Print Inspection: FC2Y

The findings of the re-licensure survey, conducted 03/04/24 through 03/07/24, 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, 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. Tag numbers beginning with the letter H refer to the Home & Community-Based Services 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 first re-visit to the re-licensure survey of 03/07/24, conducted 07/08/24 through 07/11/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:  activities of daily living

bid: twice a day

CBG: capillary blood glucose or blood sugar

CG: caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH: Home Health

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR: Medication Administration Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:Resident Care Coordinator

RN:Registered Nurse

TAR:Treatment Administration Record

tid:three times a day

The findings of the second re-visit to the relicensure survey of 03/07/24, conducted 10/29/24 through 10/30/24, are documented in this report. The survey was conducted to determine compliance with 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.

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 third re-visit to the re-licensure survey of 03/07/24, conducted 12/19/24, 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, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Refer to deficiencies in the report.

C-150 Facility Administration: Operation

o Refer to other deficiencies in the report. 160 Reasonable Precautions

1.The diet order for resident 3 was communicated to staff via TSP and the correct diet order was confirmed with the kitchen.

2.Orders are being reviewed daily by nursing to ensure timely processing of orders. A full list of diet orders will be reviewed monthly in the QI meeting.

3.Orders will be reviewed daily in the clinical meeting, and orders processed in the third check system.  

4.Administrator and Nurse.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (# 3) who had a delay in implementation of physician-ordered diet texture. Findings include, but are not limited to:

Resident 3's clinical records were reviewed, staff were interviewed, and observations of the resident were made during the period of the survey, 03/04/24 through 03/07/24.

An order was received from the hospice provider on 02/19/24 to begin pureed diet texture effective 02/19/24 for Resident 3. A temporary service plan was provided to staff on 02/25/24 informing of the change in diet status, six days following the effective date of the diet texture change. During an interview on 03/07/24 at 10:10 am, Staff 9 confirmed she received the order "around" 02/25/24. Staff 9 was unsure why there was a delay of six days to receive and implement the updated diet status.

Observations of the resident made during meal service throughout the period of the survey, 03/04/24 through 03/07/24, confirmed the correct diet texture was being provided to Resident 3.

The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents by implementing physician orders when received was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

C160 - Reasonable Precautions

1.Training for all staff on reasonable pre cautions focused on glove use, cross contaminiation and food service.

2.In service with staff prior to working with the floor  for Immediate assigned neighborhoods for CarePartners with sign off on task list - to be submitted to  Resident Care Coordinator with review with ED and Nurse. MOD through weekend - Director of Health Services.   

3.Staff training will include monthly focus on reasonable precautions.

4.Administrator/Desginee   

Based on observation and record review, it was determined the facility failed to create an environment in which residents were treated with dignity and respect, were free from neglect, and received services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#2) who was bedbound. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type 2 diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

During the acuity interview on 03/04/24, Resident 2 was reported to be on hospice, with bedbound status, and on a pureed-texture diet requiring meal assist.

1. During observations on 03/04/24, the resident was lying in a hospital bed on his/her back, with his/her eyes closed, and in no apparent distress. The head of the bed was elevated at approximately 15 degrees.

* At 12:28 pm, Staff 25 (Care Partner) brought a tray with a bowl of pureed food, placed it on the bedside table next to the resident, and exited the room;

* At 1:21 pm, Staff 27 (MT) went into the room to administer medication to the resident. He was unable to arouse the resident and left the room at 1:25 pm stating, "Will come back.";

* At 1:26 pm, the resident's lunch remained on the bedside table. Staff 25 was in the dining area standing in the kitchenette and was not involved in any resident-related activities. Facility lunch service was completed, and three residents were sitting in the dining area;

* At 1:38 pm, Staff 3 (RCC) entered Resident 2's room and administered medications. He stated,"You'll get your lunch pretty soon" and exited the room; and

* At 2:24 pm, Staff 25 came into the resident's room, picked up the lunch tray, and placed it in the refrigerator.

Facility Care Partners recorded daily meal intake percentages for all residents on individual Weekly Meal Tracking sheets, which were kept in a binder located in the kitchenette area. Entries for lunch and dinner for Resident 2 were left blank for Monday, 03/04/24.

2. During observations on 03/04/24 through 03/06/24, on multiple occasions various facility care staff provided personal care to Resident 2 while either the window blinds or the door to the resident's room, or both, were open.

The need to create an environment in which residents were treated with dignity and respect, were free from neglect, and received services in a manner that protected privacy and dignity was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

200 Resident Rights

1.The service plan for resident 2 was updated to include appropriate assistance needed for meals. Staff were provided with education on the need to provide a dignified experience and privacy when completing care tasks. The need to provide assistance with meals and privacy during care was reviewed with all staff.

2.All staff meeting is scheduled for April 18 to review proper assistance with meals and how to provide care with dignity and respect and provide for privacy. Resident rights will be reviewed at the all-staff and all-staff to complete Relias training modules for resident rights. RCC and administrator will complete routine walk-throughs to audit for compliance. Medtechs are being trained as manager on duty at mealtimes.  

3.Daily monitoring by manager on duty, as well as RCC and administrator.  

4.Administrator, nurse and RCC.

Based on interview and record review, it was determined the facility failed to report incidents of abuse and suspected abuse to the local Seniors and People with Disabilities (SPD) office, document investigations of abuse and suspected abuse including an administrator's review, and to report injuries, including injuries of unknown cause, as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include but are not limited to:

1. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia.

Review of the resident's 12/05/23 through 03/04/24 progress notes, 12/27/23 service plan, and TSP's (Temporary Service Plans) revealed the following:

* 01/09/24 - "Resident was upset that [his/her] roommate...and hospice Certified Nursing Assistant (CNA) ...were using the shared bathroom in their bedroom. Resident was shouting stating it was [his/her] bathroom and cursing at staff, the hospice CNA and roommate. As [roommate] and hospice CNA were leaving the bathroom, resident threw [his/her] milk at them and continued shouting and cursing..."

Review of the investigation into the incident revealed the incident was not reported to the local SPD office and the investigation lacked documented evidence of an administrator' review.

During a 03/05/24 interview, Staff 2 (Vice President of Operations) confirmed the incident was not reported to the local SPD office and the investigation into the incident lacked an administrator's review.

The facility was directed to report the incident to SPD. Documentation was provided to the survey team that SPD had been notified on 03/05/24.

On 03/07/24 the need to ensure reports of abuse and suspect abuse were immediately reported to the local SPD office and investigations into abuse and suspected abuse included an administrator review was discussed with Staff 2 and Witness 2 (RN Consultant). They acknowledged the findings.

2. Resident 3 moved to the facility in 03/2022 with brain stem stroke syndrome and Alzheimer's disease.

Observations of the resident, interviews with staff, and review of the resident's 02/23/24 service plan, temporary service plans, progress notes, and incident investigations were completed and revealed the following:

A progress note dated 02/14/24 noted the resident "was found on floor at 12:35 am" and had a "significant bruise below [his/her] left eye."

An interview with Witness 2 (RN Consultant) and Staff 2 (Vice President of Operations) on 03/06/24 revealed there was no evidence a prompt investigation of the incident documenting all required elements had been completed, nor was there evidence the incident had been reported to the local SPD office when abuse and/or neglect was not ruled out.

At the request of the survey team, the above incident was reported to the local SPD office and confirmation was received at 5:00 pm on 03/06/24.

The need to ensure prompt incident investigations documented all required elements, including whether or not abuse and/or neglect could be ruled out, and incidents were reported to the local SPD office if not, was discussed with Staff 2 and Witness 2 on 03/07/24. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type 2 diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

A review of the resident's clinical record between 12/05/23 and 03/03/24, observation of care between 03/04/24 and 03/07/24, and staff interviews identified the following:

* The service plan, dated 12/20/23, indicated the resident "is oriented to person and knows who [his/her] [deceased spouse] is as well.";

* Skin impairment in the form of a scab was noted by the surveyor on the resident's left shin while staff was providing personal care on 03/06/24 at 10:41 am;

* There was no documented reference to skin impairments found in the resident's clinical records; and

* During an interview on 03/06/24, Witness 2 (RN Consultant) stated, "Skin rounds and a list of wounds being monitored were on the whiteboard in the med room, and [the facility nurse], who was fired last week, erased all the info when she left . . . I know there was something on the left leg that we have been monitoring."

The skin impairment on the resident's left shin represented an injury of unknown cause.

There was no documented evidence the facility promptly investigated the injury to rule out abuse and/or neglect or reported it to the local SPD office as suspected abuse.

The need to ensure resident incidents were promptly investigated by the facility to reasonably conclude and document that a physical injury was not the result of abuse, and reported to the local SPD office as needed, was reviewed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. They acknowledged the findings. No further information was provided.

231 Incident Reports

1.Incident reports for residents 1, 2 and 3 were reported to APS.

2.Consultants will provide training to all staff on what situations require incident reports and how to complete incident reports. Consultants to train on investigation and reporting of injuries of unknown cause. Consultant to review APS reporting and investigation process with administrator and new nursing team.  

3.Incident reports will be reviewed daily in the clinical meeting.

4.Administrator and nurse.  

Based on observation, interview and record review, it was determined the facility failed to report incidents of abuse and suspected abuse to the local Seniors and People with Disabilities (SPD) office, document investigations of abuse and suspected abuse, including injuries of unknown cause, as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse for 1 of 4 sampled residents (#7) whose records were reviewed for medication errors and injuries of unknown cause. This is a repeat citation. Findings include but are not limited to:

Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder.

The resident's clinical record including incident reports, temporary service plans (TSP's), progress notes dated 05/07/24 through 07/08/24 and outside service provider notes for the same time period were reviewed during the survey.

a. Resident 7's clinical record identified the following reportable incidents related to medication errors:

* On 05/06/24 - An outside provider note indicated a medication error occurred when the resident was found with two fentanyl patches on his/her body; and

* On 07/03/24 and 07/04/24 - An incident report indicated a medication error regarding Fentanyl patches occurred on both days.

During an interview on 07/09/24 with Staff 37 (Regional Clinical Director) investigations for the above medication errors were requested. One incident report for both of the medication errors that occurred on 07/03/24 and 07/04/24 was reviewed and documented "neglect could not be ruled out."

There was no documented evidence an investigation was completed for the medication error that occurred on 05/06/24.

During an interview on 07/09/24 with Staff 37, survey requested the medication errors be reported to the local SPD office if the facility investigation determined neglect could not be ruled out.

Verification of facility reporting the medication errors was received on 07/10/24 and 07/11/24.

b. The following skin injuries of unknown cause were identified:

* On 05/16/24 - An outside provider note indicated the resident had "scattered bruising on the anterior forearm";

* On 06/21/24 - An outside provider note indicated the resident had a "healing cut on the RT [right] hand"; and

* During an interview and observation of personal care on 07/08/24, Staff 17 (Care Partner) reported the resident had a small skin tear on his/her right lower leg/shin area. The surveyor observed the area and saw a small band-aid covering a skin tear on the resident's right lower leg. Staff 17 and Staff 41 (Care Partner) both reported they didn't know how it occurred or who put the band-aid on the resident's leg. During the same observation, the resident presented with bruising to his/her left top of hand and wrist area. S/he also had an approximate two inch by one inch bruise on the left upper arm, near the elbow.

Investigations for the above injuries were requested on 07/10/24 at 12:16 pm. The facility was unable to provide evidence that they immediately investigated the injuries to the resident's anterior forearm, right hand, right shin, left hand and upper arm and reasonably ruled out they were not the result of abuse or reported the injuries of unknown cause to the local SPD office as suspected abuse.

During an interview on 07/11/24 with Staff 30 (Acting ED) and Staff 31 (ED) at approximately 12:01 pm, survey requested the above skin injuries of unknown cause be reported to the local SPD office as suspected abuse.

Verification of reporting the skin injuries of unknown cause was received on 07/11/24, prior to survey exit.

The need to ensure medication errors and skin injuries of unknown cause were investigated promptly to rule out abuse and to report the incidents to the local SPD office when abuse or suspected abuse could not be ruled out was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

Example A-Med error on 5/6/24 actually occurred on 5/2/24.

Med error on 7/3/24 and 7/4/24.  Incident reports were completed, TSP's were in place, alert charting was completed.  No adverse outcome.  APS was notified of med error.  Investigation was completed.  Two medication technicians admitted to not following seven rights of medication administration.  In addition, there was a clerical error on the part of the Pharmacy that populated the medication daily instead of every three days.  The medication technicians recognized this and did not report it to the Health and Wellness director.  The Patches were also dated appropriately.  Outside service notes will go through third check system and be reviewed as a team in the clinical meeting. The error in the EMAR system was fixed. Med tech training was completed with all med techs and will be ongoing to prevent errors from happening again. Regional team is going med-tech competency check by LN and RCC. The consultant team will be reviewing all incident reports and providing feedback to the community team.

C. Skin Concerns on 5/16/24, 6/21/24, 7/8/24

5/16/24 Scattered bruising to anterior forearm.  

6/21/24 R hand abrasion

7/8/24 multiple injuries of unknown cause.  All incidents were reported to APS, IR's were completed, TSPs put in place, alert charting started by 7/11/24.

2.  The current system in place includes three check system and review of all pending medications completed by the Health and Wellness Director.  The first two checks are completed by Medication technicians.  In addition, all medication errors include an incident report.  If neglect and abuse is not able to be ruled out the Health and Wellness Director and/or the ED will report to APS for any med errors that occur.  Regional RN will provide training on Abuse and Neglect Reporting, Root Cause Analysis. For skin injuries of unknown origin including skin tears, bruising or abrasions.  Care Staff Training related to reporting changes in skin will be completed by Regional RN and community RN by 8/2/24. Regional RN will provide training on Abuse and Neglect Reporting and Root Cause Analysis, investigations of injuries of unknown cause and reporting requirement by 8/5/24.

3.  Regional RN to review incidents and alert charting weekly via zoom with community Executive Director, RN and Resident Care Coordinator. Daily incident report review in the clinical meeting with weekly compliance checks.

4.  ED and LN or Corporate RN.

2. Resident 5 was admitted to facility in 10/2021 with diagnoses including dementia.

a. Resident 5's service plan was dated with an "effective date" of 02/23/24, each service area was updated on 08/20/23 or 10/16/23, and the evaluation occurred on 01/03/24. Therefore, the evaluation was not the basis of the resident's service plan.

b. The most recent quarterly evaluation, dated 01/03/24, did not reflect documented changes of condition in the following areas:

* Level of dressing assistance required;

* Bathing status;

* Personal hygiene status;

* Nail care instruction; and

* Level of toileting assistance needed.

During an interview on 03/07/24, Staff 2 (Vice President of Operations) confirmed the "effective date" on the service plan was the date the service plan was last reviewed and updated by the facility, and the evaluation was not the basis of Resident 5's service plan.

The need to ensure quarterly evaluations were used as the basis of the quarterly service plan was discussed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

3. Resident 6 was admitted to facility in 10/2023 with diagnoses including dementia.

The move-in evaluation failed to address the following areas:

* Interests, hobbies, social, leisure activities;

* Physical health status including list of medications and PRN use, visits to health practitioner(s);

* Ability to use call system;

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Complex medication regimen; and

* Recent losses.

The need to ensure move-in evaluations addressed all required elements was discussed on 03/07/24 with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant). They acknowledged the findings.

4. Resident 3 was admitted to facility in 03/2022 with diagnoses including Alzheimer's disease.

Resident 3's service plan was dated with an "effective date" of 02/23/24, each service area was updated on 09/10/23 or 10/30/23, and the evaluation occurred on 12/12/23. Therefore, the evaluation was not the basis of the resident's service plan.

The most recent quarterly assessment was completed on 12/12/23 and did not reflect documented changes in the following areas:

* Toileting;

* Use of psychotropic medication; and

* Evacuation assistance needed.

During an interview on 03/07/24, Staff 2 (Vice President of Operations) confirmed the "effective date" on the service plan was the date the service plan was last reviewed and updated by the facility, and the evaluation was not the basis of Resident 3's service plan.

The need to ensure quarterly evaluations were used as the basis of the quarterly service plan was discussed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure evaluations were used as the basis to develop the resident's service plan for 3 of 5 sampled residents (#s 3, 4, and 5) whose quarterly evaluations were reviewed and failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 6) whose move-in evaluation was reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to facility in 01/2020 with diagnoses including dementia.

a. Resident 4's service plan was dated with an "effective date" of 02/23/24, each service area was updated on 08/20/23 or 10/16/23, and the evaluation occurred on 01/03/24. Therefore, the evaluation was not the basis of the resident's service plan.

b. The most recent quarterly evaluation, dated 01/03/23, was not updated in the following areas:

* Use of hearing aids,

* Use of assistive devices; and

* Use of a psychotropic medication.

During an interview on 03/07/24, Staff 2 (Vice President of Operations) confirmed the "effective date" on the service plan was the date the service plan was last reviewed and updated by the facility, and the evaluation was not the basis of Resident 4's service plan.

The need to ensure quarterly evaluations were used as the basis of the quarterly service plan was discussed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

252 Evaluations  

1.Residents 3, 4 and 5 evaluations updated to include all required elements of the Oregon evaluation.

2.The consultant will train on the use of the evaluation of checklist to ensure all necessary components addressed. Evaluation and service plan schedule is being implemented. Consultant will train on admission evaluation process when the restriction of admission condition is lifted.

3.Weekly audit of evaluation schedule.

4.Administrator and nurse.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were relevant to the needs and current conditions for 2 of 5 residents (#s 7 and 9) whose quarterly evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder.

The quarterly evaluation was reviewed, interviews were conducted, and the following was identified:

a. The quarterly evaluation was not dated and there was no indication as to who completed the evaluation.

b. The quarterly evaluation failed to accurately describe the resident's current status and condition in the following areas:

* Use of suppository for bowel care management;

* Use of psychotropic medications;

* Use of tilt-in-space wheelchair;

* Communication; and

* Dietary texture (Regular diet verses mechanical soft).

The need to ensure the quarterly evaluation accurately described the resident's current status and condition was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

2. Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure.

The quarterly evaluation was reviewed, interviews were conducted, and the following was identified:

The quarterly evaluation failed to accurately describe the resident's current status and condition in the following areas:

* Sleep routine including use of recliner;

* How resident expressed pain;

* Nutrition habits and fluid preference;

* Use of psychotropic or antipsychotic medication; and

* Environmental factors including room temperature.

The need to ensure the quarterly evaluation was reflective of the resident's current status and condition was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 2  (Consultant), and Witness 8 (Consultant) on 07/11/24. They acknowledged the findings.

1.  Resident 7 Quarterly Evaluation was completed on 7/8/24 due to change in condition on 7/8/24.  The following areas were corrected- use of suppositories for bowel care, use of psychotropic medications, use of tilt back w/c, communication and dietary texture.  

Resident 9 Quarterly Evaluation was completed on 7/12/24 with corrections made to the following areas-sleep routine including use of recliner, how the resident expresses pain, nutrition habits and fluid preference, use of psychotropic or antipsychotic medications and environmental factors including room temperature.  

2.  On 7/24/24 Regional RN provided 2.5 hours of training related to quarterly evaluations and service plans to Community RN, Resident Care Coordinator and Executive Director.  Corporate RN to review assessment tool in EHR system to allow for improved ability to meet resident needs related to resident specific factors.

3.  ED, LN or Corporate RN to review quarterly evaluations on an ongoing basis.

4.Ed, LN or Corporate RN

2. Resident 5 was admitted to the facility in 10/2021 with diagnoses including dementia and delirium due to known physiological condition.

The current service plan, dated 02/23/24, and Temporary Service Plans from 01/08/24 to 03/03/24 were reviewed, and observations of Resident 5 and interviews with staff were completed during the survey. The following was identified:

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Level of assistance required with bathing, dressing, grooming, oral care, toileting, and transfer status;

* Conflicting direction for nail care; and

* Use of a psychotropic medication.

The need to ensure service plans were reflective of  the resident's current needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

5. Resident 1 was admitted to the memory care in 02/2023 with diagnoses including dementia.

Observations, interviews, and review of the 12/17/23 service plan revealed Resident 1's service plan was not reflective of the resident's current needs and preferences and lacked clear direction to staff in the following areas:

* Use of glasses;

* Mobility, including use of walker;

* Weekly outings with family member;

* Eating routines; and

* Resident-specific emergency evacuation instruction.

The need to ensure service plans were reflective of residents' current care needs and preferences and provided clear directions to staff was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24.

3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease.

The current service plan, dated 02/23/24, and Temporary Service Plans from 12/26/23 to 02/27/24 were reviewed, and observations of Resident 3 and interviews with staff were completed during the survey. The following was identified:

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Level of assistance required with bathing, dining, toileting, and grooming;

* Behavior Management Plan;

* Emergency evacuation assistance;

* Fall mat placement; and

* Use of a psychotropic medication.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 01/2020 with diagnoses including dementia and major depressive disorder.

The current service plan, dated 02/23/24, and Temporary Service Plans from 01/30/24 to 02/20/24 were reviewed, and observations and interviews with staff and Resident 4 were completed during the survey. The following was identified:

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Ability to use the call system;

* Level of assistance required with bathing, dressing, grooming, oral care, toileting, bed mobility, and transfers;

* Management of incontinence supplies;

* Use of mobility aids;

* Emergency evacuation assistance; and

* Use of a psychotropic medication.

The need to ensure service plans were reflective of  the resident's current needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. 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 and provided clear direction to staff regarding the delivery of services for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

Observations of care on 03/04/24 through 03/07/24, interviews with the resident's family and staff, and review of the current service plan, dated 12/20/23, revealed Resident 2's service plan was not reflective of the resident's current needs or lacked clear instructions to staff in the following areas:

* Use of communication board to assist resident with staff interactions;

* Incorrect reference to presence of Foley catheter;

* Incorrect reference to use of supplemental oxygen for breathing;

* Social and leisure activities;

* Dietary, nutrition, and hydration management;

* Repositioning schedule and measures to prevent skin impairments;

* Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort;

* Fall mat placement;

* Recent losses;

* Instructions for evaluation of weekly behavior management plan;

* Instructions for aspiration precautions and interventions while choking;

* Instructions on signs and symptoms of hypo- and hyperglycemia to report;

* Instructions on weight management;

* Instructions on specific changes of condition to report to hospice;

* Instructions on proper maintenance of air mattress used for pressure ulcer prevention; and

* Instructions on changes in appetite.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

260 Service plans

1.Residents 1,2, 3, 4 and 5 have been updated.

2.The consultant will provide training on service plan components and include a service plan checklist to ensure all elements are addressed. Consultants will review newly updated service plans for completeness. Service plan schedule is being implemented to track.  

3.Weekly audits of service plans.

4.Administrator and nurse.

3. Resident 10 was admitted to the facility in 09/2021 with diagnoses including Alzheimer's disease, glaucoma, spinal stenosis and osteoarthritis of the knee.

Observations, interviews with facility staff and review of the current service plan, dated 06/11/24, and temporary service plan updates were conducted during the survey. The service plan was not reflective of the resident's current needs or lacked clear direction regarding the delivery of services in the following areas:

* The resident no longer wore compression stockings;

* Instructions were lacking for providing and placing the resident's hearing aides;

* Instructions were lacking for setting the resident's room temperature; and

* Instructions were lacking for ensuring the resident's desire to sit outside, even in warm temperatures, was honored.

The need to ensure Resident 10's service plan was reflective and included adequate instructions for providing care and services was reviewed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health Services Director, RN), Staff 33 (RCC), Staff 37 (Regional Clinical Director), Staff 38 (Senior VP Operations) and Witness 8 (Consultant) on 07/11/24 at 12:35 pm. They acknowledged the findings.

2. Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure.

Observations, interviews with the resident's family and facility staff, and review of the current service plan, dated 06/10/24, and temporary service plans were conducted during the survey. The service plan was not reflective of the resident's current needs, lacked clear direction regarding the delivery of services, and/or was not implemented in the following areas:

* Sleep preferences, including the use of a recliner;

* Oral care assistance and frequency;

* Resident preference to have the door to his/her room open during the day;

* Nutrition habits, including "special diet" of bacon with breakfast; and

* Environmental preferences, including room temperature.

The need to ensure the service plan reflected the resident's current needs, provided clear instruction for staff, and were implemented was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 2 (Consultant), and Witness 8 (Consultant) on 07/11/24. 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 status and care needs, provided clear direction to staff regarding the delivery of services and were implemented for 3 of 5 sampled residents (#s 7, 9, and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder.

Observations of care on 07/08/24 through 07/10/24, interviews with the resident's family and staff, and review of the current service plan, dated 06/05/24, identified Resident 7's service plan was not reflective of the resident's current status, lacked clear direction for staff and/or was not implemented in the following areas:

* Clear instruction for emergency evacuation;

* Escorts needed to the dining room with the use of a tilt-in-space wheelchair;

* Use of assistive devices and who to report maintenance/safety concerns to (hospital bed, toilet riser, two wheeled walker);

* Transfer status (two person verses one person);

* Toileting status (two person verses one person); and

* Consistently implementing proper diet texture (mechanical soft).

Observations during the survey confirmed the resident used a tilt-in-space wheelchair, required staff escorts to the dining room for all meals, and required two-person care for all transfers and toileting needs.

On 07/09/24, during the breakfast meal observation the resident recieved meal assistance from staff and was served toasted bread and approximately one-to-two-inch fresh cut melon.

During an interview on 07/09/24 at 9:35 am, Staff 34 and Staff 44 (Dietary Aides) reported "mechanical soft is basically the way that it is cut, like finely chopped. We [the kitchen staff] chop a large bowl of fresh fruit. We bring it to the smaller kitchens and the caregivers put it on the plates. They are supposed to cut it smaller if needed. We also don't prepare the toast for breakfast; the caregivers do that [in the kitchenettes]."

During interviews on 07/10/24 with Staff 35 (Care Partner), Staff 42 (Care Partner) and Staff 43 (Care Partner) it was reported Resident 7 required two-person care for transfers, toileting, required assistance with eating and had an order for mechanical soft diet texture.

The need to ensure the service plan reflected the resident's current status and condition, provided clear instructions for staff, and was implemented was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

1.  Resident 7 Quarterly Service plan was completed on 7/8/24 due to change in condition on 7/8/24.  The following areas were corrected- clear instructions for emergency evacuation, escorts needed to dining room with use of tilt back wheelchair.  Use of assistive device on who to report maintenance safety concerns to, transfer status, toileting status, consistently implementing proper diet texture.  Resident 9 Quarterly service plan was completed on 7/12/24 with corrections made to the following areas-sleep routine including use of recliner, oral care assistance and frequency, resident preference to have door open during the day, nutrition habits including special diet and environmental factors including room temperature.  

Resident 10-Quarterly service plan was completed on 7/8/24 due to a change in condition on 7/7/24 to reflect the resident no longer had compression stockings, instructions for hearing aides, instructions for room temperature, instructions for being outside even during extreme warm temperatures.

2.  On 7/24/24 Regional RN provided 2.5 hours of training related to quarterly evaluations and service plans to Community RN, Resident Care Coordinator and Executive Director. Consultants will be reviewing updated service plans.

3.  Corporate RN to review quarterly service plans on an ongoing basis.

4.Corporate RN

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

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

During an interview on 03/07/24, Staff 2 (Vice President of Operations) confirmed the facility lacked documented evidence of a Service Planning Team for Residents 3, 4, and 5.

On 03/07/24, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

For 262:

1.Service plan team meetings are scheduled for residents 3, 4 and 5.

2.A service plan schedule has been developed and service plan team meetings will be scheduled upon service plan updates. The white board is being used to track service plans due and completed.

3.Service plan completion will be reviewed weekly and team meetings scheduled upon completion. Process will be audited monthly in the QI meeting.

4.Administrator.

3. Resident 5 moved into the facility in 10/2021 with diagnoses including dementia, hypertension, and type II diabetes.

The resident's current service plan, dated 02/23/24, Temporary Service Plans, and  progress notes dated 12/01/23 through 03/04/24 were reviewed. Observations of the resident and interviews with staff were completed between 03/04/24 and 03/07/24.

The resident experienced multiple short-term changes of condition as outlined below:

a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined action or intervention to staff on all shifts, or documented progress at least weekly through resolution for the following short-term changes of condition:

* 12/01/23 - Bloody nose;

* 12/17/23 - "blood all over [his/her] ... bloody nose"; and

* 01/12/24 - Refused all morning medications.

b. Temporary service plans were created and monitoring was initiated, but progress was not documented at least weekly through resolution, for the following short-term changes of condition:

* 01/08/24 - Change in insulin dose (Levemire);

* 01/09/24 - Discontinued insulin (Humalog) and blood sugar level check three times daily;

* 01/18/24 - Low blood sugar level and increased agitation; and

* 02/01/24 - Discontinued insulin (Levemire).

The need to ensure changes of condition were evaluated, actions or interventions were determined and communicated to staff, and residents were monitored per their evaluated care needs, with progress documented at least weekly until resolution, was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia. Review of the 12/05/23 through 03/04/24 progress notes, 12/27/23 service plan, and Temporary Service Plans (TSP's) revealed Resident 1 experienced the following short-term changes of condition:

* 12/05/23 - Wound to left calf;

* 01/09/24/23 - Resident-to-resident altercation;

* 01/21/24 - Medication refusals;

* 02/10/24 - Medication refusals; and

* 02/18/24 - Blood found in brief.

The facility lacked documented evidence actions or interventions were developed and communicated to staff on each shift and changes of condition were monitored, with progress noted at least weekly through resolution, for each of Resident 1's short-term changes of condition.

The need to ensure the facility had a system to determine and document what actions or interventions were needed for a resident's short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, and ensure progress was documented at least weekly until the conditions resolved was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease.

The resident's current service plan, dated 02/23/24, Temporary Service Plans, progress notes dated 12/01/23 through 03/03/24, and corresponding incident reports were reviewed. Observations of the resident and interviews with staff were completed between 03/04/24 and 03/07/24.

The resident experienced multiple short-term changes of condition as outlined:

a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident and communicated the determined action or intervention to staff on all shifts for the following short-term changes of condition:

* 01/10/24 - Non-injury fall; and

* 01/30/24 - Non-injury fall.

b. There was no documented evidence the facility monitored the following short-term changes of condition, with progress noted at least weekly:

* 12/26/23 - Resident tested positive for COVID;

* 01/24/24 - Medication dose changes for lorazepam and haloperidol (psychotropic medications); and

* 02/16/24 - Medication dose change for warfarin (blood thinner).

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

5. Resident 4 was admitted to the facility in 01/2020 with diagnoses including dementia and major depressive disorder.

The resident's current service plan, dated 02/23/24, Temporary Service Plans,  progress notes dated 12/02/23 through 03/02/24, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 03/04/24 and 03/07/24.

The resident experienced multiple short-term changes of condition as outlined below:

a. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined actions or interventions to staff, or documented weekly progress through resolution for the following short-term change of condition:

* 01/01/24 - Resident tested positive for COVID.

b. b. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident and communicated the determined actions or interventions to staff on all shifts for the following short-term changes of condition:

* 01/16/24 - Missed morning medications, increased tiredness; and

* 02/16/24 - Return from emergency room.

c. There was no documented evidence the following short-term changes of condition were monitored, with progress documented at least weekly through resolution:

* 02/09/24 - Extreme confusion;

* 02/12/24 - Room change; and

* 02/20/24 - Return from hospital due to increased anxiety and agitation.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition, and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) who experienced changes of condition. Resident 2 experienced ongoing weight loss. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type 2 diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

Clinical records, including the current service plan, dated 12/20/23, progress notes from 12/05/23 through 03/03/24, and outside provider notes were reviewed, and interviews with facility staff were conducted.

a. Facility weight records noted the following:

* 10/17/23 - 141.5 pounds;

* 12/14/23 - 125.4 pounds; and

* 01/02/24 - 124.0 pounds.

The resident's MARs indicated the resident was to be weighed monthly on the second day of the month. There were no weights documented in 11/2023, 02/2024, or 03/2024. The facility was asked to get a current weight for the resident during the survey, and the weight was noted as 111.0 pounds on 03/06/24, which was a decrease of 13.0 pounds since the last weight in 01/2024.

Resident 2 lost 17.5 pounds, or 12.36% of his/her body weight, in three months (10/17/23 through 01/02/24), resulting in a significant change of condition.

Observations of the resident between 03/04/24 and 03/07/24 showed the resident was unable to feed himself/herself once provided food, was observed to be lethargic or asleep for the majority of the time, was not verbally communicative with staff, and did not follow commands. The resident's intake varied, with multiple meals at more than 50%.

There was no documented evidence of ongoing monitoring of the resident's weight, and there was no documentation interventions and adjustments were in place to prevent additional weight loss.

According to Resident Assessment forms completed in 12/2023 and 01/2024, nursing consultants were aware of the weight loss but did not complete RN assessments and facility did not implement interventions as a result of this awareness.

* 12/20/23 - Resident Assessment noted "Resident has lost more than 16 pounds in the last 3 months.";

* 01/04/24 - Resident Assessment noted "Resident has lost more than 16 pounds in the last 3 months.";

* 01/26/24 - Hospice physician signed order to start "mechanical soft texture diet for ease of swallowing.";

* 01/29/24 - Hospice note stated "Patient has had continuing difficulty with chewing/swallowing and pocketing food even after change to mechanical soft texture diet."; and

* 01/29/24 - Hospice physician signed order instructing to start resident on pureed texture diet.

During meal observations conducted in the resident's room from 03/04/24 through 03/07/24, the following was noted:

* 03/04/24 - Lunch tray with a pureed-texture food was delivered to the resident's room, but the resident was not fed;

* 03/05/24 - Staff 25 (Care Partner) fed resident breakfast from 9:30 am to 10:16 am after being prompted by the surveyor, and Resident 2 consumed 100%. Lunch was fed by Staff 29 (Care Partner) from 12:30 pm to 1:15 pm, and Resident 2's total intake was 100%;

* 03/06/24 - The resident was fed breakfast from 8:45 am to approximately 9:40 am and ate 75%; and

* 03/07/24 - The resident was fed breakfast from 9:59 am to approximately 10:45 am.

In an interview on 03/06/24, Witness 2 (RN Consultant) indicated she was aware of the weight loss for the resident but had not completed any assessment of the loss.

Resident 2 experienced ongoing weight loss from 10/2023 to 03/2024.

There was no documented evidence the facility evaluated the resident, referred to the facility nurse, documented the changes, updated the service plan as needed, and monitored weekly.

b. There was no documented evidence the facility determined what resident-specific actions or interventions were needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress through resolution for the following short-term changes of condition:

* 01/04/24 - Progress note stated "Resident has had a change of condition noted related [sic] to a decrease in ... mobility. [S/he] has developed a stage 1 pressure ulcer above [his/her] coccyx.";

* 01/22/24 - Hospice note stated "Patient has potential fungal rash noted to peri-area and left armpit causing patient discomfort."; and

* 01/22/24 - Hospice physician signed order to start Miconazole 2% powder related "to erythema to the neck, chin, and face also noted to the peri wound of the coccygeal area associated with pruritus and 'fungal-like odor'."

The need to ensure the facility evaluated the resident, referred to the facility nurse when necessary, documented the change, and updated the service plan as needed for a significant change of condition, and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. They acknowledged the findings. No further information was provided.

270 Change of Condition

1.Residents 1, 2, 3, 4, and 5 were assessed for changes of condition, and their service plans were updated to reflect current needs and communicate needed interventions.

2.A weight monitoring system was implemented-RCC is coordinating monthly weights in the beginning of the month. Nursing will be reviewing weights routinely to identify and respond to weight changes. Third party notes are being reviewed in the clinical meeting and TSPs initiated for changes. Skin conditions are being tracked on the whiteboard to ensure treatment, monitoring and resolution. Medication refusals will be reviewed daily in the clinical meeting and plans to increase compliance reviewed and revised as needed.  

3.Changes of Condition will be monitored daily in the clinical meeting and tracked weekly on the whiteboard.

4. Administrator and nurse.  

3. Resident 10 was admitted to the facility in 09/2021 with diagnoses including Alzheimer's disease, glaucoma, spinal stenosis and osteoarthritis of the knee.

The resident's record including the current service plan, dated 06/11/24, Temporary Service Plans (TSPs), incident reports and progress notes from 05/06/24 to 07/08/24 were reviewed. Observations were made and interviews were conducted with facility staff. The service plan noted the resident was a high fall risk who had a history of falls, had poor safety awareness and often tried to self-transfer when s/he actually needed two staff to assist with transfers. Fall interventions were for staff to provide safety checks every two hours and to ensure the resident wore non-slip footwear.

The facility documented that between 05/09/24 and 07/07/24 the resident had eight falls. One fall resulted in bruising on the left shin and left hand. No injuries were reported for the other falls.

For five of the eight falls, the facility was unable to provide documented evidence it determined, documented and communicated to staff what actions or interventions were needed for the resident.

For seven of the eight falls, the facility failed to monitor whether the service-planned interventions had been followed prior to the resident's fall, whether the interventions were effective or whether additional or different interventions needed to be implemented. The facility did not implement any new interventions to try to address the repeated falls.

The need to ensure the facility determined, documented and communicated to staff what actions or interventions were needed for the resident following a fall and monitored whether the interventions were being followed and were effective or whether additional interventions needed to be developed was reviewed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health Services Director, RN), Staff 33 (RCC), Staff 37 (Regional Clinical Director), Staff 38 (Senior VP Operations), Witness 2 (Consultant) and Witness 8 (Consultant) on 07/10/24 at 1:45 pm and 07/11/24 at 12:35 pm. They acknowledged the findings.

2. Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure.

The resident's record including the current service plan, dated 06/10/24, Temporary Service Plans (TSPs), incident reports, and progress notes from 05/08/24 to 07/08/24 were reviewed. Observations were made and interviews were conducted with the resident's family and facility staff.

The facility failed to evaluate, determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following short-term changes of condition:

* 04/08/24: Compression socks and elevate legs;

* 05/07/24: Wound management;

* 05/10/24: Bilateral lower extremity edema;

* 05/15/24: New scab on fourth left toe;

* 05/15/24: Left wrist red circle;

* 05/29/24: New medication for UTI;

* 05/29/24: New wound, inferior/lateral multiple small open weeping sores;

* 06/01/24: Discontinued medication;

* 06/11/24: Missed medication; and

* 06/12/24: Resident to resident altercation.

The need to ensure the facility had a system to determine and document what actions or interventions were needed for a resident's short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, and monitor at least weekly until resolution was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 2 (Consultant), and Witness 8 (Consultant) on 07/11/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, document weekly progress until the condition resolved, and reviewed interventions for effectiveness for 3 of 5 sampled residents (#s 7, 9 and 10) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease and anxiety disorder.

Clinical records, including the current service plan, dated 06/05/24, progress notes from 05/07/24 through 07/08/24, and outside provider notes were reviewed, and interviews with facility staff were conducted.

The facility failed to evaluate, determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following short term changes of condition:

* On 05/06/24 - Medication error occurred when the resident was found with two fentanyl patches on his/her body;

* On 05/10/24 - Pain and restarting scheduled Tylenol;

* On 05/16/24 - "...scattered bruising on the anterior forearm";

* On 05/31/24 - Redness to the breast area and tender to the touch;

* On 06/10/24 - Redness to the coccyx area and right upper leg/brief line;

* On 06/21/24 - A "healing cut on the RT [right] hand";

* On 07/01/24 - Discontinue polyethylene glycol;

* On 07/03/24 and 07/04/24 - Medication errors regarding Fentanyl patches;

* On 07/05/24 - Discontinue twice per day Senna; and

* On 07/08/24 (during the survey) - The resident presented with a skin tear to the right lower leg/ shin area, bruising to his/her left top of hand and wrist area. S/he also had an approximate two inch by one inch bruise on his/her upper arm, near his/her elbow.

The need to ensure the facility had a system to determine and document what actions or interventions were needed for short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, and ensure progress was documented at least weekly until the conditions resolved was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

1.  Resident 7 Change in Condition was completed on 7/8/24 due to change in condition on 7/8/24.  All areas were corrected.   

Resident 9 Quarterly Evaluation was completed on 7/12/24 with corrections made to all areas.

Resident 10 Change in condition was completed on 7/8/24 All areas were corrected.

2. Training provided to RN, RCC and ED related to temporary changes in condition, TSP's, alert charting and monitoring to ensure that actions and interventions are put in place for temporary changes in condition, how to communicate those changes to staff and what actions are necessary and for what length of time, monitoring is in place until change is resolved. To be completed by 8/5/2. All new orders will be reviewed in clinical meeting to ensure TSP's and alert charting started.

3.  Corporate RN to review alert charting and TSPs on weekly basis with RN, ED and RCC via zoom. ED and LN to review daily in clinical meeting.

4.Corporate RN

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 2) who experienced significant changes of condition related to loss of weight. Resident 2 continued to experience ongoing weight loss. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type 2 diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

Clinical records, including the current service plan, dated 12/20/23, MARs from 12/01/23 through 03/04/24, progress notes from 12/05/23 through 03/03/24, and outside provider notes were reviewed, and interviews with facility staff were conducted.

According to the resident's MARs, the resident's weight was scheduled to be taken on the second day of each month, and the primary care physician and the facility nurse were to be notified of a five pound or greater weight loss or gain in one month.

The following weights were recorded by the facility:

* 10/17/23 - 141.5 pounds;

* 11/02/23 - no weight recorded;

* 12/14/23 - 125.4 pounds;

* 01/02/24 - 124.0 pounds;

* No weight was recorded in 02/2024; and

* 03/06/24 - Resident was weighed per surveyor request and recorded to be 111.0 pounds.

The resident experienced a 17.5 pound weight loss, or 12.36% of his/her total body weight, in three months (10/17/23 through 01/02/24). This represented a significant change of condition.

The resident experienced an additional significant change of condition with the loss of 14.4 pounds in three months, or 11.48% of his/her total body weight, between 12/14/23 and 03/06/24.

Review of the clinical records revealed the following:

* A facility Resident Assessment (RA) form was completed in connection with a quarterly service plan update on 12/20/23. The RA form noted "Resident lost more than 16 pounds in the last 3 months. Staff to observe, report, and document any changes in wt gain or wt loss of 5 pounds to the HSD/ED [Health Services Director/ED] or designee and to the provider and family."

The RA form was completed and signed by an LPN nursing consultant. There was no documented evidence an RN conducted an assessment which documented findings, resident status, and interventions made as a result of the assessment.

* A facility RA form was completed on 01/04/24 in connection with a change of condition assessment related to the resident's "... decreased mobility with the development of a stage 1 pressure ulcer above [his/her] coccyx." The Resident Assessment form was signed by an RN nursing consultant and noted "Resident lost more than 16 pounds in the last 3 months. Staff to observe, report, and document any changes in weight gain or wt loss of 5 pounds to the HSD/ED [Health Services Director/ED] or designee and to the provider and family."

The RN acknowledged the previously noted weight loss; however, there was no documented evidence the RN conducted a nursing assessment which included findings, resident status, or interventions made as a result of the assessment.

The most recent Service Plan stated resident "can not feed [her/himself]," but did not provide clear instructions to staff on weight and appetite management.

Resident 2 was started on a soft mechanical texture diet for ease of swallowing on 01/26/24 per hospice physician signed order. The diet was downgraded to pureed texture diet on 01/29/24 due to "Patient has had continuing difficulty with chewing/swallowing and pocketing food even after change to mechanical soft."

During meal observations conducted in the resident's room from 03/04/24 through 03/07/24, the following was noted:

* 03/04/24 - Lunch tray was delivered to the resident's room, but the resident was not fed;

* 03/05/24 - Staff 25 (Care Partner) fed resident breakfast from 9:30 am to 10:16 am, after being prompted by the surveyor, and Resident 2 consumed 100%. Lunch was fed to the resident by Staff 29 (Care Partner) from 12:30 pm to 1:15 pm, and Resident 2's total intake was 100%;

* 03/06/24 - The resident was fed breakfast from 8:45 am to approximately 9:40 am, and ate 50%; and

* 03/07/24 - The resident was fed breakfast from 9:59 am to approximately 10:45 am.

During an interview on 03/06/24, Staff 13 (Care Partner) stated, "If you really want to feed [the resident] and be patient, s/he can eat 75%. It takes time. If three of us [assigned Care Partners to the unit] [are on duty] . . . it's ok, but if somebody calls-out . . . we can't."

The ongoing weight loss and change in diet texture constituted significant changes of condition requiring an RN assessment.

There was no documented evidence the facility RN conducted assessments which included documentation of findings, resident status, and interventions made as a result of the assessments, and the resident continued to lose weight.

Witness 2 (RN Consultant) confirmed on 03/06/24 the facility was unable to produce the assessments.

The need to ensure an RN assessment was completed for residents who experienced a significant change of condition was reviewed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. They acknowledged the findings. No further information was provided.

280 Resident Health Services

5.Resident 2 has been evaluated for significant weight loss and the service plan has been updated with needed interventions.

6.All-staff training is scheduled to include what conditions need to be referred to the RN for significant change of condition. Weights are being monitored monthly and reviewed by the RN for significant changes.

7.Changes of condition will be monitored weekly on the whiteboard. Weights are to be reviewed by the RN monthly.

8.RN and administrator.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 5) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

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

During the acuity interview on 03/04/24, the resident was identified to receive insulin injections from staff and s/he was the only resident who received insulin injection.

The survey team requested the resident's current MAR and progress notes during the survey on 03/04/24, however, no documentation was provided by the end of the day on 03/04/24.

On 03/05/24, at approximately 9:00 am, Witness 3 (RN Consultant) was observed checking the resident's blood sugar level. Witness 3 stated she was going to administer an insulin injection to the resident.

On 03/05/24, at approximately 9:43 am, Staff 2 (Vice President of Operations) reported the previous night during an audit, the facility identified two undelegated staff had administered insulin injection to the resident. Therefore, the facility implemented a plan to address the findings.

During the survey, 03/05/24 through 03/07/24, Staff 7 and Witness 3 confirmed they would check the resident's blood sugar level and administer insulin injections as ordered.

On 03/07/24 at 10:30 am, the delegation task was reviewed with Staff 2 and Witness 2 (RN Consultant), and they acknowledged the findings.

C 282 Delegation

1.RN has assumed responsibility of RN delegation. Delegating RN is knowledgeable of RN delegation rules.

2.The RN is working closely with the community to communicate who is delegated and has a clear delegation supervision schedule. This RN has taken the Role of the Nurse Class for Community Based Care. Consultant has reviewed delegation requirements.

3.The delegation book will be reviewed monthly to ensure compliance.

4.RN

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 3 of 3 sampled residents (#s 2, 4, and 5) who received incontinence care and meal assistance from staff. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 10/2021 with diagnoses including dementia, hypertension, and type II diabetes.

Observations and interviews with staff during the survey identified the resident relied on staff for incontinence care needs.

On 03/04/24, at approximately 1:40 pm, the surveyor obtained permission from the resident and observed Staff 24 (Care Partner) provide incontinence care for Resident 5.

During the observation, Staff 24 wore gloves and failed to change the gloves after wiping fecal matter from Resident 5's perineum. Staff 24 flushed the toilet and touched a clean brief, a shirt, and a pair of pants while wearing the same soiled gloves.

The above observation was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24 at 10:30 am. The staff acknowledged that appropriate infection control practices were not followed.

3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease.

Observations of the resident and interviews with staff from 03/04/24 through 03/07/24 revealed Resident 3 relied on two staff for incontinence care needs.

On 03/05/24 at 9:15 am, Staff 17 (Care Partner) and Staff 18 (Care Partner) provided ADL incontinence care for Resident 3. Staff 17 and 18 donned gloves prior to providing incontinence care. Staff 17 removed the resident's soiled clothing and soiled brief, performed peri care, and then applied barrier cream to the area without doffing soiled gloves, performing hand hygiene, and donning clean gloves.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

During the acuity interview on 03/04/24, Resident 2 was reported to be on hospice, with bedbound status, and on a pureed-texture diet requiring meal assist.

During the survey, from 03/04/24 through 03/06/24, surveyor obtained permission and observed the facility staff provide personal care and feeding to Resident 2. Resident was noted to require total care assist from the staff. On multiple instances staff donned gloves without first performing hand hygiene, did not change single-use gloves between tasks, and performed feeding without wearing a protective barrier.

The need to establish and maintain effective infection prevention and control protocols was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

C 295 Infection Control

1.ED will take infection control specialist training. Staff were counseled on the importance of hand hygiene and changing gloves between clean and dirty tasks. Staff also trained in hand hygiene at mealtimes.

2.All-staff training is scheduled in April to review infection control practices. RCC, nurse and administrator will complete daily rounds ensuring resident care tasks are provided in a fashion that respects infection control practices. Training records will be updated to ensure all staff have taken the Relias infection control training.  

3.Daily and monthly.

4.Administrator, RCC and nurse.  

2. Most residents ate meals on the 300 unit. Meal service and meal  assistance for several residents was provided by caregivers and the medication technician. During observations of lunch service on 07/09/24 and 07/10/24, the following concerns regarding safe food handling were identified:

* On both days, as care staff served the meal items and went from table to table to check on residents, they repeatedly touched residents' wheelchairs, dining chairs, and residents' clothing without then washing their hands before handling another resident's plate or beverage cup.

* On 07/10/24, only one of three care givers donned an apron prior to beginning meal service to prevent cross-contamination from the uniforms they wore when providing personal care to residents.

These deficiencies increased the risk of the spread of communicable diseases to residents.

The need to ensure all facility staff consistently followed safe food handling practices was reviewed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.  

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of  3 sampled residents (#7) and multiple unsampled residents who received meal assistance from staff. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease.

Observations of the resident and interviews with staff from 07/08/24 through 07/10/24 identified the resident relied on staff for meal assistance, hydration and snacks throughout the day, and required assistance with incontinent care from caregivers.

From 07/08/24 through 07/10/24, Staff 18 (Care Partner), Staff 32 (Health and Wellness Director/RN) and Staff 43 (Care Partner) were observed providing ADL care for multiple residents throughout the survey and would also assist with plating and serving resident meals and drinks from the kitchenette.

On 07/09/24 at 9:14 am, Staff 18 was observed sitting between Resident 7 and another unsampled resident providing meal assistance for both residents. Staff 18 was not wearing gloves and an apron or other protective barrier to prevent the potential for cross contamination from their clothing when assisting with meal service. Staff 18 also failed to ensure hand hygiene was performed before assisting another resident with meal assistance.

On 07/09/24 at 12:42 pm, Staff 32 failed to ensure a barrier was between the resident and their plain clothing prior to providing meal assistance. Staff 43 took over assisting the resident with his/her meal. Staff 43 failed to wash hands before assisting the resident, failed to don clean gloves and failed to have on an apron or other protective barrier between their clothing and the resident, to prevent potential cross contamination from their clothing.  

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.  

1.In service Provided on 7/11/24 and again on 7/18/24 with staff related to infection control during meal service when assisting residents with eating.  Hand Sanitizer provided on tables with residents who need assistance with eating. Reviewed use of aprons when serving meals. Training provided on using hand sanitizer between assisting different residents, touching any items such as w/c tables, etc.    

2.  RN, ED, and RCC will provide meal monitoring 7 times weekly and at least once during breakfast, lunch and dinner to ensure appropriate hand hygiene and infection control practices are being consistently followed.

3.  Regional RN will review meal monitoring log weekly via zoom call with RN, ED and RCC.

4. ED, LN and RCC or Corporate RN.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to:

During the re-licensure survey, conducted 03/04/24 through 03/07/24, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C282 - RN Delegation and Teaching;

* C302 - Systems: Tracking Control Substances;

* C303 - Medication and Treatment Orders;

* C310 - Medication Administration; and

* C330 - PRN Psychotropic Medications.

The need to ensure a safe medication and treatment system was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

C300 Systems: Medications and Treatments

1. See other citations in this section.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#3) who was administered as-needed narcotic medication. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease.

Resident 3 had a physician order for morphine 0.25 ml by mouth every hour as needed for pain/shortness of breath.

Resident 3's 02/01/24 through 03/04/24 Controlled Substance Disposition Logs and MARs were reviewed and revealed the following:

Between 02/01/24 and 03/04/2024, there were four occasions when staff signed the medication out in the disposition log; however, the MAR lacked documentation the resident received the PRN medication.

Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Witness 2 (RN Consultant) on 03/07/24. No additional information was provided.

The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. The findings were acknowledged.

C302 Systems: Tracking Control Substances

1.Staff training done on ensuring MAR and control log are used when signing out controlled substances.

2.A Med-tech meeting scheduled for April to review elements of a safe controlled medication system including documentation, storage, signing out, shift count, discrepancies and reordering. Change of shift count is being observed multiple times per week by nursing and the administrator, and MAR audit is being completed weekly.

3.Daily and weekly.

4.Administrator and nurse.  

2. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia.

The resident's 02/01/24 through 03/04/24 MAR and signed physician's orders, dated 12/21/23 were reviewed on 03/06/24. The following was identified:

Resident 1 had physician's orders to receive the following medications:

* Omeprazole 20 mg (gastroesophageal reflux disease) one capsule daily;

* Azo D-Mannos 500 mg (probiotic) two capsules twice daily;

* Ursodiol 300 mg (gall stones) one capsule twice daily;

* Vitamin B-12 500 mg (supplement) one tablet every morning; and

* Atorvastatin 20 mg (cholesterol) one tablet at bedtime.

The medications were not included on the MAR, and the facility lacked documented evidence the medications were administered as prescribed between 12/21/23 and 03/04/24.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 5 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

Review of Resident 2's current hospice physician orders, dated 12/26/23, and MARs from 01/01/24 through 03/05/24 revealed the following:

* The physician order stated, "any medications or treatments prior to this [new] list, which are currently not listed are considered discontinued." The new list did not contain the previously given order to check blood sugar levels twice daily. According to the MARs, staff continued to check blood sugar levels from 01/01/24 through 01/18/24.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

C303 Systems: Treatment Orders

1.Resident 1 and 2 orders were reviewed for accuracy to ensure all medications and treatment orders are carried out as prescribed.

2.A third check system is in place to ensure all new orders are carried out as prescribed. Orders will be reviewed daily in the clinical meeting. Routine pharmacy audits are scheduled, and nursing is following up with recommendations. Quarterly physician orders are being sent out to ensure current orders for all medications and treatments. Consultants are providing training at routine med-tech meetings to ensure all med-techs are trained in order processing and administering orders as prescribed.  

3.Daily in the clinical Monthly MAR audits by RCC and nursing, quarterly review of physician orders.

4.Administrator and nurse.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 5 sampled residents (# 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure.

The resident's 05/06/24 through 07/08/24 MAR and signed physician's orders, dated 06/17/24 were reviewed. The following was identified:

Resident 9 had a physician's order to receive the following medications:

* Vitamin B12 5000 mcg: one tablet, under the tongue, one time a week; and

* Nitrofurantoin 100 mg: one capsule by mouth, twice daily, for 10-days.

The facility lacked documented evidence the medications were administered as prescribed between 05/06/24 through 07/08/24.

On 07/11/24, Staff 37 (Regional Clinical Director) stated she was aware the medications were not administered as prescribed.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37, Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 2 (Consultant), and Witness 8 (Consultant) on 07/11/24. They acknowledged the findings.

1. Resident 7- Medication incident reports were completed at time incidents were reported , related to Vitamin B12, TSP was in place and alert charting was completed, no adverse outcomes were noted due to increased B12.  Pharmacy interface caused medication to be populated daily instead of weekly and was not fixed on review by previous RCC.  Resident Nitrofurantoin was delivered on 5/26 order was obtained on 5/24.  Medication d/c order was obtained prior to 10 day end date.  Medications were not administered correctly as indicated prior to 6/1/24.  Medication technician training was provided by Regional RN related to 7 rights of medication administration on 5/29/24, 6/5/24, 6/12/24, medication error reporting, alert charting and monitoring for medication errors.

2.  Medications Pending reviews are completed by RN during 3rd check system.  Medication orders are reviewed, verified and entered by RN. Medication Technicians will be trained on 7 rights of medication administration prior to administering medications to residents.

3. Regional RN will review medication incident reports weekly with community RN, ED and RCC via zoom.

4. Corporate RN

2. Resident 12 was admitted to the facility in 08/2016 with diagnoses including hypertension, delusional disorder, and Alzheimer's disease.

Resident 12's current facility records and MARs from 10/01/24 to 10/29/24 were reviewed.

Resident 12's current facility records included a physician order to "administer polyethylene glycol 17 g by mouth twice daily as needed for constipation."

Review of MARs showed the polyethylene glycol was scheduled for administration at 8:00 am and 8:00 pm daily.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 30 (Acting ED), Staff 48 (RCC), and Witness 8 (Consultant) on 10/30/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 2 sampled residents (#s 12 and 13) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 moved into the facility in 11/2022 with diagnoses including Alzheimer's disease and vascular dementia.

Observation of the resident on 10/30/24 at 9:02 am, revealed Staff 50 (Care Partner) was assisting the resident with breakfast and there was a cup of liquid without a straw observed on the tray. Staff 50 reported it was regular liquid, not thickened liquid.

Review of the resident's current order, signed on 07/15/24, showed Resident 13 was prescribed to have "spoon thick thickened liquids." which indicated the facility failed to follow a signed physician order as prescribed.

The need to ensure physician orders were followed as prescribed was discussed with Staff 30 (Acting ED) and Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Witness 2 (Consultant 1) and Witness 8 (Consultant 2) on 10/30/24 at 2:38 pm. They acknowledged the findings.

1. Resident #13 has passed since time of survey. Resident #12 physician orders (PO) were updated immediately and communication was made with the physician. A new Diet Order Form was created to better streamline communication from physician to LN to Dining Director. All areas were corrected.

2. PO audits will be a routine standard practice for the community. The first audit will occur on 11/26/2024 by the community LN. On 11/12/2024, a full 3-way audit (MAR to cart to order) was completed by PharMerica. All orders will go through the third check system and PharMerica is providing additional training to medication staff on order processing and elements of a safe medication system. All diet orders have been reviewed and there is an improved system in place to communicate diet changes.

3. POs will be reviewed with physicians on a quarterly basis, pharmacy audits will occur quarterly, and POs will be reviewed by the community LN on a weekly basis and as needed.

4. The Regional Clinical Specialist with the Regional Operations Director will ensure all actions are completed and monitored moving forward.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 2 of 5 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2023 with diagnoses including dementia.

The resident's 02/01/24 through 03/04/24 MARs and physician's orders were reviewed and identified the following:

* Bisacodyl 10 mg suppository, insert one daily PRN (for constipation);

* Milk of Magnesia 400 mg, take two tablespoons daily PRN (for constipation);

* Polyethylene glycol, dissolve one packet in eight ounces liquid and take by mouth daily PRN (for constipation); and

* Senna 8.6 mg, take one tablet twice daily PRN (for constipation).

The PRN medications for bowel care lacked resident-specific parameters for the sequential order of use.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

Resident 2's MARs from 12/01/23 through 03/04/24 and physician orders, signed 12/26/23, were reviewed. According to the MARs, the resident's weight was to be taken on the second day of each month; however, the MARs for 02/2024 and 03/2024 did not contain any recorded weights or initials of the person taking the weights.

The need to ensure MARs were accurate was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No further information was provided.

310 Systems: Medication Administration

1.Residents 1 and 2 MAR updated to include indications of use and diagnoses. The weight system is also being updated to ensure MAR reflects weight monitoring.

2.Indications and diagnoses are being updated when orders third checked by nursing. Full

MAR audit to be completed to ensure indications and diagnoses are added to MAR. Monthly

MAR review is also being initiated to ensure all indications of use and diagnoses are present.  

3.Several times per week in the clinical meeting and monthly.  

4.Administrator and nurse.

2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including brain stem stroke syndrome and Alzheimer's disease.

A review of the resident's 02/01/24 to 03/04/24 MARs revealed s/he was prescribed the following PRN psychotropic medications:

* Lorazepam 0.5 mg, 1 tablet by mouth every two hours as needed for "anxiety"; and

* Haloperidol 0.25 ml by mouth every two hours as needed for "hallucination/agitation/nausea/vomiting."

There were no written, resident-specific parameters on the MAR for the PRN psychotropic medications to indicate symptoms for which they would be administered.

In an interview on 03/06/24 at 1:45 pm, Staff 10 (MT) reviewed the electronic MAR and confirmed there were no resident-specific parameters for the resident's PRN psychotropic medications.

The need to include resident-specific parameters on the MAR for all PRN psychotropic medications was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications that were given to treat a resident's behavior had written, resident-specific parameters for 2 of 2 sampled residents (#s 3 and 4) who were prescribed psychotropic medications. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2020 with diagnoses including dementia and major depressive disorder.

A review of the resident's 02/01/24 to 03/04/24 MARs revealed s/he was prescribed PRN psychotropic medication:

* Olanzapine 5 mg, 1 tablet twice daily as needed for delirium.

There were no written, resident-specific parameters on the MAR for the Olanzapine to indicate symptoms for which it would be administered.

In an interview on 03/06/24, Staff 23 (Care Partner) reviewed the electronic MAR and confirmed there were no resident-specific parameters for the resident's PRN psychotropic medication.

The need to include resident-specific parameters on the MAR for all PRN psychotropic medications was reviewed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

330 Systems: Psychotropic Medication

1.Residents 3 and 4 MARs were updated to include resident-specific signs and symptoms of use and non-pharmaceutical interventions to try prior.

2.A full MAR audit is being completed to identify and update all parameters for PRN psychotropics. MAR will be reviewed monthly to ensure all parameters are in place.

3.Several times per week in the clinical meeting and monthly during scheduled MAR review.

4.Administrator and nurse.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities had a thorough assessment completed by the facility registered nurse, a physical therapist, or an occupational therapist prior to use which included documentation of less restrictive alternatives evaluated prior to use for 1 of 1 sampled resident (#2) who had side rails on the bed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 01/2021 with diagnoses including unspecified dementia and type II diabetes mellitus. S/he was subsequently admitted to hospice in 10/2023 with admitting diagnosis of cerebrovascular disease.

During the acuity interview on 03/04/24, staff facility stated there were no side rails being used by any current residents. Upon observation on 03/04/24, Resident 2's hospital bed was observed to have two half-length side rails in the up position.

An entry in the resident's Progress Notes, dated 12/13/23 at 1:06 am by Staff 28 (Clinical Director), recorded, "Assessment for side rails completed." However, there was no documented evidence the facility registered nurse, a physical therapist, or occupational therapist conducted a thorough assessment or that other, less restrictive alternatives were evaluated prior to the use of the device. Witness 2 (RN Consultant) confirmed on 03/07/24 there was no assessment available.

During a phone interview on 03/07/24, Witness 1 (Family Member) confirmed the family was aware of the side rail use and had agreed to it as a fall prevention measure.

The need to ensure the facility registered nurse, a physical therapist, or an occupational therapist had conducted a thorough assessment and other, less restrictive alternatives were evaluated prior to the use of a supportive device with restraining qualities was reviewed with Staff 2 (Vice President of Operations) and Witness 2 on 03/07/24. They acknowledged the findings. No further information was provided.

340 Restraints and Supportive Devices

1.Resident 2 side rail has been thoroughly assessed by the RN and the service plan updated to reflect use.

2.Room audit was performed to identify other assistive devices and assessments completed with service plan updates.  

3.Devices will be assessed quarterly and with significant change of condition that may impact safe use of the device.  

4.RN and administrator.

Based on interview and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) included information for 1 of 5 residents (#4) to inform the generated staffing plan and failed to update the ABST for each resident at least quarterly. Findings include, but are not limited to:

Review of the facility's ABST on 03/05/24 found Resident 4's ADL information was located in the archive record of the tool and, therefore, did not inform the generated staffing plan, which potentially created inaccurate staffing calculations.

In addition, the review revealed 15 of the 33 current facility resident's ABST records were last updated in 2022 and not at least quarterly as required.

During a 03/06/24 interview, Staff 2 (Vice President of Operations) acknowledged the ABST was not reflective of the ADL's needs for Resident 4 and had not been updated at least quarterly for multiple residents.

The need to ensure the ABST included information for each resident to inform the generated staffing plan and was updated for each resident at least quarterly was discussed with Witness 2 (RN Consultant) on 03/07/24. She acknowledged the findings.

361 Acuity-Based Staffing Tool

1.The Acuity Based Staffing Tool is being updated to reflect current residents' needs.

2.Consultants have provided training on completing the ABST with each admission and scheduled service plan update and with significant change of condition.

3.Weekly with service plan updates and monthly with QI meetings.

4.Administrator.

Based on observation, interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) to accurately reflect the time needed to care for 2 of 5 residents (#s 7 and 9) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 moved into the memory care community in 10/2022 with diagnoses including dementia and congestive heart failure.

The resident's ABST, service plan available to staff dated 06/10/24, and active Temporary Service Plans (TSP) were reviewed, interviews with the resident's family and facility staff were conducted, and observations of the resident were made.

The resident's ABST failed to capture the amount of staff time needed to provide care in the following areas:

* Personal hygiene including oral care;

* Assistance with bowel and bladder management; and

* Time spent providing treatments.

The need to ensure the ABST addressed the amount of staff time needed to provide care for the resident was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 39 (Quality Assurance RN), Witness 8 (Consultant), and Witness 2 (Consultant) on 07/11/24. They acknowledged the findings.

2. Resident 7 moved into the memory care community in 07/2020 with diagnoses including Alzheimer's disease.

During the acuity interview on 07/08/24 staff reported the resident required two staff to transfer, required full ADL care including one-on-one meal assistance and was on hospice.

Review of the facility's ABST for Resident 7 identified the facility failed to convert evaluated care needs into accurate staff hours used to generate the facility's staffing plan in the following areas:

* Time spent supervising, cueing or supporting while eating;

* Time spent for bowel and bladder management;

* Time spent repositioning in bed or chair;

* Time spent transferring in or out of bed or chair; and

* Additional care and services for two person care needs.

The need to ensure the facility's ABST converted evaluated care needs into accurate staff hours used to generate the facility's staffing plan was discussed with Staff 30 (Acting ED), Staff 31 (ED), Staff 32 (Health and Wellness Director/RN), Staff 33 (Resident Care Coordinator), Staff 37 (Regional Clinical Director), Staff 38 (Senior Vice President of Operations), Staff 40 (Senior Vice President Clinical RN) and Witness 2 (Consultant) on 07/10/24. They acknowledged the findings.

1. Resident 7- ABST was updated 7/10/24.  ABST tool is reflective of average time spent performing ADL's by staff, not extreme instances.

Resident 9-ABST was updated 7/11/24

2.  ABST training to be provided by Regional Operations Director by 8/5/24.  Education will include how to explain use of ABST tool and reasoning for staffing.

3. Monthly by Regional Operations Team

4. ED and Regional Operations Team.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Fire drill and fire and life safety training records for the last six months were requested at the entrance conference on 03/04/24. Documentation was provided for last three months, not six months as requested. The documentation was reviewed during the survey and the following deficiencies were identified:

1. The facility failed to conduct fire drills every other month; therefore, documentation was lacking in the following required areas:

* Date and time of fire drill;

* Location of simulated fire origin;

* The escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time-period needed;

* The number of occupants evacuated; and

* Evidence alternate routes were used during the fire drills.

During the interview on 03/06/34, Staff 6 (Maintenance Director) reported he was new to the facility and confirmed he had not conducted fire drills for last 3 months.

2. Fire and life safety instruction was not consistently provided to staff on alternate months. On 03/07/24 at 10:30 am, Staff 2 (Vice Present of Operations) confirmed there was no additional documentation related to fire and life safety prior to 12/2023.

The requirements regarding fire drills and fire and life safety instruction for staff on alternating months was reviewed with Staff 2 and Witness 2 (RN Consultant) on 03/07/24. The staff acknowledged the findings.

420 Fire, Life and Safety: Safety

1.Approved fire drill form has been provided that meets the required elements of a fire drill. Staff were provided with training on fire procedures and policies.

2.A schedule has been implemented for ongoing drills and an agenda developed for ongoing staff training on fire, life and safety procedures.

3.Monthly during fire drills and reviewed in the QI meeting.

4.Administrator and maintenance.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed with Staff 6 (Maintenance Director) on 03/06/24, and the following deficiencies were identified:

* There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission; and

* There was no documented evidence of fire and life safety training provided to residents at least annually.

The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 6 on 03/06/24 and Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings. No additional information was provided.

422 Fire and Life Safety: Training for Residents

1.Residents will have received their annual training of Life Safety Program including fire drills and evacuation plan.  

2.New residents will receive the fire drill and evacuation plan within 24hrs of move in. All residents will receive fire and life safety (including fire drills and evacuation) annual retraining with any updates. Those residents needing special assistance will be identified and the care plans will reflect evacuation plans for each resident.  

3.Monthly QA meeting will review compliance of the Fire and Life Safety Program.  

4.Maintenance Director/ED

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

Refer to C231, C252, C260, C270, C295, C303, C361, Z142 and Z162.

1.  Implement Plan of Correction- The ABST has been updated for resident 7 and 9.

2. ED, RN, Regional RN Regional Operations Team will follow POC to Correct Deficiencies-ABST will be reviewed to ensure it reflects all current resident needs.  Moving forward, the ABST will be reviewed as required upon admission, within 30 days quarterly and with change of condition.

3. ED, RN, Regional RN, Regional Operations Team will review Quarterly to ensure continued compliance.

4.  Corporate RN and Operations Team.

Based on 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.

Refer to C303.

Concerns were identified in the following areas and the facility was provided with technical assistance:

H1515: OAR 411-004-0020(2)(b) Physical Setting: Individual Accessible.

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(b) The setting is physically accessible to an individual.

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:

During the re-licensure survey, conducted 03/04/24 through 03/07/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the number and severity of citations.

Refer to C150, C160, C200, C231, C361, C420, and C422.

Referral--Non Healthcare Rules

Phone interview with Tood Whitehead, Administrator on 05/02/24 at 4:15 pm. The facility origanally submitted aPOC for the referral tag Z142 the POC did not address the non health care RALF rules cited in the survey. After discussion with Todd, he gave permission to have the original POC for Z142 removed  and "refer to POC for cited areas" submitted in its place. Change was made by Mo Mills, Surveyor on 05/02/24.

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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 231, C 295, and C 361.

Refer to C 231, 295 and 361

Based on interview and record review, it was determined the facility failed to ensure staff completed all required annual training for 3 of 4 veteran direct care staff (#s 11, 12, and 26) whose training records were reviewed. Findings include, but are not limited to:

A review of staff training records on 03/05/24 with Staff 4 (Business Office Manager) revealed the following:

Staff 11 (Care Partner), hired 01/11/22, Staff 12 (Care Partner), hired 07/22/20, and Staff 26 (Care Partner), hired 09/24/20, had not completed the required 16 hours of annual training related to provision of care for residents, including six hours related to dementia care.

The need to ensure all veteran staff completed 16 hours of annual training was discussed with Staff 2 (Vice President of Operations) and Witness 2 (RN Consultant) on 03/07/24. They acknowledged the findings.

Z155 - Staff training:

1. Staff members audited during survey have been given their training assignments.

2. A full training audit will be completed to ensure that staff have completed the required 16 hours of annual training related to provision of care for residents, including six hours related to dementia care. New hires will complete all training required and training audit forms will be utilized.

3. Staff training records will be audited monthly in the QI meeting.

4. Administrator and BOM

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:

During  the re-licensure survey, conducted 03/04/24 through 03/07/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to C252, C260, C262, C270, C280, C282, C295, C300, C302, C303, C310 , C330, and C340.

Referral--Healthcare Rules

Phone interview with Tood Whithead Administrator on 05/02/24 at 4:15 pm. The facility origanally submitted aPOC for the referral tag Z162 the POC did not address the non health care RALF rules cited in the survey. After discussion with Todd, he gave permission to have the original POC for Z162 removed  and "refer to POC for cited areas submitted in its place. Change was made by Mo Mills, Surveyor on 05/02/24.

Z164 - Individualized activity plan

1.The Residents social identified during survey as being out of compliance, will be reviewed, parameters obtained, and individualized activity plans created.  

2.An audit of all residents will be conducted, and social profiles updated as needed.  

3.Social profiles will be completed for all residents upon move-in, upon any change of condition, and annually thereafter. These profiles will be routinely reviewed by the LED, ED, and HSD to ensure accuracy before service plan meetings with families.

4.LED/Designee/ED

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 252, C 260, C 270 and C 303.

Refer to C 252, 260, 270 and 303

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

Refer to  C 303.  

Refer to C303.