Print Inspection: JCHM

The findings of the re-licensure survey, conducted  08/08/22 through 08/11/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/11/22, conducted on 01/12/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect and to have a safe and homelike environment for 4 of 4 sampled residents (#s 5, 6, 7 and 8) related to inappropriate sexual behaviors. Residents 5, 6, 7 and 8 were repeatedly touched by Resident 4, in an intimate manner without consent. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in June 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan dated 08/03/22, temporary service plans, incident investigations and progress notes dated 05/01/22 through 08/08/22 were reviewed.

The service plan indicated the resident was able to independently transfer and walk around the facility. The resident required minimal assistance with ADL care. The resident was noted to have decreased physical boundaries, was increasingly difficult to redirect and entering other resident rooms more frequently. The resident was engaging in "inappropriate sexual behavior" with other residents.

Progress notes dated 05/01/22 through 08/08/22 showed numerous instances when Resident 4 was observed to rub other residents' shoulders, attempted to kiss other residents, grabbed/groped/fondled others breasts, placed his/her hand inside another resident's pants and/or was found partially naked with another resident. Residents 5, 6, 7 and 8 were involved in these incidents.

There was inconsistent documentation to show all incidents were thoroughly investigated to determine effectiveness of current interventions and determine if new interventions were needed to prevent reoccurrence and protect residents from unwanted intimate touch.

Resident 6 and Resident 7 had inconsistent documentation related to their ability to consent to physical interactions with Resident 4 and when they were a willing participant. Intervention around the potential relationships vs. unwanted touch were not documented and evaluated with each occurrence.

Multiple observations of Resident 4 between 08/08/22 and 08/11/22 showed the resident interacting with multiple other residents in the unit during activities, in the common areas and at meals. Resident 4 was observed with non-sampled residents who were involved in previous incidents, as well as observations of Residents 5, 6, 7 and 8. No touching was observed. The resident was verbally interactive with everyone who was able to converse.

a. Resident 5 was admitted to the facility in March 2021 with diagnoses including dementia.

Resident 5 experienced two incidents of agitation and yelling outbursts regarding Resident 4 following an incident when Resident 4 put his/her hand in Resident 5's pants. Resident 5 was upset by the incident and wanted Resident 4 to stop.

b. Resident 6 was admitted to the facility in August 2020 with diagnoses including dementia.

Resident 6 experienced four incidents with Resident 4, both potentially consensual and not consensual. The incidents involved intimate touch of the breasts while awake and while Resident 6 was sleeping.

c. Resident 7 was admitted to the facility in February 2020 with diagnoses including dementia.

Resident 7 experienced eight incidents with Resident 4, both potentially consensual and not consensual. The incidents included intimate touch of the breasts, Resident 7 was found with Resident 4 and both residents were naked from the waist down and two incidents where Resident 7 appeared distressed and was found alone in a closed bathroom with Resident 4.

d. Resident 8 was admitted to the facility in July 2013 with diagnoses including dementia.

Resident 8's service plan indicated s/he had lost the ability to talk and seldom spoke words. The resident communicated with hugs, kisses and laughter. The resident required extensive assistance from staff for ADLs. The resident used a merriwalker (frame device to help with independent walking) to maneuver around the facility. The resident had no awareness of his/her place in space and the environment.

Resident 8 experienced one incident noted as an accidental swipe of his/her breast by Resident 4 and a second incident when his/her breast was fondled while seated in the common area by Resident 4.

The facility failed to ensure residents were treated with dignity, respect and had a safe environment due to reoccurring sexually inappropriate behaviors of Resident 4. Interventions put into place were insufficient to ensure Resident 4 did not continue to touch other residents without their consent. Resident 4 touched other residents first then if the result was a statement of no or stop then Resident 4 would leave on his/her own or be removed by staff.

An immediate plan of correction was requested at the time of survey to ensure resident safety. The facility implemented a 1:1 for day and evening shift. On night shift the resident was typically only active within his/her room. The facility's plan included a door alarm with frequent checks, a baby monitor to improve staff ability to hear the alarm and locked resident doors for the other residents.

The need to ensure all residents were treated with dignity and respect and had a safe environment was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/10/22 and 08/11/22. The staff acknowledged the findings.

C200-   Resident Rights- Residents rights were violated by another resident despite facilities attempts to intervene and a request to move the resident who was violating rights out of the facility. With support from the Immediate Plan of Correction, we as a facility were able to require a 1:1 caregiver for the resident and it assisted the family of the resident to see that the facility was no longer a good fit for their loved one and the resident was moved out approx. 2 weeks later.

Resident 6- Touch had been reported to APS and is still under investigation, this was reported prior to survey. Chart notes were reviewed, and it was noted that one incident was unclear from staff and should have been reported to admin. Staff training to occur by in regard to not using "slang" or opinion-based charting but instead describing in details actual behaviors witnessed.  but

Resident 5- Incidents were reported to APS and are under investigation.

Resident 7- Incidents were investigated both reporting consensual relationship. Mini-mental examines were performed however it was unclear to staff how to determine this willingness of either resident when dementia is involved. Looking to the state for additional guidance on this, reviewing training in Oregon Care Partners and looking at GOHBI training for staff and leadership as the latest training information in from 1999.

Resident 8- Incident was found in charting by RA that was not reported to leadership, Med Tech or carried over to charting in QMAR, therefore missed in an audit. It was reported to APS before survey was completed.

2) The facilities disclosure statement and rental agreement are being rewritten and submitted to the state for approval to enforce additional care and support when a resident is putting others at risk. In addition, Leadership is looking for additional training materials, support and courses to take as we thought we had done everything in our power to protect the residents in our care, however we still fell short. Additional training on requesting a 14 day move out notice for the safety of the residents was reviewed.

3) Policies will be reviewed annually.

4) The administrator is responsible for the correction and monitoring of it.

Based on interview and record review, it was determined the facility failed to ensure resident to resident altercations related to sexual behaviors were promptly investigated to rule out abuse and reported to the local SPD office as required for 1 of 2 sampled residents (#4) whose incidents were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in June 2021 with diagnoses including dementia.  

The service plan indicated the resident was able to independently transfer and walk around the facility. The resident required minimal assistance with his/her ADL care. The resident was noted to have decreased physical boundaries, was increasingly difficult to redirect and was entering other resident rooms more frequently. The resident was engaging in "inappropriate sexual behavior" with other residents.

Review of incident investigations and progress notes from 05/01/22 through 08/09/22 showed the following:

* A progress note dated 05/26/22 indicated Resident 4 was found touching Resident 7's bare breast in the living room. No investigation was completed for the incident.

* Progress notes dated 06/06/22 indicated two incidents of inappropriate sexual behavior occurred. Resident 4 was fondling Resident 7's breasts and later in the afternoon was found groping Resident 8's breasts as well. No investigations were completed for either incident.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reported when required was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/11/22. The staff acknowledged the findings.

The facility reported the requested incidents involving sexual behaviors to the local SPD office on 08/11/22. Confirmation of the reports were provided prior to survey exit.

C231 Reporting Abuse- The violation occurred as staff had made chart notes that were not seen by leadership and not reported to leadership. Per policy a resident-to-resident altercation form or concern report should have been completed which triggers proper investigation. It was discovered that the behavior notes and PRN charting by Resident Assistants do not carry over to progress notes in QMAR unless a certain box is checked in the system, allowing for additional error during daily Stand-Up meeting audits. Since discovery a ticket for assistance has been placed with QMAR, as well as a request to change to Point Click Care which will also allow investigation within the system verses on paper. This will address the inconsistency in documentation to prove all incidents were thoroughly investigated. Administrator and RN will review notes from survey and see what needs to be added to investigation and create a form to ensure all areas are covered.

1 ) Resident 4- Began inappropriate sexual behaviors, interventions were attempted but not well charted in the Careplan nor the progress notes. These notes and interventions were moved from their paper chart to their Careplan. In addition, resident had a move out notice in place prior to survey. TSP was put in place along with a 1:1 caregiver until the time of move out.

2) Reporting and Investigating policy is being reviewed and revised. Once it is complete staff will be retrained. In the meantime, administration is reviewing resident charts daily and has provided instructions and visual aids to resident assistants and medication techs as to reporting/initial investigations/and following up. Training to be reviewed on Incident reporting, Basic investigations, Team Huddle/Fact gathering, APS reporting, Reporting to RN/Admin, and Careplan/TSP changes that may need to occur with resident to resident altercations. In addition Cameras were installed in common areas and are now functional to review incidents and assist with investigations.

3) Admin on call will be notified of Resident to Resident altercations and initial investigations will occur. Direct Care staff were instructed in staff meeting 8/23/2022 about reporting immediately, not at end of shift and not placing in charting without verbal notification. Charts will be reviewed daily at Stand-Up meetings (M-F) with administration, med techs will verbally review incidents at change of shift and call out if any incidents occur at huddles. Charting will also be reviewed by administration M-F and weekend charting will be reviewed on Monday. This will occur until our team has shown improvement and has a clear policy and procedure for monitoring to resolution.

4)The Administrator will be responsible to see that the corrections are completed/monitored in conjunction with the RN Manager.This  resident is no longer in the care of Brookside Manor, however we will update our policies to be better prepared for any future incidents that may occur.  

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

Observations of the resident, interviews with staff, and review of the service plan dated 07/27/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Increased agitation and verbally abusive with family interaction;

* Exit seeking;

* Anxiety and belief s/he is trapped/hostage; and

* Activities.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/10/22 and 08/11/22. The staff acknowledged the findings.

3. Resident 4 was admitted to the facility in June 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan dated 08/03/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Increased agitation and difficulty redirecting;

* Inappropriate sexual behaviors;

* Door alarm;

* Residents involved in altercations that should be kept separated;

* Frequent checks and knowing the resident's location; and

* Consensual relationships vs. unwanted touch and lack of consent.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator) and Staff 2 (RN)  on 08/10/22 and 08/11/22. The staff acknowledged the findings.

4. Resident 5 was admitted to the facility in March 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan dated 07/20/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Agitation and anxiety; and

* Altercation with Resident 4.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/10/22 and 08/11/22. The staff acknowledged the findings.

5. Resident 6 was admitted to the facility in August 2020 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan dated 07/16/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Consensual relationships vs. unwanted touch and lack of consent; and

* Altercations with Resident 4.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/10/22 and 08/11/22. The staff acknowledged the findings.

6. Resident 7 was admitted to the facility in February 2020 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan dated 08/10/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Consensual relationships vs. unwanted touch and lack of consent; and

* Altercations with Resident 4.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/10/22 and 08/11/22. The staff acknowledged the findings.

7. Resident 8 was admitted to the facility in July 2013 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the service plan dated 07/20/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Altercations with Resident 4.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/10/22 and 08/11/22. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs, provided clear direction to staff and were followed for 7 of 8 sampled residents (#s 2, 3, 4, 5, 6, 7 and 8) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2022 with diagnoses including atrial fibrillation.

Review of Resident 3's 06/02/22 service plan, observations of the resident, and interviews with staff revealed the resident's service plan was not reflective of the resident's care needs and did not provide clear direction to staff in the following areas:

* Ambulation;

* Evacuation assistance; and

* Use of call system.

The need to ensure the resident's service plan was reflective of the resident's care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/09/22. They acknowledged the findings.

C260- Service Plans-

1)We intend to move to Point Click Care for a more integrated Care plan/assessment tool, however in the meantime, the RCC who has taken over careplans will review training on Careplans, ensure that clear direction is provided to staff providing care and that the careplan reflects current abilities. TSP's will be added to CP for reference around falls and behaviors as our current process does not continue to track what has been attempted, what was unsuccessful and what was successful.

Resident 3- Resident was admitted to MCC on 8/2, CP noted here was from when he was on ALF, but CP was again updated after survey to ensure it is accurate for their current abilities.

Resident 2- CP was updated to reflect interventions for behaviors, reapproaching ideas, and provider appointments as well as referral to behavioral health. Activities assessment will be completed with a better understanding of the residents likes/dislikes and abilities as the resident had only been here approx. 2 weeks.

Resident 4- CP was updated with all interventions tried as well as outcomes, and specific to residents who were affected by residents' behaviors. In addition, resident had the move out notice in place and it was not in his careplan and nor was the plan to call family for additional support as needed. 1:1 was implemented until move out date.

Resident 5- CP was updated to discuss altercation with resident 4 and anxiety and redirection around that. or any other residents that they wish to have relationships with

Resident 6- CP was updated to discuss relationship and redirection approaches with resident 4

Resident 7- CP was updated to discuss relationship and redirection approaches with resident 4 or any other residents that they wish to have relationships with

Resident 8- Resident #4 is no longer in the facility and resident is not able to consent to relationships. Staff meeting around consent was held in July 2022. Again, we are looking for additional training materials.

2)Policy for resident-to-resident altercations will be reviewed and will add to ensure that the non-instigating residents careplan is also addressed at the time. Policy for Change of Condition to be reviewed to ensure that activities and abilities are also reviewed and addressed. Training for activities staff to occur.

3)Careplans will be reviewed per regs once compliance is determined, and until then CP and areas to address will be reviewed at Stand-up meetings.

4)The Resident Care Coordinator will be responsible for accurate careplans.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored at least weekly to resolution and that interventions were re-evaluated to determine effectiveness for 6 of 8 sampled residents (#s 1, 4, 5, 6, 7 and 8) who experienced changes of condition. Resident 4 repeatedly touched other residents in the memory care unit in an intimate manner without consent (Residents' 5, 6, 7, 8). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in June 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan dated 08/03/22, temporary service plans, incident investigations and progress notes dated 05/01/22 through 08/08/22 were reviewed.

The service plan indicated the resident was able to independently transfer and walk around the facility. The resident required minimal assistance with his/her ADL care. The resident was noted to have decreased physical boundaries, was increasingly difficult to redirect and was entering other resident rooms more frequently. The resident was engaging in "inappropriate sexual behavior" with other residents.

Progress notes dated 05/01/22 through 08/08/22 showed numerous instances when the resident was observed rubbing other residents' shoulders, attempting to kiss other residents, entering other residents' rooms and refusing to leave, putting his/her hands in other residents' pants and grabbing/groping other residents' breasts.

The following incidents were noted in the resident's progress notes:   

* On 05/21/22, Resident 4 was found in the bathroom with Resident 7;

* On 05/26/22, Resident 4 was watching a movie with Resident 7. Resident 4 was observed fondling the resident's breast. Resident 7 "seemed undisturbed." Later in the evening Resident 4 attempted to kiss a non-sampled resident on the lips;

* On 06/01/22, Resident 4 was observed rubbing a non-sampled resident's shoulders. The resident appeared uncomfortable, and staff separated the residents;

* On 06/05/22, Resident 4 was observed taking Resident 7 from room to room around the facility while touching his/her breasts under his/her shirt;

* On 06/06/22, Resident 4 was "fondling" Resident 7's breast while seated in the living room;

* On 06/06/22, Resident 4 was "groping" Resident 8's breast in the common area;

* On 06/09/22, Resident 4 was found standing over Resident 7 in his/her bedroom. Resident 7's shirt was up;

* On 06/10/22, Resident 4 was in the bathroom with Resident 7. After the residents were separated Resident 4 re-approached Resident 7 to rub shoulders and Resident "firmly said STOP!";

* On 06/17/22, Resident 4 touched Resident 5's breasts then put his/her hand down Resident 5's pants. Resident 5 became very upset, objected to the advances and Resident 4 stopped. The residents were separated. Adult Protective Services was notified;

* On 06/17/22, a second incident occurred. Resident 4 was found with Resident 7 behind closed doors, both residents were naked from the waist down. Adult Protective Services was notified;

* On 06/18/22, Resident 4 was observed touching Resident 7's breasts. Resident 7 indicated "she likes him.' The residents were separated and frequent checks were initiated for both;

* On 07/01/22, Resident 4 was observed touching a non-sampled resident's breasts. Resident 5 was upset when Resident 4 came anywhere near him/her calling Resident 4 a "molester.";

* On 07/08/22, Resident 5 stated Resident 4 was touching him/her and tried to hold his/her head under water. Documentation was not clear if touching accusation was new touch or from previous incident;

* On 07/23/22, Resident 4 "felt up" Resident 6 and refused to leave the room when staff attempted to separate. Staff were able to get Resident 4 to leave the room after multiple attempts;

* On 07/24/22, Resident 4 was rubbing the shoulders and back of a non-sampled resident under their shirt. The non-sampled resident and staff told Resident 4 to stop, s/he complied; and

* On 07/25/22, Resident 4 and Resident 6 engaged in "lovey dovey" behavior. No other information was documented regarding the specific behaviors. Separate meal seating and 15-minute checks initiated; and

* On 07/26/22, Resident 4 was found with his/her hand on Resident 6's bare breast while s/he was sleeping. Adult Protective Services was notified.

There was inconsistent documentation to show all incidents were thoroughly investigated to determine effectiveness of current interventions and determine if new interventions were needed to prevent reoccurrence and protect residents from unwanted intimate touch.

Resident 6 and Resident 7 had inconsistent documentation related to their ability to consent to physical interactions with Resident 4 and when they were a willing participant. Intervention around the potential relationships vs. unwanted touch were not documented and evaluated with each occurrence.

Multiple observations of Resident 4 between 08/08/22 and 08/11/22 showed the resident interacting with multiple other residents in the unit during activities, in common areas and at meals. Resident 4 was observed with non-sampled residents who were involved in previous incidents as well as observations of Residents' 5, 6, 7 and 8. No touching was observed. The resident was verbally interactive with everyone who was able.

a. Resident 5 was admitted to the facility in March 2021 with diagnoses including dementia.

Resident 5 experienced two incidents of agitation and yelling outbursts regarding Resident 4 following an incident of unwanted intimate touch.

Review of the resident's progress notes for June and July 2022 showed monitoring of the resident's condition after the incident of intimate touch but there was no documentation to show evaluation of interventions was completed to address current interventions, develop new interventions and prevent reoccurrence.

b. Resident 6 was admitted to the facility in August 2020 with diagnoses including dementia.

Resident 6 experienced four incidents with Resident 4 both potentially consensual and not consensual.

Review of the resident's progress notes for June and July 2022 showed no monitoring of the resident's condition after each incident was documented. Interventions were not evaluated for their effectiveness; new interventions were not developed, and documentation was inconsistent related to Resident 6's ability to consent and approval of Resident 4's touch for each incident.

c. Resident 7 was admitted to the facility in February 2020 with diagnoses including dementia.

Resident 7 experienced eight incidents with Resident 4 both potentially consensual and not consensual.

Review of the resident's progress notes for June and July 2022 showed no monitoring of the resident's condition after each incident was documented. Interventions were not evaluated for their effectiveness; new interventions were not developed, and documentation was inconsistent related to Resident 7's ability to consent and approval of Resident 4's touch for each incident.

d. Resident 8 was admitted to the facility in July 2013 with diagnoses including dementia.

Resident 8's service plan indicated s/he had lost the ability to talk and seldom spoke words. The resident communicated with hugs, kisses and laughter. The resident required extensive assistance from staff for ADLs. The resident used a merriwalker (frame device to help with independent walking) to maneuver around the facility. The resident had no awareness of his/her place in space and the environment.

Resident 8 experienced one incident noted as an accidental swipe of his/her breast by Resident 4 and a second incident when his/her breast was fondled in the common area by Resident 4.

Review of the resident's progress notes for June and July 2022 showed no monitoring of the resident's condition after each incident was documented. Interventions were not evaluated for their effectiveness; new interventions were not developed, and documentation was inconsistent related to Resident 8's ability to consent and approval of Resident 4's touch.

Resident 4 had additional incidents of inappropriate sexual touch with two non-sampled residents and a third resident who no longer resided at the facility.

Interventions utilized by the facility included frequent checks, cameras in the memory care unit, door alarm, locking other resident doors at night so Resident 4 could not enter, involvement in activities, UTI check, be aware of the resident's location, redirect when getting touchy with other residents and keep in common areas.

None of the implemented interventions were specific to each incident between Resident 4 and the other involved residents. Interventions were not evaluated for effectiveness as Resident 4 continued to intimately touch other residents without consent on multiple occasions.

An immediate plan of correction was requested at the time of survey to ensure resident safety. The facility implemented a 1:1 staff to resident ratio for day and evening shift. On night shift the resident was typically only active within his/her room. The facility's plan included the door alarm with frequent checks, a baby monitor to improve staff ability to hear the alarm and locked resident doors for the other residents.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, provided clear, resident-specific directions to staff and that interventions were evaluated for effectiveness was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/10/22 and 08/11/22. The staff acknowledged the findings.

2. Resident 1 was admitted to the facility in 07/2017 with diagnoses including dementia.

The resident's 06/23/22 service plan, 05/08/22 through 08/08/22 temporary service plans and fall investigations, and the 06/1/22 through 08/08/22 MAR were reviewed.

a. Facility documentation indicated Resident 1 had experienced multiple falls during the time frame reviewed.

The resident's current service plan revealed the resident was at risk for falls, used a walker, had diminished vision, declined to wear glasses, and had poor depth perception. Multiple fall prevention and safety interventions were identified.

There was no documented evidence the facility consistently and thoroughly investigated each fall to determine what service planned interventions were in place at the time or monitored the interventions for effectiveness.  

b.  Resident 1 experienced short-term changes of condition related to skin which were not monitored at least weekly through resolution.

The need to thoroughly investigate falls to determine what interventions were in place at the time, monitor the interventions for effectiveness, and monitor all short-term changes of condition through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/09/22. They acknowledged the findings.

C270 Change of Condition

1)Resident 1-CP was not updated with COC monitoring after incident with resident #4, policy will be updated to address this and also added to the investigation report for additional reminder to monitor this resident as well.

Resident 4- CP was not updated with COC monitoring after incident with resident #4 policy will be updated to address this and also added to the investigation report for additional reminder to monitor this resident as well.

Resident 5 CP was not updated with COC monitoring after incident with resident #4 policy will be updated to address this and also added to the investigation report for additional reminder to monitor this resident as well.

Resident 6 CP was not updated with COC monitoring after incident with resident #4 policy will be updated to address this and also added to the investigation report for additional reminder to monitor this resident as well.

Resident 7 CP was not updated with COC monitoring after incident with resident #4 policy will be updated to address this and also added to the investigation report for additional reminder to monitor this resident as well.

Resident 8- CP was not updated with COC monitoring after incident with resident #4 policy will be updated to address this and also added to the investigation report for additional reminder to monitor this resident as well.

2)Change of condition reporting and monitoring policy is being reviewed and revised. Once it is complete staff will be retrained. In the meantime, administration is reviewing resident charts daily and has provided instructions and visual aids to medication techs as to monitoring/reporting's/and following up. Training to be reviewed on Incident reporting, Basic investigations, Team Huddle/Fact gathering, APS reporting, Reporting to RN/Admin, what it means to monitor to resolution.

3)The change of conditions will be reviewed daily at Stand-Up meetings (M-F) with administration, med techs will review at change of shift, and charting will also be reviewed by administration M-F and weekend charting will be reviewed on Monday. This will occur until our team has shown improvement and has a clear policy and procedure for monitoring to resolution.

4)The RN Manager will be responsible to see that the corrections are completed/monitored in conjunction with the Administrator.

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 C200 and C231.

Administration Compliance

Please refer to plan of correction for C200 and C231

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

Refer to C260 and C270.

Compliance with Rules Health Care

Please refer to plan of correction for C260 and C270

Based on interview and record review, it was determined the facility failed to ensure activity evaluations were current, addressed all required elements, with individualized activity plans developed for each resident based on their evaluations for 1 of 4 sampled residents (#1) whose records were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2020 with diagnoses including dementia.

Review of the resident's 01/28/22 Activity/Interests Evaluation and the activity plan identified in the 06/23/22 service plan revealed they were not reflective of the resident's current status related to interests, abilities and skills, physical abilities and limitations, emotional and social needs and patterns, adaptations necessary for the resident to participate and identification of activities for behavioral interventions.

The need to ensure activity evaluations were current, addressed all required elements, with individualized activity plans developed for each resident based on their evaluations was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/11/22. They acknowledged the findings.

Activities:

Resident #1- CP updated to match her current abilitiies

Please refer to plan of correction for C260