Print Inspection: G7GA

The findings of the Change of Management survey, conducted 06/13/22 through 06/17/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the change of ownership survey of 06/17/22, conducted 12/27/22 through 12/28/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

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

During the Change of Management survey, conducted 06/13/22 through 06/17/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

1. Administrative management team  including Executive Director, department managers  and Park Avenue Life Stye Management for Clinical and Operations Directors have reviewed, revised and updated all policies and procedures and intitiated trainings for all new and existing staff. Please see each citation for more information

2. A change of administrator is in process to provide effective oversight including ensuring the quality of care and servces. An admininstrator and designee have submitted information for approval by DHS. Both are completing required Criminal Background checks and other state requirements including attendance of OHCA Administrator Training Class form 7.25.2022 to 7.29.2022 prior to completing the licensing exam.

3.  Administrative management including community and management company leadership participate in weekly audit reporting with quality improvements.

4. Administrator and/or designee.

Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents related to the evacuation capability of the residents and staff. The lack of an updated emergency plan, adequate direct care staff, lack of fire safety evacuation training for residents and staff, and lack of emergency evacuation equipment placed residents at potential risk of harm. Findings include, but are not limited to:

1. The building consisted of four floors, with the endorsed MCC on the first floor and an ALF on the second, third, and fourth floors under a separate license. The MCC had two emergency exits located on the northwest and northeast sides of the MCC. The exit on the northwest side opened to an outside sidewalk, and the exit on the northeast side opened to a stairwell leading down to the parking garage.

During the Change of Management survey, 06/13/22 through 06/17/22, the survey team identified the following concerns:

* The MCC was home to 27 residents, including six requiring two-person assist for transfers with a Hoyer or Sit-to-Stand Lift and 14 residents with high care needs.

* The 06/2022 MCC staffing schedule showed there was one resident care assistant for the night shift and one MT working between the MCC and the ALF, which was under a separate license. On 06/15/22, Staff 1 (Memory Care Director) and Staff 3 (ED) confirmed the staff scheduled at night and stated there was one MT between the MCC and ALF.

* On 06/15/22, Staff 3 and Staff 5 (Maintenance Director) were interviewed regarding the facility emergency evacuation plan and training. When asked if the facility had evacuation equipment, Staff 3 indicated she had been trying to get equipment.

One resident care assistant on the night shift for 27 memory care residents, including six requiring a Hoyer lift or sit-stand. Staff 3 and Staff 5 acknowledged the need for proper evacuation equipment and the need to for adequate staffing levels. During the interview, the following concerns were identified:

* Facility evacuation plan was not updated;

* Lack of staff and resident emergency evacuation training;

* The MCC residents and staff would need to have emergency evacuation training; and

* Facility lacked emergency evacuation equipment needed for evacuating safely.

The above areas were reviewed and discussed, and the need to ensure the facility was prepared, trained, and had adequate staffing in case of an emergency, including the night shift, was discussed with Staff 1, Staff 3, and Staff 5 on 06/15/22. They acknowledged the findings.

The survey team requested the facility provide a short-term and long-term plan of safety which was received on 06/15/22.

2. Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.

* On 06/13/22 through 06/16/22, during meal observations, staff assisted residents to the dining room. Staff did not wash residents' hands, offer hand sanitizer, or provide hand hygiene prior to serving the meals.

* On 06/14/22, the surveyor observed there was no paper towel dispenser available next to a handwashing sink in the activity kitchenette, and there were no paper towels in the dining room kitchenette.

* On 06/14/22 at 12:03 pm, during the lunch meal, an unsampled resident was observed sitting at a table in the dining room spitting on the floor. The staff did not clean the area. The resident was also shouting, and the staff did not redirect. On 06/15/22 at 9:48 am, the resident was observed sitting in a chair next to another resident, spitting on her/his arm and the floor. No staff was present, nor had the area been cleaned.

The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Memory Care Director) on 06/14/22. She acknowledged the findings.

3. Refer to C530.  

1. Fire and Emergency Evacuation Plan has been reviewed and updated. Evacuation equipment obained and is used in all staff evacuation trainings.

All residents have been evaluated for ability and need for level and type of assistance to participate in drills and evacuations. All newly hired staff have been trainied prior to providing services (date or hire). Existing staff are being trained on fire drills and the newly updated Emergency Plan and Evacuation procedrures.

2. & 3. Weekly reports for employees not in attendance for routine monthly training and drills will be sent to each department manager for follow up with employee.  Reisdent Service Plans will reflect willingness and ability to participate in these events, on move in and review/re-evaluated every 90 days or before, if changes in a resident condition.  

4. Department Managers and Administrator.

Reasonable Precautions

1. All new hires are completing the 2hr infection control. Any current staff that has not completed the 2 hour infection control will be completing this training.

RN will be completing training on 8/25 with All Staff.

2. Infection control training added to new hire orientation.  

3. Training will be audited weekly for 12 weeks and audits will be reviewed by Quality Assurance Committee and recommedations made based on audit review.

4. Health and Wellness Director (RN) or designee    Adequate Direct Care Staff:

1. State provided acuity-based staffing tool updated by Memory care direcotr at https://ltcfacilityportal.oregon.gov and calculated the number of staff hours required to meet the scheduled and unscheduled needs of all residents in Memory Care:

a.Extra staff employed by Cornell Landing were added to all shifts.  

Staff reeducated on the acuity guideline policy for all potential move-ins. The acuity guidelines require the interdisicplinary team to discuss the acuity of a resident prior to move-in and ensure that staffing levels and/or equipment available will meet the needs of the resident.

2.and 3. Staffing hours will be monitored on a monthly basis by the Resident Care Coordinator, the Health & Wellness Director, and the Memory Care Director. When alterations to staffing hours are required based on the above-mentioned procedure, a determination will be made to hire more staff or in the case of a short-term change in condition bring outside providers (i.e., hospice, home health, agency, etc.).

4.The Memory Care Director under the direction of the Executive Director and the Health and Wellness Director will make the determination to approve new move-ins, hire staff, and/or bring in outside providers.

Emergency Evacuation Equipment:

1.The following evacuation equipment has been purchased:

a.4 Evac-chairs have been purchased and will be placed in the stair wells on each floor - two on the NE and 2 on the NW stairwells.

b.Evacation blankets Have been purchased and will be kept in various locations throughout the building where staff can easily access them in the event of an emergency requiring their use (i.e., commercial laundry room in Memory Care, Storage closet on 4th floor, etc.).

c.Maps and directions for exiting installed at every stairwell.

2.Staff will receive monthly training in emergency and fire/life safety. The Maintenance Director will be responsible for ensuring equipment is located in the correct areas and in good working order.

3.Inspections should be performed on equipment quarterly and after any trainings and/or actual evacuations to ensure equipment is not damaged, in need of repair and/or replacement.

4.The Maintenance Director will monitor quarterly.

Universal Precautions for Infection Control: Hand Hygiene

1.Staff have been trained to offer hand hygiene to residents before meals, after activities, and after toileting. The staff have been given training in the importance of hand hygiene before meals as a way to decrease risk cross contamination of germs from hands to food and ultimately into the mouth of residents as well as the risks associated with lack of hand hygiene for both residents and staff.

Residents are invited to perform hand hygiene throughout the day using various methods including:

a.Use of sink and soap

b.Hand sanitizer

c.Waterless soap that can be wiped with a cloth or paper towel

d.Hand wipes

Providing residents with multiple types of hand hygiene and increased opportunities to perform hand hygiene will make it easier for them to perform the process and diminish resistance (although residents are still encouraged to make their own decisions).

2.The systems will be updated in the following ways:

a.Frequent in-person training on the importance of hand hygiene will occur regularly with staff.

b.Simple signs inviting residents to wash their hands will be placed throughout Memory Care will be placed in highly visible areas.

c.Increased monitoring of staff during activities like toileting and meals to ensure that residents are offered frequent hand hygiene as part of their daily routine.

3.This will be monitored daily

1.The Memory Care Director, The Health and Wellness Director, the Assistance Health and Wellness Director, the Resident Care Coordinator with additional oversight and support from the Executive Director.  

Paper Towels:

1.New dispenser placed by sink. Paper towels immediatetly filled.

2. Paper towel check added to housekeeping checklist to verify that paper towels are replaced when running low.  back up rolls available for staff use.  Staff educated on location.   

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to:

Observations made on the memory care unit between 06/13/22 and 06/17/22 revealed there were no group activities occurring on a consistent basis. Multiple residents who were in the common areas, throughout the survey, were not provided any individual or group activities.

Residents were observed sitting in common areas for long periods of time watching television, people-watching or remained in their rooms. Multiple residents were observed pacing the halls frequently without being engaged in any individual or group activities. Further observations included:

* The activity calendar posted on the unit included providing meals and snacks to residents;

* On 06/14/22, crafting, soccer practice and interactive games were scheduled on the  calendar but not offered on the unit;

* On 06/15/22, balloon volleyball, science labs and happy hour were scheduled on the unit but not offered; and

* On 06/16/22, brain busters, "get fit", stories by the fireplace and walks around the neighborhood were scheduled on the calendar but not offered on the unit.

Staff were observed, on two occasions, escorting a small group of residents off the memory care unit to attend an activity at the assisted living facility upstairs.

During an interview on 06/14/22, Staff 1 (Memory Care Director) stated the facility had hired a new activity director, however the employee had not yet started working. She further stated an activity aide and the direct care staff were providing activities as time allowed between resident care and other duties.

Interviews on 06/15/22 with multiple facility staff revealed there were currently no activity staff assigned to the memory care unit to conduct activities on the unit. An activity staff from the assisted living facility upstairs provided games, puzzles, pictures for coloring, etc. for direct care staff to engage in one on one activities as time allowed. There were no exercise or group activities provided and the activities identified in multiple sampled resident service plans were not provided.

The need to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs was discussed with Staff 1 on 06/16/22. She acknowledged the findings.

1. Newly hired Activity Director (AD) has completed evaluations for residents identified during survey including ability, interest and need for any accomodations. Ongoing evaluations of all residents in progress: information for resident choices,preferences, abilities and accomodations are incorporated into their SP.

2. AD will develop new Activity Schedules for regular postings. AD will keeps record of  resident attendance and leve of participation in activittes. AD will follow up residents as needed to determine further interests and and accomodations needed. Life Loop system is being used.

3. AD will generate weekly report to Administrator.

4. Activities Director.

Based on interview and record review, it was determined the facility failed to ensure initial evaluations were updated within 30 days of move-in and quarterly evaluations were completed timely and were reflective of the residents' current needs for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022. Review of Resident 1's records showed the facility completed an initial evaluation dated 05/03/22. Progress notes and incident reports from move-in on 05/03/22 through 06/02/22 revealed the resident had two non-injury falls, one fall with injury, and was sent to the emergency room for elevated blood pressure and an episode of unresponsiveness.

There was no documented evidence the initial evaluation had been updated with the documented changes within the first 30 days following the resident's move into the facility.

2. Resident 3 was admitted to the facility in 04/2021. Documentation of Resident 3's quarterly evaluation was requested during the survey. A review of Resident 3's records revealed no evidence of a quarterly evaluation. In an interview with Staff 2 (Director of Nursing Services) on 06/16/22, she confirmed the facility had not completed a quarterly evaluation for the resident.

The need to ensure initial evaluations were updated with changes and modified as needed within 30 days of move-in and quarterly evaluations were completed timely was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings

3. Resident 2 was admitted to the facility in 12/2019. The most recent evaluation was dated 02/11/22. The resident had experienced a decline in multiple areas and should have been re-evaluated in May 2022. The facility failed to update the evaluation at least quarterly.

4. Resident 4 was admitted to the facility in 04/2021. The resident's most recent evaluation was dated 01/26/22. The resident had experienced a general, overall decline and should have been re-evaluated in March 2022. The facility failed to update the evaluation at least quarterly.

In an interview on 06/16/22, Staff 1 (Memory Care Director) acknowledged the facility was behind in performing quarterly updates for many of the facility's residents.

The need to perform evaluations, at least quarterly, with updates to health status, needs and preferences was discussed with Staff 1 and Staff 2 (Director of Nursing Services) on 06/16/22. They acknowledged the findings.

1. All residents identified during survey have been assessed and evaluations completed with updates and current information.  

2. A tracking document /calender has been developed for use as  tool to assist nurses and adminisrator to complete evauations for each recurring SP in advance of 90 days. Addional YARDI (electronic documentation) training has been provided for staff to complete documetnation thouroghly and on time.

3. Daily clinical stand up meetings with nurses and administrator will include review of current evaluations scheduled and completed. Initial evaluations will be completed with documentation prior to move in date for SP development and all staff to follow. New move in Evaluation and SP will be reviewd and updated with in 30 days.  The timeliness of completing all evaluations will be reviewed monthly by  the Quality Improvement Committee.

4. Administrator and/or designee  

3. Resident 1 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease and a stroke.

Review of the resident's initial service plan dated 05/27/22, and observations and interviews conducted between 06/13/22 and 06/16/22, revealed Resident 1's service plan was completed 24 days after the resident moved into the facility and was not reflective and did not provide clear instruction to staff in the following areas:  

* Recent falls and interventions;

* Episode of unresponsiveness and trip to the emergency room; and

* Current skin condition.

4. Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's and Dementia with behavioral disturbance.

Observations of the resident and interviews with staff from 06/13/22 to 06/16/22 and review of the most current service plan, dated 04/18/21, and temporary service plans revealed the service plan had not been updated for over a year. The service plan was not reflective of the resident's current care needs and lacked specific instruction to staff in the following areas:

* Overall decline in physical health and increase in ADL care needs;

* Hospice services;

* Change in sleep pattern;

* Increased aggressive behaviors including altercations with other residents and interventions;

* Current level of orientation and ability to understand and be understood;

* Toileting and assistance needed;

* Skin condition and foot care;

* Weight loss and interventions;

* Diet and food texture modification;

* Nutritional supplement and frequency; and

* Falls and interventions.

In an interview on 06/14/22, Staff 2 (Director of Nursing Services) confirmed that Resident 3's service plan had not been updated and that the facility was working on reviewing and updating residents' service plans.

The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff regarding delivery of services, were created and updated timely and available to direct staff was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were updated quarterly and reflective of residents' current care needs for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2's service plan, dated 02/11/22, was reviewed along with Temporary Service Plans (TSPs) dated between 03/05/22 and 06/12/22 .

The service plan had not been updated, at least quarterly, to incorporate the TSP's that were still pertinent to the resident's care.

2. Resident 4's service plan, dated 01/26/22, was reviewed along with TSP's dated between 02/25/22 and 04/26/22.

The service plan had not been updated, at least quarterly, to incorporate the TSP's that were still pertinent to the resident's care.

The need to ensure the service plans were updated, at least quarterly and included pertinent information addressed in TSP's was discussed with Staff 1 (Memory Care Director) and Staff 2 (Director of Nursing Services) on 06/16/22. They stated a Resident Care Coordinator was recently hired and updating service plans would be a priority.

1. All residents indentified during the survey have been assessed, service plans have been reviewed and updated appropriately.  

2. The tracking doucment tool will be utilized as describe in  POC for C252 to assist nurses and administrtors to track due dates and time lines for all residents' SP

3. Daily clinical stand up will include list of SP coming due and the schedule for completing similar to C252 POC. Audits will be completed twice a month to determine.

4. Health and Wellness Director.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of  4 sampled residents (#s 1, 2 and  3).  Findings include, but are not limited to:

Resident 1, 2 and 3's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Memory Care Director) on 06/17/22. No further information was provided.

1. The Health and Wellness Director or desingee to Contact designated family members along with residents to invite and attend scheduled Service Plan meetings. Service Planning Teams consist or Administrator or designee, Nurse and one other staff member (either Med Tech or caregiver familiar with  the resident service needs) and the team will particiapte in each SP. Service Plan meetings and teams will be scheduled for two different days each week.

2. By setting up  two reoccuring weekly meeting with advance notice to all participants will help to ensure team attendance and timley completion of SP.

3. Weekly as stated in 2 above.

4. Administrator and/or designee.

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.

The resident's 05/27/22 service plan, 05/03/22 through 06/05/22 progress notes, incident reports, and temporary service plans (TSPs) identified the resident had experienced falls on the following dates:  

* On 05/05/22 resident had a non-injury fall in the dining room. A TSP written the same day lacked documented resident-specific fall interventions;

* On 05/27/22 resident had a non-injury fall in the dining room. A TSP written the same day lacked documented resident-specific fall interventions; and

* 05/30/22 resident had a fall with injury and sustained a laceration to his/her left lower leg, A TSP written the same day noted a sign was added to the resident's walker to help remind him/her to keep hold of the walker with ambulation. There was no documented evidence the identified intervention was monitored for effectiveness.

The need to ensure the facility determined and documented what actions or interventions were needed and monitored their effectiveness was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions developed, and the condition monitored, for 2 of 4 sampled residents (#s 1 and 2 ) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 2019 with diagnoses including depression and Parkinson's disease.

a. A review of the resident's weight records from 01/30/22 through 04/28/22 revealed slow, steady weight loss. There was no documented evidence the facility determined or documented actions or interventions needed to address the weight loss.

b. Resident 2 experienced unwitnessed falls on 03/25/22 and 05/10/22. Incident reports were reviewed following the falls. The incident reports did not include any information about the interventions that had been in place at the time of the falls and did not address any new interventions identified as a result of the falls, and to be monitored to determine the effectiveness of the interventions.

c. Progress notes documented Resident 2 developed a bruise on 05/15/22. The record lacked any evidence the bruise was monitored, at least weekly, through resolution.

The need to identify and monitor changes of condition, identify interventions and monitor their effectiveness was reviewed with Staff 1 (Memory Care Director) and Staff 2 (Director of Nursing Services) on 06/16/22 . They acknowledged the findings.

1. Res #1. A care cooordination meeting plan is in process of completion for fall risk reduction and fall prevention interventions. Pharmacy will review medications that may be contributing fall risk. Physical Therapy and Nursing are completing assessments with person centered approach to interventions to include in the SP. Res #2 A care coordinaiton meeting is planned with Hospice to review the goals of care along with pharmacy review of medicaitons that may be contibuting to loss of appetite /weight loss.

2. A change of conditon system now includes training all staff on  regulations for observing, reporting, monitoring and documenting any noticiable changes in a residents routine or overall conditon. Training on the mandatory use of tools is in process and inlcudes:  STOP AND WATCH  for cargivers and SBAR for Med Techs and Nurses. Alert charting and Temporary or other changes on the SP will be directed by nurses and communicated to health services staff. Nurse is on call for any questions or concerns regarding a resident potential change of condition. Documentation will follow in the progress notes inlcuidng reviewing effectviness of  interventons  and  when a short term condtion has been resolved and wll be taken off ALERT.  An ALERT White Board will be located in MEDROOMS with HIPPA protections for daily tracking at a glance and shift change reporting.

3. Nurses will follow up daily on STOP & Watch and review the ALERT Charting daily. Weekly clincal standup meetings will include  review of all residents

CoC on ALERT.  

4. Nurses and Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN completed a significant change of condition assessment, which included findings, developed interventions based on the condition of the resident, and updated the service plan for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's disease.

Over the past three months, the resident had been diagnosed with COVID-19 and had symptoms, had a decline in physical and cognitive functioning and had been admitted to hospice services.

Progress notes dated 03/11/22 through 06/13/22, incident reports, service plans, temporary service plans, and weight documentation were reviewed during the survey. The following deficiencies were identified:

* Between 03/29/22 and 05/02/22, Resident 3 lost 8.8 pounds or 6.24% body weight; and

* Between 03/29/22 and 06/17/22, Resident 3 lost 23.4 pounds or 16.59% body weight.

This weight loss represented a significant change of condition for Resident 3 for which an RN assessment was required.

There was no documented evidence the facility RN conducted an immediate assessment of the weight loss which included documentation of findings, resident status and interventions made as a result of this assessment. The resident's service plan was not updated and there was no evidence current interventions were evaluated for effectiveness or new interventions were developed and implemented.

The need to ensure significant changes of condition were assessed and documented by the facility RN, and changes were made to the resident's service plan based on the findings of the assessment, was reviewed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2019 with diagnoses including depression and Parkinson's disease. During the acuity interview on 06/13/22 the resident was identified as having wound treatments.

Resident 2 was observed during the survey with bandages to both outer ankles.

The clinical record, including the current service plan, dated 02/11/22, progress notes dated 03/06/22 through 06/13/22, and temporary service plans, were reviewed during the survey and revealed the following:

a. On 05/03/22, in the progress notes, the facility RN documented a stage two pressure wound to the resident's left outer ankle and a stage three pressure wound to the resident's right outer ankle. The notes included interventions of requesting Home Health services, continuation of a nutritional supplement and ordering a floor mat.

This represented a significant change of condition. There was no documented evidence the facility RN conducted an assessment of the resident's condition which included findings and a description of the resident's status as a result of the assessment.

b. Resident 2 had experienced multiple mood changes, medication changes and periods of increased sleepiness. Weight records were reviewed and showed the following information:

* On 02/12/22, weighed 145 pounds;

* On 03/14/22, weighed  138 pounds;

* On 04/28/22, weighed 134 pounds; and

* On 06/16/22, weighed 129 pounds.

Resident 2 experienced a weight loss of 7 pounds from 02/12/22 to 03/14/22. This was a 4.8% weight loss in 1 month, and on 04/28/22 had lost an additional 4 pounds which represented a significant loss. The facility had not obtained a weight on the month of May. On 06/16/22, Resident 2 was weighed, per the surveyors request, and had lost an additional five pounds since 04/28/22 for a total loss of 16 pounds in three months, which represented 11% of his/her body weight.

This represented a significant change of condition. There was no documented evidence the facility RN conducted an assessment of the resident's condition which included findings, a description of the resident's status and interventions implemented as a result of the assessment.

In an interview on 06/15/22, Staff 2 (Director of Nursing Services) stated the current (new) electronic system was not programmed to notify staff of a significant weight loss in 3 months. Staff 2 had not been aware of the weight loss, however, she acknowledged the weight loss may have been attributed to the recent medication changes and fluctuating sleep pattern the resident experienced.

On 06/15/22, the need to conduct an RN assessment following a significant change in condition, which included all the required elements of an assessment, was discussed with Staff 1 (Administrator) and Staff 2 (Director of Nursing Services). They acknowledged the findings.

1. Res#3 passed away on hospice care7/18/22.

Res #2 is currently receiving hospice care and her Service Plan has been updated to reflect this singinficant change of condition.

2.Nurses will follow up with in 24 hours of any potential change of condition with a nursing assessment and documentation in progress notes; either a temporary SP for a temporary change of conditon or a new SP  for a significant change of conditon (such as  the addition of hopsice serivces) or loss of previous functional ability. All accidents, injuries, emergency room encounters will be called to the nurse on call if nurse is not on duty at the time of the incident for timely notificaton and follow up directions for care staff.  

3. Daily stand up meetings will include changes to service plans based on changes of resident conditions. any accidents injuries and emergency room visits along with resident changes of condtion.

4. Health & Wellenss Director

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

During the change of management survey conducted on 06/13/22 through 06/17/22, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C 303: Systems: Medication and Treatment Orders;

* C 305: Systems: Resident Right to Refuse; and

* C 310: Systems: Medication Administration.

During the exit meeting on 06/17/22, Staff 1 (Memory Care Director), Staff 3 (Executive Director) and Staff 4 (Assistant Health and Wellness) were informed the overall medication and treatment administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas.

1.All residents identified on survey have been assessed, reviewed and addressed by nurses with specific written and verbal instructions  with Med Techs. Medical orders for time sensitve administration and other tasks related to accurate administrations such as Blood pressures, physical postioning, empty stomach or with food are incuded in the MAR.  Policies and procedures have been reviewed and updated to include time frame for other medicaitons without time sensitivity that include time frames for Breakfast, Lunch, Dinner and Bedtime administration. If medical orders donoot prohibit resident preferences , these will be included on the SP along with time sensitive meds. All resident refusal have been faxed to prescribers.Oregon Care Partners traing on Role of the Med Tech and Safe Mediction Use for Older Adults  has been scheduled for Med Techs and Administrator.

2 & 3. Nurses will review all medical orders and ensure accuracy for time sensitive medicaions administered on time along with MT following the complete medical order and notification to prescriber for all refusals with reason why resident is refusing if known. Nurses will complete audits 2 times weekly for orders and administration accuarcy and follow up. Nurses will , track and report medication errors; and direct staff in the overall safety and well being of the resident in each occurance.

4. Nurses will track and audit weekly for 12 weeks and report monthly to Quality Improvement Committee which inlcudes the Administrtor.

Based on interview and record review, it was determined the facility failed to carry out orders as prescribed for 2 of 4 sampled residents (#s 2 and 4) whose orders and MARs were reviewed. Resident 2 was not administered a time sensitive medication timely which put the resident at risk for potential harm. Findings include, but are not limited to:

1. Resident 2's physician's orders and the 06/01/22 to 06/13/22 MAR, were reviewed. The following deficiencies were identified:

Resident 2 was admitted in 12/2019 with diagnoses including Parkinson's disease. Following a neurologist visit on 05/16/22, orders were provided to the facility to administer carbidopa-levidopa 25-100 mg tab (for Parkinson's disease) as follows:

Week 1: 1.5 tablet TID: at 7:30 am, 11:30 am and  4:30 pm.

The MAR showed the carbidopa-levidopa was administered from 06/02/22 through 06/05/22 at 4:30 am, 7:00 am and 11:30 am.

The MAR instructed staff to administer the medication at 4:30 am instead of 4:30 pm on four occasions. Upon review of actual administration times, medication technician's (MT's) administered the carbidopa-levidopa at incorrect times (when compared to the order) on nine out of twelve occasions between 06/02/22 and 06/05/22.

In an interview on 06/15/22, Staff 2 (Director of Nursing Services) acknowledged the order times had been transcribed incorrectly and administered at the incorrect times. The time sensitive importance of the medication put the resident at potential risk of harm.

Upon further review of additional administration times, Staff 2 acknowledged MT's administered the carbidopa-levidopa late on three additional occasions between 06/06/22 and 06/13/22, and the MAR listed an incorrect administration time of 7:00 am.

2. Resident 4 was admitted in 04/2021 with diagnoses including Alzheimer's disease and osteoarthritis. Resident 4's physician's orders and the 06/01/22 to 06/13/22 MAR, were reviewed. The following deficiencies were identified:

On 05/19/22, a physician's order instructed staff to administer Oxycodone (for pain) and to "give at 0600 prior to getting up for the day ..."

The instructions were printed on the MAR, however the MAR showed the administration time for the first dose at 8:00 am. In an interview on 06/16/22, Staff 8 (MT) stated the resident was "already up when [she] administers the 8:00 am dose" of the Oxycodone.

In an interview on 06/16/22, Staff 1 (Memory Care Director) acknowledged the findings and stated the administration time would be changed to follow the order as prescribed and MT's informed to ensure the resident receives the medication as intended for pain control.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 and Staff 2 on 06/16/22. They acknowledged the findings.

See POC C 300C

303- Systems:

Treatment orders

1. Resident 2: RN immediately verified correct times were in place on MAR with note of time sensitive medication.

Resident 4: RN immediately verified correct times were in place on MAR .

RN completed 1:1 training with med tech that gave medication late.

2. Med Tech meeting held 6/28/22 including training on approving medication as prescribed and administering time sensitive medications correctly.

2 & 3. Nurses will review all medical orders and ensure accuracy for time sensitive medicaions administered on time along with MT following the complete medical order and notification to prescriber for all refusals with reason why resident is refusing if known. Nurses will complete audits 2 times weekly for orders and administration accuarcy and follow up. Nurses will , track and report medication errors; and direct staff in the overall safety and well being of the resident in each occurance.

4. Nurses will track and audit weekly for 12 weeks and report monthly to Quality Improvement Committee which inlcudes the Administrtor.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when a resident refused to consent to a medication or treatment order for 1 of 1 sampled resident (#3) who had documented refusals of medication. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's and Dementia with behavioral disturbances.

A review of the resident's current physician orders and 05/01/22 through 06/13/22 MARs identified the resident had refused medications on 20 occasions in May and 24 occasions in June.

There was no documented evidence the physician had been notified of the refusals.

The need to ensure the facility had a system to notify the physician or other practitioner when a resident refused to consent to a medication or treatment order was discussed with Staff 1 (Memory Care Director) on 06/17/22.

See POC C 300

Residents PCP has been notified of refusals. Policies and Procedures have been updated to include reporting every time a resident refuses. Med Techs have been instructed on P&P and will document on the electroinc MAR along with faxing the PCP.

2. Health and Wellness Director or nurse designee will audit documenation of refusals weekly. Med Tech will include refusals and notficaitons in shift to shift reports.

3. Health and Wellness Director will audit and report weekly for 12 weeks.  Audits to be reviewed during monthly QA meeting.

4. Health and Wellness Director and/or nurse designee.  

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication-specific instructions when indicated for 1 of 4 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022 with diagnoses including a stroke, atrial fibrillation (abnormal heartbeat), hypertension, and hypothyroidism.

Resident 1's MARs from 05/03/22 through 06/13/22 and physician orders were reviewed and noted the following:

* The resident had physician orders for Levothryoyxine (thyroid), Xarelto (blood thinner) and furosemide (diuretic) that required medication-specific instructions. There were no medication-specific instructions ( significant side effects, time-sensitive dosage, when to call the prescriber or nurse) for any medication listed on the MARs; and

* Resident 1's clinical record identified the resident was allergic to donepezil, penicillin, and pollen. There were no documented evidence Resident 1's medication allergies had been transcribed onto the MARs.

The need to ensure MARs were accurate, including medication-specific instructions and resident medication allergies, was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.  

1. Resident #1 MARS and SP has been updated with current allergies.

2. YARDI system has been updated to include and transfers this information to MAR. Med Techs will notify nurse if any MAR does not include specific notations for allergies including NKDA (No Known Drug Allergies) Allergies will be included on SP , MARS and will be reviewed every 90 days.

3. MARs will be reviewed by nurses monthly to include allergies.

4. Health and Wellness Director and/or nurse designee.  

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

The endorsed Memory Care Community was located on the 1st floor of a four-story building.  The second, third, and fourth floors were assisted living under a separate license.

The Memory Care Community was home to 27 residents at the time of the survey. During the entrance conference on 06/13/22, the following was identified:

*14 residents were identified with high ADL care needs;  

* Six residents required two-person assistance for transfers with a Hoyer or Sit-to-Stand Lift;

* Four residents needed assistance with meals; and

* Four residents were identified with behavioral issues, including resident altercations.

On 06/15/22, the surveyor requested a copy of the staffing plan and the facility's procedure for determining appropriate staffing levels.

The staffing plan for the MCC was the following:

Three caregivers and one med tech per day and swing shifts, one caregiver in the MCC, and one med tech working between the MCC and the ALF for the night shift.

During an interview with Staff 3 (ED) on 06/15/22, it was revealed the facility failed to utilize a written, defined system to determine appropriate numbers of caregivers and general staff based on resident acuity and service needs.

Observations and interviews conducted during the survey on 06/13/22 through 06/17/22 showed the following:

* The MCC staff were not direct caregivers but universal workers. In addition to providing resident care, MCC staff duties included setting up and serving food and beverages, cleaning up after meals, light housekeeping, and doing residents' laundry.

The regulation requires that if universal workers are used, the facility must increase the number of staff to maintain adequate resident care and services. The number of staff was not increased to meet resident needs.

* On 06/14/22 at 10:00 am, two residents in wheelchairs and one in a Geri chair were sitting in front of a blank television screen until 10:20 am, when Staff 1 (Memory Care Director) turned on a show for the residents.

* In an interview with Staff 1 (Memory Care Director) on 06/14/22 at 10:32 am, she verified there was no designated activity worker for the MCC that day, and the one activity assistant working was in the assisted living.

* There was a lack of scheduled and unscheduled activities provided for residents living in the MCC;

* Multiple times throughout the survey, three unsampled residents were observed wandering in and out of other resident rooms;

* Staff were interviewed throughout the survey and expressed an overall concern that there was not enough care staff to provide quality care.

The MCC residents depended on staff for care needs, nourishment, safety, mobility, activities, and engagement.    

* An interview on 06/14/22 at 11:30 am with Witness 1 stated that s/he visited the MCC daily and was concerned with the lack of staffing. Witness 1 further indicated that s/he was worried if s/he was not there, who would assist the resident to the dining room or activities.

The need to ensure the facility had a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and there was a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

1. Staffing with full time employees inlcudes the following: Day shift= 1 Med Tech + 3 caregivers.Swing  shift= 1 Med Tech+3 cargvers Night Shift= 1 Med Tech + 2 caregivers. This represents dedicated staff in MC.

2. Acuity Based Staffing Tool used and updated monthly as needed to track resident care for scheduled and unscheduled needs and staffing will be adjusted as required.

3. Monthly or as needed as residents' condition change and or new residents move in.

4. Administrator.

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

Review of fire and life safety records provided by the facility on 06/13/22 revealed a lack of documented evidence the facility conducted fire drills every other month and provided fire and life safety instruction to staff on alternate months.

On 06/15/22, Staff 4 (Maintenance Director) and Staff 3 (ED) confirmed the facility was not conducting fire drills on the memory care unit nor had staff been receiving fire life and safety instruction on alternate months.

The need to ensure the facility conducted fire drills on the memory care unit and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 Memory Care Director) and Staff 4 an on 06/15/22.

Refer to C 160 (1)

1. Maintenance Manager has revised and updated the Emergency Disaster Plan and Fire drill procedures; conducted trainings and evacations with staff and residents; developed alternating monthly schedules for staff and resident trainings and drills.

2. Detailed documentation regarding each training and drill procedure along with attendance is in prgress. Details include but are not limited to evacuation routes,safety points outside the building, how many people participated; amount of time to evacauate etc.,  

3. While fire drills are not announced in advance, both veral (daily stand up meetings) and written reports will be provied to administrator for results of drills and trainings utilizing the information required including all required aspects.Sumary reports will be provided to Quality Improvement Committee.

4. Maintenace Manager.

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

Fire and life safety records reviewed on 06/15/22 revealed there was no documented evidence residents were being instructed on fire and life safety procedures within 24 hours of admission and annually.

The need to ensure residents were provided instruction per the Oregon Fire Code was reviewed with Staff 1 (Memory Care Director), Staff 3 (Executive Director) and Staff 4 (Maintenance Director) on 06/17/22. They acknowledged the findings.

See POC C420

Residents ability and type of assistance or equipment needed to evacuate has been evauated and included on their SP.

Training for Residents on Fire and Life Safety Procedures.

1.While each resident has advanced dementia, it is not prudent to review the emergency evacuation procedures with them on move-in. However, each resident will be included in routine evacuation and emergency drills. Each resident will also be evaluated on move in for what type of assistance may be needed to evacuate the building.

2.Every other month during fire drill procedures, staff will follow SP to assist each resident as needed.

3.SP will be reviewed every 90 days for assistance needed during fire drill to determine if there any changes.

4.Health and Wellness Director or designee

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

Observations of the memory care environment on 06/13/22 through 06/16/22 showed the following areas in need of cleaning or repair:

* Walls throughout the dining room and kitchenette had food splatters, spills, smears, and    chipped paint;

* Food spills and debris were visible along the baseboards in the dining room, and kitchenette; * Dining room and kitchenette flooring had a sticky residue;

* Flooring around the kitchenette floor drain was chipped and uneven with stuck-on food particles around the drain, and garbage was in the drain;

* Drawers in the kitchenette had food particles;

* Accumulation of dust, dirt and food debris was underneath and behind the steam table and refrigerator;

* The oven located in the activity kitchenette had a buildup of burnt food debris and grease;

* Multiple resident carpets had large stained areas;

* Multiple resident baseboards and walls were nicked and gouged;

* Multiple chipped and gouged wall corners in resident rooms and bathrooms exposing the metal underneath;

* Room 118 bathroom door was missing;

* Sections of carpet had been removed in Room 123, exposing the cement floor;

* Bathroom in Room 127 had dried fecal matter on and around the toilet and floor; and

* There were two laundry rooms on the memory care unit; both had dirt, dust, and detergent on the floors, in between, behind, and on top of the washer and dryers.

The areas needing cleaning and repair were shown to and discussed with Staff 1 (Memory Care Director ) on 06/14/22 and 06/16/22. She acknowledged the findings.  

1. Kitchen cleaning and repairs

Rsident rooms #118, #123, #127

2. Weekly community rounding to be completed by department heads as assigned by administrator for 12 weeks.  Weekly rounds will be audited by Administrator and/or designeed, identified issues to be addressed in a timely manner and reviewed monthly during QA meeting.

3. Weekly for 12 weeks and reviewed during monthly QA.  QA committee will determine continued need for audits based on review of audtis.

4. Administrator and/or designee.   

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant to wash soiled linens and clothing and provided a one-way flow of soiled linens and clothing from the soiled area to the clean area. Findings include, but are not limited to:

A tour of MCC's two laundry rooms was conducted on 06/16/22 with Staff 10 (Resident Care Assistant) and revealed the following:

The MCC used residential washing machines that did not indicate the rinse temperature. The washers were connected to an Ecolab detergent dispenser that was mounted on the wall above the washers, and there was a manual control panel on the wall between the dispensers that had a button for one scoop and a button for two scoops. During the tour at 3:45 pm, the surveyor observed the Ecolab dispensers were empty in both laundry rooms.

In an interview with Staff 10 regarding the empty dispensers and the laundry process, she reported that she was not aware of how the dispensers worked, and to start a load of laundry, she added the clothes in the washer, turned the knob to the wash cycle and pressed the hot water button. When asked if she had to push anything on the control panel, she reported no.

In the large laundry room in the MCC, there was a separate soiled utility room with a flushing sink. Staff 10 reported she had never used that room, nor had she seen anybody use it. She further stated that if clothes were extremely soiled, they were placed in the commercial-sized washer, which had an automatic disinfectant dispenser.

At 4:30 pm, the surveyor and Staff 1 (Memory Care Director) toured the laundry rooms and discussed the above findings. She was unaware the detergent dispensers were empty and could not find any detergent. She further reported that to dispense the detergent into the washers, staff had to press either the one scoop or two-scoop buttons for the detergent to be added. Due to the lack of a chemical disinfectant, Staff 1 was instructed not to use the residential washers until they obtained more detergent. She agreed.

The need to ensure the facility had a process for handling and laundering soiled linen, dispensers had detergent, all staff doing laundry were trained on how to use the Ecolab control panel, and there was a one-way flow of soiled linens and clothing from the soiled area to the clean area of the laundry room and staff were trained on when and how to use the flushing sink was discussed with Staff 1 on 06/16/22. She acknowledged the findings

On 06/17/22, that following morning, Staff 5 (Maintenance Director) informed the survey team that the Ecolab detergent had been added to the dispensers.

1. Laundry policy and procdure had been updated to include how to handle soiled laundry, when to use the flushing sink and how to ensure detergent dispensers are kept filled and are operated properly. Laundry needs will be included on Resident Service Plans and indicate staff using disenfecting procedures during laundry cleaning.

2. All new and existing staff are scheduled to complete two hour infecion control training via Oregon Care Partners. Staff meetings scheduled to review and demonstrate updated P&P on Laundry disenfecting, how to obtain detergent refills and activate the disinfectant. How and when to use flushing sink and treat soiled laundry before placing in the machines.  

Instructions  will also be posted

in laundry rooms for easy reference and reminders.

3. Weekly observation with report to Admnistrator.

4. Maintenance Director.

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

Refer to C150, C160, C242, C360, C420, C422, C513 and C530.

Refer to C 150, C160, C242, C360, C420, C422, C 513 and C530. Trai

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 8 and 9) had documentation of completed orientation and pre-service training prior to performing any job duties and demonstrated knowledge and performance in all required areas within 30 days of hire. It was also determined 2 of 2 sampled direct care staff (#s 7 and 18) failed to complete a minimum of 16 hours of annual in-service training annually on required topics, including 6 hours of annual in-service training on dementia care. Findings include, but are not limited to:

Staff training records were reviewed with Staff 6 (Business Office Manager) on 06/16/22. She explained the facility had been unable to access the online training records for employees. A review of the records provided revealed the following:

1. Staff 8 (MT) was hired 01/03/22 and Staff 9 (Resident Care Assistant) was hired 04/06/22.

a. The facility was unable to provide records of completion of orientation and pre-service training, including dementia training, for Staff 8 and 9.

b. Except for certification of First Aid and Abdominal thrust training, the facility was unable to provide documentation of completion of the required competencies within 30 days of hire for Staff 8 and 9.

2. Staff  7 (Resident Care Assistant) was hired 08/24/20 and Staff 18 (Resident Care Assistant) was hired 09/24/20. Review of annual training, based on their anniversary date of hire, revealed the following:

a. Staff  7 and 18 lacked documented evidence of having completed at least 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting with at least 6 hours of annual in-service training on dementia care.

Staff training requirements were reviewed with Staff 6 on 06/16/22. She acknowledged the findings and stated a plan for the facility to access and track training documentation going forward.

1. Staff # 8 and #9 have completed all required training including  2 hour infection control and 6 hour Pre Service Dementia. Staff # 7 and #18 have completed 16 hours of annual training on required topics including

2. Audits have been completed on all staff to identify what training was completed and when it has been completed. Results of these audits and training requirements outstanding will be reviewed with each employee with expectated dates of completion. Documentation with competencies will be collected and organized in each employee file. Trackkng documents for each required training topic and date completed will be kept in real time. Pre-service trainng will be completed prior to scheduled work with residents. Review of resident service plans and training for any special needs identified on residnets service plan will be included for direct care staff traininng. A list of required trainigs will be developed and provided each employee with deadline completion dates. Annual hours of inservice trainig  for 16 hours will be developed inb advanced and provided to each employeeand wil be posted in the department in advance.

3. Weekly audits will be conducted on new employees and existing staf trainings for 12 weeks.  Talent Acquistion Director will track and coordinate with  Department Managers. Audits to be reviewed monthly during QA meeting.

4. Administrator and/or designee.  

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

Refer to C252, C260, C262, C270, C280, C300, C303, C305 and C310.

See POC C252, C260, C270, C280, C300, C305, C310.

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans for each resident were developed and included in service plans for 2 of 2 sampled residents (#s 1 and 3) residing in the MCC. Findings include, but are not limited to:

1. Review of Resident 1's current service plan, dated 05/27/22, identified the resident had a diagnosis of dysphasia and s/he was not to have bread, pasta, or rice due to difficulty swallowing and ensure s/he had fluids; however, there was no resident specific information related to the resident's food and fluid preferences.

2. Resident 3's record was reviewed during the survey. Between 03/05/22 and 06/10/22, the resident experienced significant wt. loss, required a soft diet, nectar thickened liquids, and a nutritional supplement twice a day.

The service plan available to staff and survey was dated 04/22/21. The service plan lacked staff instructions related to the resident's individual nutritional and hydration needs, nor had the service plan been updated regarding the resident's nutritional status.

During the survey, it was observed that snacks were not consistently offered to residents throughout the day, and residents were not encouraged to consume fluids regularly.

The need to develop individualized service plans addressing residents' nutrition and hydration needs and fluids and snacks were consistently offered to residents' throughout the day was discussed with Staff 1 (Memory Care Director) on 06/17/22. She acknowledged the findings.

1. Resident 1 and 3 service plans have been updated with each residents food and fluid preferences. Res #3 weight loss has been re-evaluated with updated intervenitons on the SP . Weekly weights as ordered for residents with signficant weight loss will be obtained and reviewed by nurse for further interventions as indicated.  Monthly weights to be obtained for residents without weekly needs.

2.Routine daily hydration rounds will be ocnducted by care staff. In between each meal, 6-8 ounce fluids of choice will be encouraged. Consumption will be noted and reported to nurse if any swallowing difficulty or lack of intake.Care staff will collect each residents food preference; assist them to complete their menu selections and provide information to include on their SP.

3. Weekly aduits of weights to be completed by Health and Wellness Director for 12 weeks.  Audits to be reviewed monthly during QA.     

4. Administrator and/or designee.  

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

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

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

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

There were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

Observations and interviews indicated the residents were dependent on staff to initiate activities and scheduled activities did not happen with frequency or consistency on the unit.

On 06/16/22 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plans for each resident was discussed with Staff 1 (Memory Care Director) who acknowledged the findings.

See POC C 242

1.Evauatons have been completed for Residents 1, 2, 3 , 4 for current abilities and skills, emotional and social needs and patterns, physical abilities and limtiations, and adaptions need for each to partiicpate in activities they prefer. Challenging behaviors are identified and root cause analysis is used to identify possible triggers for behaviors. These have been included in the updates service plans for staff to follow. Redirections and engaging residents in mantaining routines is included in updated service plans for challenging behaviors.

2. Staff training on challenging beaviors is in progress inlcuding possble triggers. On going use of  reporting tools including STOP AND WATCH and SBAR to provide accuate and timely information for nurse to follow up with TSP for Behavioral Interventions and or additonal interventions is progressing.

3.Daily shift reports will include bevahioral interventions. Health and Wellness Director will evaluate effectivenss and document weekly or more often as needed. Nurse will report in daily stand up meetings.

4. Adminstrator.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled resident (#3) with documented behaviors. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's disease. Review of Resident 3's progress notes, temporary service plans, and incident reports identified that between 03/05/22 and 06/10/22, Resident 3 had documented behaviors including exit seeking, agitation, and aggression towards staff and other residents including three resident-to-resident altercations where Resident 3 was the aggressor.

There was no documented evidence the facility evaluated Resident 3's behavioral symptoms.

The service plan available to staff and the survey was dated 04/18/21 and lacked information about the resident's current behaviors and failed to provide specific interventions or instructions to guide caregivers in monitoring the resident or responding to the resident's behavior symptoms.

On 06/17/22, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Memory Care Director). She acknowledged the findings.

1. Resident passed away on Hospice care 7/18/22.

2. All care staff have been trained on various challenging behaviors; how to approach residents; and report to RN for further evaluation and development of TSP or new Service Plan depending on change of condtion. All residents new to MC will be evaluated and service planned for increased anxiety, exit seeking and wandering due to MC new environmnent and progressive brain disease process. Nurse consultant providing on going reviews and feedback for development of evaluations and service plans to address emotional needs and behaviors.

3. Every 90 days or more often as needed.

4. Health & Wellness Director

Based on observation and interview, it was determined the facility failed to ensure residents' rooms were individually identified to assist residents in recognizing their room. Findings include, but are not limited to:

During environmental observations on 06/13/22 and 06/14/22 it was noted seven occupied rooms in the memory care unit lacked identifying information to assist residents with locating their rooms. Though resident names were posted, the size of the postings and print were small. There were no additional individual identifiers outside the resident rooms to assist residents in recognizing their rooms.

The need to ensure resident rooms in the memory care unit were individually identified to assist residents in recognizing their rooms was discussed with Staff 1 (Memory Care Director) on 06/14/22. She acknowledged the findings.

1. All residents have their rooms identified on the hallway wall adjacent to their door. A shodow box with resident identified items are depicted in the shadow box. The font size for their name is being enalrged for easier visualization.

2. On the day of move in- each resident's shadow box and name for room identification will be completed and placed near their door.

3. On every new resident 's date of move in.

4. Activity Director.