 1.5 mg, 1 capsule two times daily; and

* Simvastatin 10 mg, 1 tablet by mouth daily .

During an interview on 03/03/22 with Staff 25 (RCC), the orders were reviewed and facility staff were unable to locate any orders to discontinue the medications, but were unable to determine why the current MAR was missing these medications. Staff 25 stated she would follow up with the physician to determine whether the medications should be re-started.

The need to ensure medications were administered as ordered was reviewed with Staff 1 (Administrator), Staff 21 (Executive Director), and Staff 25. They acknowledged the findings.

1. For the residents identified in the deficiency, a complete audit of their physician orders and MAR's has been conducted and the MAR's are reflective of all current orders. Staff have been educated to verify new physician orders and compare to the MAR.  Staff to initial once comparison is accurate and complete.

2. RN or designee will audit all physician orders and initial and date that they have been added to the MAR's accurately.

3. Weekly

4. RCC / RN will be directly responsible to assure systems are working and overseen by Adminstrator.  

Based on interview and record review, it was determined the facility failed to ensure medication and treatment recommendations made by the registered pharmacist were reviewed or implemented. Findings include, but are not limited to:

On 10/06/21, the facility provided copies of pharmacist medication reviews completed on 06/10/21 for numerous residents. The pharmacist requested further clarifications and/or made recommendations.

As of the survey, there was no documented evidence the facility had reviewed and/or notified the residents' prescriber of the pharmacist recommendations.

The failure to follow up on pharmacy recommendations was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director) on 10/06/21. During the interview they stated the facility failed to submit the recommendations to the prescriber for clarification and/or implementation. No further information was provided.

1.  The facility pharmacist reviewed all medications and treatments and made recommendations.  All recommendations were reviewed and followed up on by facility nurse.

2.The facility pharmacist will be scheduled quarterly to review all medications and treatments.  The community will add this quarterly review to their quality  assusrance audit.

3. Quarterly

4.RCC/ Facility RN and overseen by Memory care director.  

2. Resident 3 moved into the facility in 2019 and diagnoses which included diabetes and esophageal reflux.

Resident 3's MARs, reviewed from 09/01/21 - 10/04/21, revealed the following inaccuracies:

a. Resident 3 had an order for staff to check CBGs (blood sugars) "two times per day every week on Monday, Wednesday, and Friday."

According to a physician's order, dated 12/16/20, staff were instructed to "notify PCP for CBGs less than 70 or greater than 400."

The MARs lacked information about the CBG parameters.

b. The MARs instructed staff to administer Mintox Regular Strength Oral Suspension 30 ml PRN for esophageal reflux. The MARs lacked a frequency for how often the Mintox could be administered each day.

c. Between 09/01/21 and 10/04/21, staff initialed on the MARs the resident received Vitamin D3 (supplement) 50 mcg (2000 units) each day. However, there was no order for the medication in the resident's record.

During an interview on 10/06/21 at 1:20 pm, Staff 1 (Administrator) and Staff 6 (MA) compared the MAR, PCP orders and medication cards. They stated the resident was not receiving the medication and staff were initialing for a medication that was not being administered.

d. Resident 3 had an order for CBGs (blood sugars) twice a day every week on Monday, Wednesday, and Friday, and Lantus insulin 10 units daily.

According the to MARs, staff were administering the insulin at 7:00 am, but not checking the morning CBG until 8:00 am, one hour after the insulin had been given.

Staff 9 (MA) was interviewed on 10/05/21 at 3:45 pm. During the interview she stated the CBGs were checked before the insulin was given, not after as noted on the MAR. She acknowledged the MAR was inaccurate.

The need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed in interviews on 10/05/21 and 10/06/21 with Staff 1, Staff 2 (RN) and Staff 3 (Regional Director). Staff 2 stated she would review the MAR and make corrections to ensure it was accurate and provided clear instruction to staff.

3. During the survey, MARs for Residents 1, 2 and 3, reviewed from 09/01/21 - 10/04/21, revealed MAs were not consistently using their own initials when administering medications.

Refer to C 300, Example 1.  

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

1. Resident 1 was admitted to the facility in 01/2021 with diagnoses including hypertension and Alzheimer's disease.

Review of Resident 1's 09/01/21 through 10/04/21 MAR's and physician orders revealed the following:

* An order for daily blood pressure monitoring lacked parameters and instructions for staff as to when they should contact the provider or licensed nurse for readings outside of parameters; and

* An order for Olanzapine 2.5 mg (to treat dementia with behavioral disturbances and hallucinations) one tablet by mouth or two tablets by mouth two times daily, lacked clear parameters as to when staff should administer one tablet versus two tablets.

The lack of medication specific instructions and directions regarding when staff should contact the provider or nurse was discussed with Staff 2 (RN) on 10/06/21.  She acknowledged the findings.

The need to ensure Resident 1's MAR's were accurate and included clear parameters and direction to staff for medication and treatment administration was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

1. For residents identified in the deficiency the RN  updated the MAR to reflect parameters for PRN's. Staff were educated on documentation of medication administration and documenting effectiveness of PRN medications.

2. The RN or designee will complete a weekly audit on the MAR's.The medication aid on each shift will review the MARS with the oncoming Med Aid before the end of their shift.

3. Weekly

4. RCC / RN will be directly responsible to assure systems are effective. Overseen by director

Based on interview and record review, it was determined the facility failed to ensure MARs included all medications and treatments ordered by the provider, resident-specific parameters for PRN medications and initials of the person administering the medications for 2 of 3 sampled residents (#s 7 and 12) whose medication records were reviewed. This is a repeat citation. Findings include, but are not limited to:  

1. Resident 7 was admitted to the facility in 2015 with diagnoses including constipation.

The resident's 02/2022 and 03/01 through 03/02/22 MARs and physicians orders dated 12/29/21 were reviewed and revealed the following:

* There were  blanks on 02/11/22 and 02/12/22 for the pm doses of Ciproloxacin eye drops with no explanation of what happened; and

* There were blanks on 18 occasions between 02/04/22 and 02/28/22 for bowel tracking with no explanation of what happened.  

The need to ensure MARS were accurate and included the initials of the person administering the medication or tracking the required information was discussed with Staff 1 (Administrator) and Staff 3 (Regional RN) on 03/04/22. They acknowledged the findings.

2. Resident 12 moved into the facility in 02/2022 with diagnoses including dementia.

Resident 12's MARs, reviewed from 02/17/22 - 03/04/22, revealed the following inaccuracies:

* A physician's order on 02/23/22 for Hydroxizine, 25 mg every 6 hours, included instructions to administer it, as needed, for anxiety and at hs (hour of sleep) to assist with sleep. The February and March MARs instructed staff to offer the medication if the resident was "itching" or having a hard time falling asleep.

During an interview on 03/04/22, Staff 2 (Regional RN) acknowledged the parameters and reason for use were not transcribed accurately.

The need for the facility to ensure MARs were accurate was discussed with Staff 1 (Administrator), Staff 2 and Staff 21 (Executive Director) on 03/04/22. They acknowledged the findings.

1. For the two residents identified in the deficiency, staff were educated on documentation of medication administration, treatments and tracking.

2. The RN or designee will complete a weekly audit of the MAR's.The medication aid on each shift will review the MARS with the oncoming Med Aid prior to the end of their shift.

3. Weekly

4. RCC / RN will be directly responsible to assure systems are effective and accurate.

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

During the acuity interview on 10/04/21, the facility was home to 25 residents. Six residents were identified to require the assistance of two staff for transfer assistance. Three residents were observed to require assistance with eating during the survey.  

In addition to caregiving and medication duties, staff were observed to serve all meals.

Review of the schedule and time cards for 09/01/21 through 10/05/21 revealed the facility had two staff scheduled for the swing shift, one MA and one caregiver, and one staff scheduled for the overnight shift, on multiple occasions. MT's were reported to not generally help with caregiving due to being busy with medication pass duties.

The failure to adjust staffing levels, based on caregiving staff duties including meal service, and meeting the needs of multiple residents requiring the assistance of two staff, was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director). They acknowledged the findings and reported the facility was attempting to hire more staff.

1. The community will adequately staff to meet the scheduled and unscheduled needs of the residents.

2.Staff will continued to be recruited and hired. The community will continue to search for agency that will work in the the Baker City area.

Universal employees will be recruited to provide non caregiving task.

3. Daily

4. Memory Care Director

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 16 and 18) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/06/21 and revealed Staff 16 (MA) and Staff 18 (MA), hired on 08/02/21 and 08/16/21 respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training.

The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

1. For the staff identified in the deficiency, First Aid  and abdominal thrust training was completed.

2. All staff will have documented evidence of completion of First Aid certification and training in  abdominal thrust within 30 days of hire. A record of all trainings will be kept and reviewed daily, weekly and monthly for compliance.  All staff found not in complaince will be removed form the schedule.

3.Daily, weekly and monthly.

4.Business Office Manager and Memory Care Director.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month at different times of the day, evening and night shifts, and failed to include required components on fire drill records. Findings include, but are not limited to:

Fire and life safety records, reviewed between 04/2021 - 09/2021, revealed the following:

* Fire drills were not consistently conducted every other month at different times of the day, evening and night shifts; and

* Fire drill records lacked the following components:

- Location of simulated fire;

- Escape route used;

- Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

- Evacuation time-period needed; and

- Number of occupants evacuated.

In an interview on 10/06/21 at 3:00 pm, Staff 1 (Administrator) acknowledged the facility failed to consistently conduct fire drills on alternating months at different times of the day, evening and night shifts, and fire drill records lacked the required components.

1. Fire drills will be conducted every other month for both Assisted Living and Memory Care communities. Training for staff will be conducted on alternate months for both Assisted Living and Memory Care communities.  Records on fire drills and training will be kept for both Assisted Living and Memory Care communities.

2. Drills will be added to Tels system of tasks and documentation uploaded to the system.

3. Monthly

4. Director of Plant Operations / ED and Memory Care Director

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

Fire and life safety records were requested during the survey. The following deficiencies were identified:

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

* Documentation that annual fire and life safety training was provided to residents, including all required training topics; and

* Alternate exit routes were used during fire drills.

Additionally, staff interviewed during the survey were not aware of the designated point of safety.

The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, alternate exit routes were used during fire drills, and all staff were aware of the designated point of safety was discussed with Staff 1 (Administrator) on 10/06/21 at 3:00 pm. She acknowledged the findings. No further information was provided.

1. A fire life saftety traing has been conducted with all residents.  A fire life safety training has been completed with all staff.

2. Upon move in and annually all resident will be trained on fire life safety.  Upon hire and ongoing all staff will be trained on fire life safety.

3.Monthly and quarterly.

4.The facility Maintenance Director and Administrator.

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

Refer to C231, C270, C280, C290, C303, C310, Z142 and Z162.

1.  A plan of correction was developed and implemented for the identified deficiencies.

2.  The plan will be reviewed with the on site managers and the correction implemented. The plan will be reviewed in daily clinical stand up and weekly in a survey compliance meeting.

3.  Daily, weekly and monthly.

4. The community RN and Administrator.

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

Observations of the facility on 10/04/20 through 10/06/20 revealed the following areas were in need of cleaning and/or repair:

* Multiple handrails, walls, window frames, doors and door frames throughout the facility were dinged, chipped, gouged, scrapped and had spills and splatters.

* The common bathroom in the back of the facility was observed with damage to the wall and fecal matter on the base of the toilet and the floor on 10/04/21 and 10/05/21;

* The front common bathroom lacked a doorknob, this was repaired on 10/06/21;

* The carpet throughout the facility was damaged, stained, and warping in areas;

* Square tables in the dining room were damaged with bare areas, chips and dings out of the table surfaces;

* Multiple chairs in the dining room and living room had scraped legs, arms and/or spills and food debris;

* There was a pervasive unpleasant odor throughout the unit and in Room 116 on all days of the survey; and

* Multiple resident room garbage cans were observed filled with soiled incontinent products.

The need to ensure the environment was kept clean and in good repair, and free from unpleasant odors was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director). They acknowledged the findings and reported the facility was scheduled for a remodel.

1.The furniture, bathroom, walls, windows and bathrooms have been cleaned.  The bathroom doorknob was repaired.The carpets were cleaned.

2.The furniture, bathroom, walls window door frames will be repaired. A cleaning checklist will be implemented and staff will be trained on the cleaning checklist.  Daily shift round will be completed.

3.Daily, Weekly and monthly

4. Maintenance Director, Housekeeping, Memory Care Director.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

During a walk-through of the facility on 10/04/21 at 1:45 pm, multiple exit doors were found to have no working audible alarm or system in place to alert staff when a resident exited the building.

The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited was discussed with Staff 1 (Administrator) on 10/04/21. She acknowledged the findings.

1. Alarms were placed on all exit doors.

2.The Maintenance Director will check doors monthly during fire life safety check.  Doors will be checked during quarterly audit.

3. Monthly and quarterly.

4. Maintenance Director and Memory Care Director

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:

The licensee is responsible for the operation of the Memory Care Community and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision, training, and overall conduct of the staff.

During the re-licensure survey, conducted 10/04/21 through 10/06/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the citations issued during the survey.

1. A situation was identified which constituted an immediate plan of correction to residents' health and safety in the following areas:

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments.

The facility put immediate plans of correction in place during the survey and the situation was abated.   

2. Refer to deficiencies in the report.

1.  The facility will provide administrative oversight to ensure adequate resident care and services. For the situation identified which constituted an immediate plan of correction, a plan was submitted by the facility. This plan was approved.

2.The facility will train the Memory Care Director on administrative oversight and the delivery of resident care and services.

3.Daily, weekly and monthly oversight

4.Regional Support team and memory care director.

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 C160, C 231, C 240, C 360, C 372, C 420, C 422, C 513, and C 555.

1. See C160, C 231, C 240, C 360, C372, C 420,

C 422, C 513, and C 555.

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 C231 and C455.

1. See C 231.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 16, and 18) completed all required pre-service dementia training and 30-day competency demonstration. Findings include, but are not limited to:

A review of staff training records revealed:

1. Staff 8 (CG) and Staff 18 (MA), were hired 08/02/21 and 08/16/21. Staff 8 and 18 completed the required six hours of department approved pre-service dementia training on 08/10/21 and 09/14/21, not prior to providing care or services to residents.

There was no documented evidence they had completed the following elements of the required dementia training prior to performing any job duties:

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

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

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

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

2. There was no documented evidence that Staff 16 (MA), hired 08/20/21, signed a written job description and completed the required pre-service dementia training.

3. There was no documented evidence Staff 8, Staff 16, and Staff 18, demonstrated competency in their job duties within 30 days of hire in the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

The facility's failure to ensure staff completed all required training in a timely manner was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director) on 10/06/21. They acknowledged the findings.

1. For the staff identified in the deficiency all job descriptions were reviewed and signed.For the staff identified in the deficiencyall competencies were reviewed and completed.

2.  All staff will take thethe required six hours of

department approved pre-service

dementia training prior to providing resident care.  All staff will be provided a job description upon hire. All staff will demonstrate competency in their job

duties within 30 days of hire. Documentation of all pre service training, job descriptions and compentencies will be kept in the staff personnel record.

3.Weekly audit, monthly audit and quartly audit.

4. Business Office Manager, Memory Care Director.

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. An unsafe medication system requiring immediate correction was identified during the survey. Findings include, but are not limited to:

Refer to C 252, C 260, C270, C 280, C 290, C 300, C 303, C 304, and C 310.

1. See C 252, C 260, C270, C 280,

C290, C 300, C 303, C 304, and C 310.

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

Refer to C270, C280, C290, C303 and C310.

1. See C 270, C 280,

C 290, C 303,and C 310.