Print Inspection: M7ML

The findings of the re-licensure survey, conducted 10/04/21 through 10/06/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit to the re-licensure survey of 10/06/21, conducted 01/10/22 through 01/12/22, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, the facility failed to ensure 1 of 1 sampled resident (#3) was treated with dignity and respect and given the opportunity to select or refuse to consent to physician orders. Findings include, but are not limited to:

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

During an interview with Staff 5 (MT) on 10/05/21 at 6:15 pm, she reported the resident had a history of refusing medications. Staff 5 indicated if the resident refused his/her medications, she put it in his/her dessert to "disguise" it, but did not tell the resident.

During an observation and interview on 10/06/21 at 8:20 am, Staff 14 (MT) revealed she had dissolved the resident's morning medication in his/her coffee "for a few weeks" because of frequent refusals.

On 10/05/21 and 10/06/21, Staff 2 (Memory Care Coordinator) and Staff 1 (Administrator) were informed Resident 3's medication had been administered without his/her consent. The need to ensure the resident was treated with dignity and respect and provided the opportunity to select or refuse to consent to physician orders was discussed. They acknowledged the findings.

On 10/06/21, Staff 1 indicated the practice would be stopped immediately and a new plan to address resident medication refusals would be implemented.

C200 resident rights; Resident # 3 has the right to refuse his medications, we have made community instructions to med techs to give resident # 3 and all residents the right to refuse their medications.

We have implemented training for medication technicians regarding resident right to refuse their medications. We are also training on why a resident would have a crush order, it is not to trick the resident its due to not being able to swallow the pill form.

We have updated resident #3 care plan and community instructions on the MARS.

In order to prevent this from happening again, all crush orders must be approved by the RN in advance prior to the request for a crush order being requested. So we can determine if the resident has a true swallowing issue and needs a crush order to prevent tricking the resident into taking medications.

RN and Administrator to monitor when 2nd checking new orders for residents as they are received this will require ongoing monitoring.

Based on interview and record review, it was determined the facility failed to ensure incidents and resident altercations were promptly investigated to rule out abuse and reported to the local SPD office as appropriate for 2 of 3 sampled residents (#s 2 and 3) whose incidents were reviewed. Findings include, but are not limited to:

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

The resident's care plan dated 08/17/21 and interviews with care staff between 10/04/21 and 10/06/21 indicated the resident was dependent for all ADL care and had frequent falls. The resident was unable to direct his/her own care.

Review of incident investigations and progress notes from 07/01/21 through 10/04/21 showed the following:

* A progress note dated 09/07/21 indicated the resident had a swollen and puffy face. There was no additional information about the potential injury.  

* A progress note dated 09/29/21 indicated a bump was discovered on the resident's head, near the hairline. The area was "bluish" in color and appeared to be bruised. There was no additional information on the cause of the bump/bruise.

* A progress note dated 10/01/21 indicated the resident had a "black eye," and the resident stated it was from running into the tables. There was no additional information about the cause of the injury.

Investigations of the 09/07/21, 09/29/21 and 10/01/21 injuries of unknown cause were not completed to rule out potential abuse and were not reported to the local SPD office when appropriate.  

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

The facility was asked to report all three injuries of unknown cause to the local SPD office. Confirmation of the reports were provided prior to survey exit.

2. Resident 3 was admitted to the facility in July 2021 with diagnoses including Alzheimer's disease.

Interviews with staff and review of progress notes dated 07/09/21 through 10/04/21 and incident investigations revealed the following:

* On 08/21/21, "Resident...yelling at other residents and threatening other residents...stating [s/he] was going to kick the shit out of all of us ....would walk around dining room telling other residents to shut their mouths or [s/he] would shut them for them...other resident in dining room started to become afraid."

* On 08/22/21, Resident told another resident to "shut up and she need to leave no one likes her here ...went to hit another resident." The MT documented that she prevented the other resident from being hit.

There was no documented evidence the facility investigated the incidents to rule out  potential abuse. The need to investigate all potential incidents of abuse was discussed with Staff 1 (Administrator) and Staff 2 (Memory Care Coordinator) on 10/05/21. They acknowledged the findings.

C231 Abuse investigation and reporting;  

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

Resident # 3 care plan and interventions have been added to assist staff We have also requested to have an order to have a behavior specialist come in to assist with his redirection when he is upset in order to try to prevent future outbursts.

The Memory Care Coordinator is taking the administrator class on 10/18/21 to 10/21/21. Administrator, Health Services Director and Memory Care Administrator are taking the Elder abuse, investigation and reporting OCP class and have received and are studying the abuse reporting guide to make sure we are properly reporting incidents that could be potential abuse including verbal threats.

Monitoring by the administrator that all incidents are appropriately reported by the memory care administrator to APS as needed.

Based on interview and record review, the facility failed to ensure that move-in evaluations for 2 of 2 sampled residents (#s 3 and 4) addressed all required elements and were updated as needed within 30 days of admission. Findings include, but are not limited to:

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

The move-in evaluation, dated 07/09/21, failed to address the following required elements and was not updated as needed within 30 days of admission:   

* Physical health status: visits to health practitioner(s), ER, hospital, or nursing facility in the past year;

* Personality, including how the person copes with change or challenging situations;

* Complex medication regimen; and

* Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature.

The need to ensure move-in evaluations addressed all required elements and were updated as needed within 30 days of admission was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in August 2021 with diagnoses of Alzheimer's dementia.

The move-in evaluation, dated 08/23/21, failed to address the following required elements and was not updated as needed within 30 days of admission:   

* Physical health status: visits to health practitioner(s), ER, hospital, or nursing facility in the past year;

* Personality, including how the person copes with change or challenging situations;

* Complex medication regimen; and

* Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature.

The need to ensure move-in evaluations addressed all required elements and were updated as needed within 30 days of admission was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

C252 New Move in evaluations. The current initial, quarterly and Change in condition resident evaluation form has been updated on our electronic system with the addition of missing questions, such as how a person copes with change or challenging situations, complex medication details, and the impact of environmental factors, we have also added in the behaviors section how do each of the potential behaviors affect the resident and what does it look like and how is it best dealt with. We have added additional details that also connect with the care plan. The current form that requests the past physicians' visits, hospitalizations, diagnosis's and medication list will be attached to the initial evaluation a to be addressed when creating the service plan.

All residents who move from Waverly Place Assisted Living will be processed as if they are coming from a separate facility. We will be ending the chart and starting over in the electronic system as well as the hard copy binders.

The new memory care coordinator is taking the Administrators class 10/18/21 to 10/21/21 in order to have a better understanding of the rules and regulations.

This will be monitored by the Administrator when move in takes place.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and was followed by staff for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Findings include, but are not limited to:

The facility utilized documents labeled Service Plan and Care Plan to direct staff on the care of the residents. Staff 1 (Administrator) indicated the two documents were completed together, should contain the same information and date. The documents were available for staff review in binders located in the kitchenette of the memory care unit.

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

Observations of the resident, interviews with staff and review of the care plan dated 08/17/21, showed the care plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Transfer assistance, bowel incontinence and toileting needs;

* Trapeze use;

* Falls and safety interventions; and

* Pain.

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), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

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

Observations of the resident, interviews with staff and review of the care plan dated 08/17/21, showed the care plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas:

* Transfer assistance, toileting; grooming and dressing;

* Meal assistance, health shakes and finger foods;

* Falls and safety interventions; and

* Daily walks and mobility assistance.

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), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

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

Observations of the resident, interviews with staff and review of the care plan dated 08/30/21, showed the care plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Behavioral interventions related to exit seeking, destruction of property, resistance to care, belief that s/he was being poisoned, going into other resident rooms, verbal and physical aggression;

* Cell phone use; and

* Toileting/continence.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and was followed was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

4. Resident 4 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease.

Interviews with staff and review of the 07/09/21 care plan revealed it was not reflective of the resident's care needs related to use of dentures.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

C260 Residents #1, 3, and resident 4 care plans have been updated to reflect the needs of the resident and provide clear direction to the staff both on paper and the eletronic hand held devises.

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

We currently working on re-assessing all memory care residents with the improved assessment that will assist us in building a better person centered care plan that includes how to better address the resident diagnosis by the caregiver on the electronic POC devices and on the care plan itself. All staff will read and sign the hard copy of the quarterly care plans and will be filed into the charts along with a copy that is readily accessible to all staff.

Memory Care Coordinator is taking Oregon Care Partners Course to improve Service Plans.

Our new RN has completed the Role of the RN class 10/14/21 and will continue to attend OHCA trainings in order to meet the ongoing needs of the community.

Both Health Services Director and the Administrator will audit assessments and care plans monthly for accuracy in order to offer person center care plans that meets the needs of the residents and give clear instructions for care by staff.

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, and the condition was monitored to resolution at least weekly for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced changes of condition.  Findings include, but are not limited to:

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

Observations of the resident, interviews with staff and review of the resident's 07/08/21 service plan, 07/01/21 through 10/04/21 progress notes, and physician communications were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Multiple injury and non-injury falls;

* Emergency room visit and pain;

* Scrapes and abrasions to multiple body parts;

* Agitation and destructive behaviors; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

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

Observations of the resident, interviews with staff and review of the resident's 07/19/21 service plan, 07/01/21 through 10/04/21 progress notes, and physician communications were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Multiple injury and non-injury falls;

* Swollen and puffy face;

* Bruises to the arm, hip, buttocks and head;

* Weight loss; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

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

Review of the resident's 07/09/21 through 10/04/21 progress notes, incident investigations and interviews with staff revealed the resident experienced short-term changes of condition related to behaviors during the time frame reviewed.

Progress notes dated 07/17/21 through 10/04/21 indicated the resident experienced the following short term changes related to behaviors:

* Refusing meals;

* Trying to get into other residents' rooms;

* Destruction of property;

* Yelling and threatening other residents and staff;

* Resident to resident altercations on 7/30/21 and 9/6/21;

* Believing s/he was being poisoned; and

* Hitting, pulling, and kicking the courtyard gate.

There was no documented evidence the facility evaluated the resident, determined and documented what actions and interventions were needed for all the changes, communicated them to staff on all shifts, monitored the effectiveness of the existing behavioral interventions, and updated the service plan when the resident's behaviors continued to escalate.

The need to ensure the resident was evaluated when s/he experienced short-term changes of condition related to behaviors, actions and interventions were determined, documented and communicated to staff on all shifts, service plan updated and the resident monitored consistent with his/her evaluated needs was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (RN) on 10/05/21. They acknowledged the findings.

4. Resident 4 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease.

Review of the 08/24/21 through 10/04/21 progress notes, interviews with staff and observations of the resident, indicated the resident had experienced the following short-term changes of condition:

* Making statements to staff that s/he wanted to die;

* Exit seeking;

* Increased anxiety; and

* Aggression to staff.

There was no documented evidence the facility evaluated the resident, determined and documented what actions and interventions were needed for the resident, communicated them to staff on all shifts, updated the service plan and monitored the resident.

The need to ensure the resident was evaluated when s/he experienced short-term changes of condition related to behaviors, determined what actions and interventions were needed for the resident and communicated them to staff on all shifts, updated the service plan and monitored the resident consistent with his/her evaluated needs was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (RN) on 10/05/21. They acknowledged the findings.

C270 Change of Condition and monitoring; The facility hired a new RN due to the previous RN having quit without notice. The new RN has completed the Role of the RN class on 10/14/21.

Residents # 1, 3, 4 care plans have been updated to reflect changes and the RN is monitoring the residents.

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

The "wisdom to act" featured is going to utilized on the electronic devices to notify the Administrator, RN and RCC of changes in condition with residents the Administrator, RN and RCC will take the training and implement the use and training to the staff. This feature is able to be used by the care givers and med techs to quickly relay changes.

This will be monitored by the memory care administrator for effective use as well as audits of weekly monitoring on a regular basis by administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 2 of 2 sampled residents (#s 1 and 2) who experienced a significant change. Resident 2 experienced a severe weight loss with ongoing significant loss, without intervention. Findings include, but are not limited to:

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

Progress notes and physician communications dated 07/01/21 through 10/04/21, and interviews with care staff on 10/04/21 and 10/05/21 showed the resident required one person, full assistance with care. The resident had an overall decline in condition in June 2021. The resident was noted to have intermittent edema and poor to fair meal intake.

a. Review of the resident's "Weight Report" from March 2021 through September 2021 showed the following:

* The resident experienced a 18.5 lb weight loss from March 2021 to September 2021 which constituted a 15% severe weight loss in six months.

* The resident experienced an 8.5 lb weight loss from June 2021 to September 2021, which constituted a 7.5% significant weight loss in three months.

* The resident experienced a 5.9 lb weight loss from August 2021 to September 2021, which constituted a 5.39% significant weight loss in one month.

A current weight was requested for the resident. The resident's weight was noted as 95.6 lbs on 10/06/21. This represented an additional 7.9 lb weight loss from September 2021 to October 2021, which constituted a 7.63% severe loss in one month.

The resident's 08/17/21 service plan indicated the resident had nutritional shakes three times daily due to weight loss to help maintain his/her weight. Weights were to be done weekly for monitoring. The service plan did not reflect the resident's need for finger foods, assistance with utensils and assistance with fluids.

Physician orders dated 08/02/21 included orders for weekly weights and staff were to notify the RN if a there was a three pound weight variance from the previous weight. There was no order for any nutritional shakes or supplements on the most recent physician orders.

The resident's 09/01/21 through 10/04/21 MAR showed three of the five opportunities for weekly weights were not recorded on the MAR. The MAR contained no information regarding any health shake or nutritional supplements for the resident.

Staff interviews conducted 10/04/21 to 10/06/21 revealed the resident frequently required staff to feed him/her the meal. Staff indicated the resident ate better when finger foods were an option as s/he became more confused with the use of utensils. The staff further indicated the resident had become very small and lost a great deal of weight in the last month or so. Four staff interviewed indicated they did not provide any health shakes or other shakes to the resident and stated the resident did not receive any type of shake during their shifts.

Observations of the resident on 10/04/21 through 10/06/21 showed the resident was inconsistently assisted with meal intake. Snacks were observed on three occasions. The resident was provided a half a sandwich on each of the three occasions, the resident ate over 75% of the sandwiches provided. The resident did not independently seek out food or fluids during observations but could drink once the cup was in his/her hand and staff cued him/her. A water cup was kept near the resident and filled on 10/04/21, the resident inconsistently had fluids available during the remainder of the observations. When the resident was asleep or very groggy staff made minimal attempts to awaken the resident and provide food at meal times. The resident was observed to ignore utensils and use his/her fingers for 2 of 3 meals, intake was 25% or less of the meal. Staff were observed to fully feed the resident his/her meal on one occasion, intake was approximately 25%. On 10/06/21 the resident was observed not to receive a breakfast meal due to grogginess. The resident was observed to feed herself the lunch meal, items that required utensils had a moderate success rate getting to the resident's mouth. The resident ate 100% of a roll for the 10/06/21 lunch meal.  

In interview on 10/05/21, Staff 3 (Health Services Director/RN) indicated she did not have any assessment of the resident's weight loss. Staff 3 stated she started work with the facility in September 2021.

The facility failed to ensure an RN assessment was completed timely for the ongoing weight loss with documented findings, resident status and interventions made as a result of the assessment.

The resident experienced an ongoing significant to severe weight loss without consistent documentation and implementation of interventions, RN assessment and consistent meal and fluid assistance from staff.  

b. On 05/25/21 the resident was admitted to hospice services due to a decline in his/her condition and increased care needs.

The facility failed to ensure an RN assessment was completed related to the resident's decline and the hospice admission which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed timely, related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

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

On 06/25/21 the resident was admitted to hospice services due to a decline in his/her conditions, increased falls and care needs.

The facility failed to ensure an RN assessment was completed related to the resident's decline and the hospice admission which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed timely, related to significant changes in condition which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C280 - Significant change in condition - RN assessment.  The facility is prepared to hire a temporary RN should the RN quit that has dedicated hours to fill in as the Role of RN at Waverly Place Assisted Living. Administrator will make sure that the fill in RN has information readily available to monitor changes in conditions.

The current new RN has completed the Role of the RN class and understand the duties the RN. The memory care coordinator is taking her administrator class oct 18 - Oct 21st 2021 she will be better equipped to assist the RN so the RN can effectively perform her duties to maintain compliance.

Resident # 1, is being monitored, and each individual need has been addressed with the PCP, Hospice or Home Health care plans and community instructions have been updated.

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

Memory Care Administrator will monitor weekly to assure that proper documentation and monitoring is happening throughout the community. Administrator will meet with RN weekly to discuss current change in condition monitoring.

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

Delegation records for Resident 5, reviewed with Staff 2 (RN) on 10/04/21, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 2 (Memory Care Coordinator), Staff 7 (MT) and Staff 17 (MT) to include:

* Nursing assessment and condition of the client to determine if the client's condition was stable and predictable;

* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons; and

* Frequency the client should be reassessed, including rationale.

The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Administrator) and Staff 2 on 10/05/21. They acknowledged the findings.

282 - Delegation.  The RN now has a better understanding of the Role of the RN she has completed the class on 10/14/21. Since finishing the class RN is in the process of re-delegating all the medication technicians.

The RN used the same forms and process as the previous RN who quit left behind, being new to the role she did not know she did not have the correct information. She has since learned how to properly delegate. Including an assessment of each of the diabetic resident's history to determine if their condition is stable and predictable. Also, a bio & history of med techs she is delegating insulin tasks in order to determine they are safely delegated.

RN will monitor the delegation tasks monthly and resident assessments as required per State of Oregon.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits were maintained in the residents' records, and that recommendations were implemented for 2 of 2 sampled residents (#s 1 and 2) who were receiving home health services from outside providers. Findings include, but are not limited to:

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

During the acuity interview on 10/04/21, Resident 1 was identified as receiving outside provider services related to hospice.  

Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 07/01/21 through 10/04/21 were completed.

The resident was admitted to hospice services on 06/25/21 related to a decline in condition and increased falls. Hospice nursing visits were to occur one to three times per week as needed for general care and catheter care.

Hospice nursing visit notes were not consistently documented and/or recommendations were not implemented as follows:

* There were no visits documented for 07/16/21, 08/13/21, 09/07/21 and the week of 09/13/21;

* Nursing recommendations on 07/30/21 instructed staff to have the resident's weight available for the next visit;

* Nursing recommendations on 09/02/21 instructed staff to monitor Foley catheter output and let hospice know if the urine output decreased; and

* Nursing recommendations on 09/24/21 instructed staff to monitor urine output and notify hospice if output was less than 200 ml and push fluids.

There was no evidence the recommendations were implemented and/or communicated to staff.

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

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

During the acuity interview on 10/04/21, Resident 2 was identified as receiving outside provider services related to hospice.  

Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 07/01/21 through 10/04/21 were completed. The resident was admitted to hospice services on 05/25/21 related to a decline in condition. Hospice nursing visits were to occur one to three times per week as needed for general care.

Hospice nursing visit notes were not consistently documented and/or recommendations were not implemented as follows:

* There were no visits documented for 07/20/21, 08/13/21, 09/07/21 and the week of 09/13/21;

* Nursing recommendations on 08/17/21 instructed staff to apply barrier cream with brief changes;

* Nursing recommendations on 08/20/21 indicated "barrier cream to buttocks PRN to prevent skin breakdown;" and

* Nursing recommendations on 09/29/21 indicated the resident had a bruise to the head and instructed staff to "investigate cause" and monitor for changes in mentation or sleepiness.

There was no evidence the recommendations were implemented and/or communicated to staff.

The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C290 Outside providers - Resident #1 care plan and MARS community instruction has been updated to reflect the previous notes. Hospice was contacted regarding inconsistent visits and not leaving notes. Outside provider notes will be documented in a 3-point check system by MT, then MCC and then last the RN to assure that the instructions are clear and accurate and that the instructions for care are available to care staff.

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

MCC and RN will monitor the resident chart for notes and changes weekly until resolved.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 1 and 2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

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

Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 08/04/21 included the following orders:

* Morphine 20 mg/1.0 ml, take 0.25 ml every 30 minutes PRN for pain.

The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/21 through 10/04/21 showed the following:

* On 09/05/21 two Morphine doses were recorded on the MAR, but were not documented on the disposition log; and

* On 09/06/21 three doses were recorded on the MAR, but only two doses were documented on the disposition log.

Comparison of the medication bottle to the disposition log, showed the amount of medication left was reflected accurately on the log.  

The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). The staff acknowledged the findings.

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

Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 08/02/21 included the following orders:

* Lorazepam 0.5 mg, take one tablet every four hours PRN for nausea/shortness of breath.

The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/21 through 10/04/21 showed the following:

* On 09/03/21 a dose of Lorazepam was recorded on the disposition log, but not on the MAR;

* On 09/11/21 a dose of Lorazepam was recorded on the MAR, but not on the disposition log; and

* An undated entry included staff signature and one tablet dispensed, was noted on the disposition log.

Comparison of the medication dosing card to the disposition log, showed the amount of medication left was reflected accurately on the log.  

The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C302 - Tracking Controlled Substances - RN and RCC will utilize a weekly med room audit form that includes monitoring of the eldermark MAR system and comparing it to the narc book weekly. All medication technicians being re-assigned the eldermark training regarding the proper use of the electronic MARS.

Administrator will follow this process to maintain compliance with monthly monitoring of audit forms.

Based on interview and record review, the facility failed to ensure medication orders were carried out as prescribed and that written, signed practitioner orders were documented in the resident's record for all medications that the facility was responsible to administer for 1 of 4 sampled resident (#3) whose facility record was reviewed. Findings include, but are not limited to:

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

Review of Resident 3's current physician orders included the following medications:

* Famotidine (stomach upset);

* Lexapro (psychotropic);

* Multivitamin (supplement); and

* Zyprexa (psychotropic)

During interviews with Staff 5 (MT) and Staff 14 (MT) on 10/05/21 and 10/06/21, they reported they administered the resident's medications crushed in dessert or dissolved in juice/coffee on multiple occasions.  There was no documented evidence the facility had an order to administer the medication in that manner.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C303 MD Orders - Resident # 3 has an order for crushed medications however resident does not have a swallowing issue and has the right to refuse his medications facility has requested that this order be d/c.

Staff training will consisted of the following; OCP medications and dementia this class will help them understand that an order must be obtained to administer medications in any other form other than the way they are packaged in whole form. Training to educate the MT that a crushed order is for a resident with swallowing issues, and that the RN must be notified prior to a crush order being requested.

Memory Care Administrator will monitor that all orders are followed as prescribed the PCP as they are received.  

Based on interview and record review, it was determined the facility failed to ensure the physician was notified when a resident refused to consent to a medication order for 1 of 1 sampled resident (# 3) whose record was reviewed: Findings include, but are not limited to:

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

Review of the resident's current physician orders, 09/01/21 through 10/04/21 MAR and physician communications revealed the resident had refused to consent to multiple medication orders, including:

* Lexapro (psychotropic) four times;

* Famotidine (upset stomach) eight times;

* Quetiapine (psychotropic) twice; and

* Zyprexa (psychotropic) five times.

There was no documented evidence the facility had notified the physician when the resident refused to consent to the medication orders.

The need to ensure the physician was notified when a resident refused to consent to a medication was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). They acknowledged the findings.

C305 - Resident Right to Refuse - Staff training on the following;  

If a resident refuses his/her medication a fax must be sent immediately following the refusal and documented ion the chart and, on the MARs, as why the medication was not given.

A specific fax transmittal form has been created to notify the PCP of medication refusals.

MCC Administrator will monitor the MAR's to make sure that the PCP's are being noticed, this will be an ongoing process.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident-specific parameters for PRN medications for 2 of 4 sampled residents (#s 1 and 2) whose medication records were reviewed. Findings include, but are not limited to:

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

Review of the resident's 07/01/21 through 10/04/21 progress notes, physician communications, and the 09/01/21 through 10/04/21 MARs showed the following:

* Morphine 20 mg/ml take 0.25 ml, PRN for shortness of breath; and

* Lorazepam 0.5 mg take one tablet every four hours PRN for shortness of breath.

There were no parameters to direct staff which medication to give to the resident first for shortness of breath.

* Morphine 0.25 ml every 30 minutes and Tylenol 650 mg every four hours, were ordered PRN for pain.

There were no parameters to direct staff which medication to give to the resident first for pain.

* Milk of Magnesia, Docusate Sodium/Senna and Bisacodyl Suppository PRN for constipation.

There was no information for staff on when to start the medication, which medication to use first and in what order.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

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

Review of the resident's 07/01/21 through 10/04/21 progress notes, physician communications, and the 09/01/21 through 10/04/21 MARs showed the following:

* Morphine 20 mg/ml take 0.25 ml, PRN for restlessness and anxiety; and

* Lorazepam 0.5 mg take one tablet every four hours PRN for restlessness and anxiety.

There were no parameters to direct staff what the resident's restlessness and anxiety looked like or what medication to use first.

* Morphine 0.25 ml every 30 minutes, Tramadol 50 mg three times a day six hours apart, and Tylenol 650 mg every eight hours were ordered PRN for pain.

There were no parameters to direct staff which pain medication to give to the resident and in what order.

* Multiple blanks related to the resident's hourly toileting schedule, which was tracked on the MAR.

There was no additional information to indicate what occurred on the unsigned days.

The need to ensure MARs were complete and included clear direction to staff for PRN medication administration was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. The staff acknowledged the findings.

C310 - Accurate MARS - Resident # 1 MARS has been updated with resident specific instructions for the administration of this PRN pain medication.

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

When new PRN pain medications are ordered when MCC and RN are doing 2nd and 3rd check they will confirm that the resident specific parameters are included with the order and entered on the MARS.

A complete audit of all memory care PRNs will be looked at and resident specific parameters will be requested and entered in the MARS for accurate administration of the medications.

MCC and RN will monitor the parameters for PRN's as they come in from the PCP's and make sure they are entered into the MARS.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 3 sampled residents (#1, 2 and 4) who were prescribed a PRN medication to address behaviors. Findings include, but are not limited to:

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

Review of the resident's 09/01/21 through 10/04/21 MARs and progress notes and 08/04/21 hospice orders showed the following:

* Haloperidol (antipsychotic medication) 5.0 mg half a tablet, every four hours PRN agitation.

The Haloperidol was administered once on 09/06/21.  

The MARs did not contain resident-specific parameters for staff describing how the resident expressed agitation. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medications.

The need to ensure there were resident-specific descriptions of how the resident expressed agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). The staff acknowledged the findings.

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

Review of the resident's 09/01/21 through 10/04/21 MARs and progress notes and 08/02/21 hospice orders showed the following:

* Lorazepam (antipsychotic medication) 0.5 mg tablet, take one tablet every four hours PRN restlessness and anxiety.

The Lorazepam was administered seven times between 09/01/21 and 10/04/21.  

The MARs did not contain resident-specific parameters for staff describing how the resident expressed restlessness or anxiety. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medications.

The need to ensure there were resident-specific descriptions of how the resident expressed agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). The staff acknowledged the findings.

3. Resident 4 was admitted to the facility in August 2021 with a diagnoses of Alzheimer's disease.

Review of the resident's 09/01/21 through 10/04/21 MAR and 08/23/21 current physician orders revealed the following:

* An order for Clonazepam 0.25 mg daily PRN for anxiety.

The facility administered Clonazepam seven times between 09/01/21 and 09/15/21.

There were no resident-specific descriptions regarding how the resident expressed anxiety and no non-drug interventions for staff to attempt prior to administration of the medication.

* A 09/15/21 order for Lorazepam 0.5 mg daily PRN anxiety was added to the MAR on 09/17/21.  

Lorazepam was administered five times between 09/17/21 and 10/04/21. Clonazpepam was administered once.

The MAR lacked resident-specific descriptions regarding how the resident expressed anxiety and non-drug interventions to attempt prior to the administration of medication. Additionally, there were no parameters listed on the MAR which instructed staff which anxiety medication to administer first.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety, non-drug interventions for staff to attempt prior to the administration of psychotropic medications and parameters which instructed staff which medication to administer first listed on the MAR was reviewed with Staff 1 (Administrator),  Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

C330 Psychotropic Medications -

New RN has completed the Role of the RN on 10/14/21 and understand the role. MCC has is currently taking the administrators course and will have a clear understanding of the rule.

Resident # 1 care plan and community instructions on the MARS has been updated to include how the residents expresses agitation and the addition of 3 non-drug interventions to try prior to administering the PRN.  

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

Resident # 4 care plan and community instructions on the MARS has been updated to include how the residents expresses anxiety as well as what medication to administer first. and the addition of 3 non-drug interventions to try prior to administering the PRN.  

RN along with MCC administrator will go through all memory care resident charts and update all PRN psychotropics with non-drug interventions specific to the resident.  This will be monitored by the RN as new orders are received from the Physicians.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Fire and life safety records were reviewed with Staff 16 (Maintenance Director) on 10/05/21. Staff 16 reported the facility was not evacuating or relocating residents during fire drills, therefore, the facility's fire drill documentation did not include the following elements:  

* Escape route used; and

* Number of occupants evacuated.

The need to ensure all fire drills were conducted in accordance with the OFC, was discussed with Staff 1 (Administrator), Staff 2 ( Memory Care Coordinator) and Staff 16 on 10/05/21. They acknowledged the findings.

420 - Fire Drills - In order to comply, we are;

1.)Two normal fire drills week one.

2.)Week two practice runs of the evacuation route on different shifts.

3.)Week three and every week after 1 drill per week on different shifts until December.

4.)Starting December 1, 1 drill with evacuation every other week.

5.)Beginning January 1, 1 drills with evacuation per month.

Documented drills will be on every shift. This will be monitored monthly by the administrator.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Fire and life safety records were reviewed with Staff  16 (Maintenance Director) on 10/05/21. Staff 16 reported the facility was not evacuating or relocating residents during fire drills. The facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills; and

* Annual fire and life safety training for residents, including all required training topics.

Two of three facility staff interviewed on 10/05/21 were unaware of the designated point of safety.

The need to ensure all fire drills were conducted in accordance to the OFC, was discussed with Staff 1 (Administrator) and Staff 2 (Memory Care Coordinator) and Staff 16 on 10/05/21. They acknowledged the findings.

C422 - Fire and Life Safety

Weekly meetings 1:1 with each current resident will be conducted to go over safety training, fire and other natural disasters. Meetings will consist of general safety procedures, evacuation methods, responsibilities during fire drills, where the designated meeting place is outdoors.

Upon new move in within 24 hours safety training will be dome with the resident that covers safety training, fire and other natural disasters, general safety procedures, evacuation methods, responsibilities during fire drills, where the designated meeting place is outdoors along with responding to questions the residents may have.

Each resident will receive printed instructions for future reference, each training will be documented and kept in the resident file and in a resident training binder by room number.

Administrator, Director of maintenance and other designated staff will provide training. Administrator will maintain all training records and monitor monthly.

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

Refer to C 200, C 231, C 420 and C 422.

Z142 - Referral Memory Care Coordinator is currently taking the 40 Hour Administrators Course in order to get her Administrators License.

Administrator is enrolled in the 40 Hour courses and will attend this as a refresher 11/15/21 to 11/19/21 in order to be more effective in achieving compliance. Administrator will take the OCP Elder Abuse Prevention, Investigation and Reporting and Resident rights course. To maintain compliance with C200 & C231

Administrator has implemented new scheduled document trainings to achieve compliance for C420 and C422 trainings that include resident evacuation and education.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff completed all required pre-service orientation training prior to beginning job duties and demonstrated competency in their job duties within 30 days of hire, and 1 of 3 long-term staff  failed to complete the required number of hours of annual training. Findings include, but are not limited to:

Staff training records were reviewed on 10/06/21.

1. Training records lacked documented evidence the following pre-service orientation elements were completed:

a. Staff 8 (CG), hired 07/28/21:

* Abuse reporting requirements;

b. Staff 10 (MT), hired 07/09/21:

*Abuse reporting requirements; and

*Standard precautions for infection.

2. Training records lacked documented evidence that competency was demonstrated within 30 days of hire for the following:

a. Staff 8 (CG), hired 07/28/21:  

*Changes associated with normal aging; and

*General food safety serving and sanitation.

b. Staff 12 (CG), hired 07/16/21 :

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

* Conditions that require assessment, treatment observation and reporting.

3. Training records for Staff 9 (CG), hired 05/09/19, lacked documentation of completion of 10 hours annual training related to the provision of care in community based care and 6 hours of training related to dementia care.

The need to ensure all required training was completed within the specified time frames was discussed with Staff 2 (Memory Care Coordinator) on 10/06/21. She acknowledged the findings.

Z 155 Staff # 8, #9, #10, and #12 are currently working on staff training for compliance.

We have ended our contract with Relias due to not being assigned the proper training modules for compliance. We have printed the class list from Oregon Care Partners and have created a new hire online training checklist along with other trainings we require. We are also re-building our record keeping binder by month/date hire so we have the appropriate trainings annually.

We are auditing all of the staff to make sure we are compliant and making sure they have the appropriate training as required.

Administrator will oversee the training and the record keeping monthly to maintain compliance.

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

Refer to C 252, C 260, C 270, C 280, C 282, C 290, C 302, C 303, C 305, C 310 and C 330.

Memory Care Coordinator is currently taking the 40 Hour Administrators Course in order to get her Administrators License. This will help her understand the health care rules and maintain compliance with the rules.

Administrator is enrolled in the 40 Hour courses and will attend this as a refresher 11/15/21 to 11/19/21 in order to be more effective in achieving compliance.

RN has completed the Role of the RN class and now has a better understanding of her Role.

All three will enroll in continuing education as offered by OHCA and OCP in order to understand and implement the health care rules as required.

Administrator will monitor monthly that ongoing trainings are documented and kept on file. for review.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 4 of 4 sampled residents (#1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3 and 4's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN) on 10/05/21. They acknowledged the findings.

Z163 - Residents # 1, # 3 and # 4 care plans have been updated regarding the individual nutrition and hydration needs of each resident. By adding more detailed food preferences and beverages. We are going to update all resident care plans. In the initial assessment we have added additional questions to address the nutritional and hydration needs of the residents.

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

This will be monitored and updated by the memory care coordinator/administrator monthly by making changes to the care plans as the resident needs change.

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

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

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

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

Observations on 10/04/21 and 10/05/21 showed multiple residents wandering the halls, calling out and napping in the TV area for large chunks of the day without consistent interaction or intervention from staff.

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

The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Administrator), Staff 2 (Memory Care Coordinator) and Staff 3 (Health Services Director/RN). The staff acknowledged the findings.

Z164 Activities - The resident service plans for residents # 1, 3 & 4 have been updated to include more detailed information in regard to current abilities and skills, emotional and social needs and patterns, Physical abilities, adaptations for the resident to participate and things that can help with behaviors.

Resident # 2 has moved to her daughter's house she is on hospice to pass away.

Memory Care coordinator is going through each memory care resident and adding all the addressed items to all the care plans.

As new residents move in, we will include in the initial assessment current abilities and skills, emotional and social needs and patterns, Physical abilities, adaptations for the resident to participate and things that can help with behaviors.

The assessment form is currently being updated.

As the resident has changes in their needs the memory care coordinator will update the care plans with the input of the cativity director. the administrator will monitor random care plans for accuracy and changes monthly.

Based on observation, 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 4 sampled residents (# 4) with documented behaviors. Findings include, but are not limited to:

Resident 4 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease.

Review of the resident's current service plan, 08/23/21 through 10/04/21 progress notes, interviews with staff and observations of the resident revealed the following:

The resident's 08/24/21 service plan did not identify the resident exhibited behavioral symptoms which negatively impacted the resident or others.

The following behaviors were documented in the resident's clinical record:

08/24/21: "Exit seeking;"

08/29/21: "Increased anxiety...pacing the hallways;"

08/29/21: "Exit seeking this afternoon;"

09/11/21: On alert for suicidal comment: "You can help me die;"

10/02/21: "Increased agitation and aggression this shift, resident yelling at staff and other residents...slapped staff members hand;"

On 10/05/21, Resident 4 was observed pushing on the exit door and pressing buttons on the exit keypad. S/he stated multiple times that s/he wanted to leave and became upset and yelled at staff who attempted to redirect the resident.

During interviews with Staff 4 (CG) and Staff 13 (CG) on 10/05/21, they indicated the resident had engaged in exit seeking behaviors since admission to the facility and had stated that mornings and on multiple occasions s/he had a desire to die.

There was no documented evidence the facility had developed an individualized service plan for behavioral symptoms for the resident related to suicidal thoughts and verbalizations, exit seeking, agitation and aggression.

The need to develop individualized behavior plans for residents with behavioral symptoms that negatively impacted the resident or others in the community was discussed with Staff 1 (Administrator) and Staff 2 (Memory Care Coordinator) on 10/05/21. They acknowledged the findings.

Z165 - Individualized Behavior - Resident # 4 has been re-assessed with the new improved assessment and his care plan has been updated to reflect his behaviors. We requested an order from his PCP for a behavior specialist to come in to give us additional tools and staff training in order to be able to handle his behaviors.

All residents in memory care are being re-assessed to include individualized behaviors that are relative to each residents' behaviors.  

Memory Care Coordinator and the Administrator will monitor plans on a regular basis to reflect the ongoing needs and changes. Administrator will be notified of new behaviors and care plan changes.