Print Inspection: T0CC

The findings of the change of ownership survey, conducted 05/23/23 through 05/25/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 05/25/23, conducted 12/06/23 through 12/07/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 05/25/23, conducted 03/12/24 through 03/13/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

During the change of ownership survey, conducted 05/23/23 through 05/25/23, oversight to ensure the quality of services rendered in the facility was found to be ineffective, based on the number of citations.

Refer to deficiencies in the report.

See Plan of Correction (POC) for all citations.

Based on observation and interview, it was determined the facility failed to provide a safe and homelike environment. Findings include, but are not limited to:

Observations on 05/23/23 and 05/24/23, noted multiple resident room entrance doors throughout the facility locked when closed.  Multiple residents were prevented from entering their rooms without staff assistance.  In addition, multiple closet doors in the resident rooms were locked, preventing residents access to their personal belongings.

Interviews were completed with multiple care staff who reported they were instructed to lock the resident's closet and entrance doors.

The need to provide a safe and homelike environment was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 5/25/23. They acknowledged the findings and stated the resident room entrance and closet doors would be unlocked unless the resident was able to unlock the doors without assistance and/or wanted the doors locked.

1. The actions that will be taken to correct the rule violations include:

    a) The community unlocked the residents cabinet doors and flipped the switch on the residents key pad, unlocking the residents main door.

2. How will the system be corrected so this violation will not happen again?

    a) The staff will receive in-service training on residents rights specifically on ensuring residents have access to their rooms and personal belongings at all times unless specified otherwise in their service plan. This will ensure the facility maintains a safe and home-like environment for all residents.  

    b) The Resident Care Coordinator (RCC) or designee will conduct a daily audit of room doors, and cabinet doors to ensure residents have access to their rooms and personal belongings.

    c) The bottom right cabinet drawer will be the only drawer locked to store potential hazardous items.

    d) The Licensed Nurse will document through the service plan any resident who wishes to lock their main entry door and is capable of locking/unlocking his/her door.

3. Results of the audits will be reviewed weekly to evaluate effectiveness of plan until 100% of compliance is achieved.

4. The Administrator will be responsible to see that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to investigate incidents to rule out abuse and/or report to the local SPD office if abuse or neglect could not be ruled out for 3 of 3 sampled residents (#s 1, 2, and 3) with falls, falls with injury, and resident-to-resident altercations. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 03/2022 with diagnoses including dementia, bipolar disorder, and a history of falls.

The resident's progress notes, dated 01/18/23 through 05/23/23, and facility incident reports were reviewed. The following was identified:   

* On 03/28/23, Resident 1 had a fall resulting in a skin tear to the right elbow and bruising to both arms; and

* On 05/07/23, a fall with bruising and swelling to the right eye, eye brow, and temple area.

There was no immediate investigation of the falls with injuries to rule out abuse and/or report to the local SPD office.

The need to ensure falls with injuries were immediately investigated and reported to the local SPD office if abuse and neglect could not be ruled out was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

The surveyor requested Staff 1 report the two falls with injuries to the local SPD office on 05/24/23, and verification was received on 05/25/23.

2. Resident 2 was admitted to the memory care community in 02/2023, with diagnoses including Alzheimer's Disease, anxiety and hypertension.  

Review of Resident 2's progress notes, dated 02/22/23 through 05/23/23, incident reports, and interim service plans indicated the following:  

The facility failed to report to the local SPD office and to conduct and document investigations, including measures taken to protect residents and prevent any reoccurrence, for the following two incidents of abuse:

* 02/27/23 - Resident 2 roughly grabbed a caregiver in a wrist lock, which led to a physical altercation with another resident; and

* 05/20/23 - Resident 2 grew upset in a common area and struck another resident on the back.

On 05/24/23, the surveyor discussed the incidents of abuse with Staff 1 (ED) and requested the incidents be reported immediately to the local SPD. On 05/25/23 Staff 1 provided verification the incidents had been reported.

On 05/25/23, reporting incidents of abuse and initiating measures to prevent reoccurrence was discussed with Staff 1, Staff 2 (Wellness Director/LPN), Staff 3 (RN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC). They acknowledged the findings.

3. Resident 3 was admitted to the facility in 10/2022 with diagnoses including dementia and spinal stenosis.

A review of the resident's clinical record, including progress notes, incident reports, and temporary service plans, dated between 03/05/23 and 05/23/23, and staff interviews identified the following:

* 04/02/23 - resident found on the floor;

* 04/21/23 - resident found on the floor; and

* 05/13/23 - resident found on the floor.

The resident was unable to describe the circumstances related to these falls and had no history of falls prior to a decline in vision in 03/2023.

There was no documented evidence these incidents had been investigated to rule out abuse and/or neglect nor evidence the local SPD was notified.

The need to investigate resident incidents to rule out abuse and/or neglect or notify SPD if abuse could not be ruled out was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) The incidents for Residents 1 and 2 were reported to state agency upon notification of findings. A full investigation of the incidents for Residents 1, 2, and 3 were completed. Based on the investigations, there were no indications of abuse or neglect.

2. The system will be corrected so that the violation will not occur again by:

    a) When an incident of abuse or  suspected abuse, occurs in the community, whether overheard or witnessed by observation, an Incident Report will be completed and reported to the local SPD or AAA office immediately. Any injury of unknown cause must be reported as suspected abuse unless immediate facility investigation reasonably concludes and documents

that the physical injury is not the result of abuse.

     b) All staff will complete the Oregon Care Partners' training course - "Elder Abuse Prevention, Investigation, and Reporting" by July 8, 2023.

3. The Health and Wellness Director (HWD) or designee will conduct weekly and random audits of completion of incident reports, investigation and reporting to ensure compliance. Audit findings will be discussed at monthly Quality Assurance (QA) meetings for review and revisions to the plan.

4.The Administrator  will be responsible to ensure that corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to ensure resident evaluations were completed quarterly for 1 of 3 sampled residents (#3) whose evaluations were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 10/2022 with diagnoses including dementia and spinal stenosis. A review of the resident's record revealed his/her quarterly evaluation had not been completed.

The need to ensure resident evaluations were completed quarterly was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) Resident's quarterly evaluation for Resident 3 was conducted to reflect the resident's current needs and preferences.

2. The system will be corrected so the violation will not occur again by:

    a) The Licensed Nurse will ensure that resident evaluations are are conducted at the time of move in, within 15-30 days of move in, with any change in condition, and quarterly to accurately reflect the residents needs and preferences.

    b) The Licensed Nurse will maintain a monthly schedule of required resident evaluations to ensure timely completion. Changes of conditions will be discussed at daily stand-up meetings to ensure evaluations are conducted timely.

3. The Regional Clinical Operations Lead or designee will complete weekly audits to ensure compliance. Areas of non-compliance will be addressed immediatley. Results of findings will be reviewed at monthly QA meetings to identify need to modify plan.

4. The Administrator  will be responsible to ensure that corrections are completed and monitored.   

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, were followed by staff, were readily available to staff, and were updated quarterly for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 03/2022 with diagnoses including depression and bipolar disorder.

Observations of the resident, interviews with staff, review of the current service plan, temporary service plans for the last 90 days, and incident reports showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Transfer assistance instructions for when to use one or two staff;

* Skin issues;

* Bladder incontinence;

* Wheelchair mobility; and

* Pain location and non-pharmacological interventions.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations) and Staff 7 (RCC) on 05/25/23. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 10/2022 with diagnoses including dementia and spinal stenosis.

The resident's current service plan updated 04/07/23, temporary service plans dated 04/03/23 through 05/16/23, and progress notes dated 03/05/23 through 05/22/23, were reviewed, and staff were interviewed.

The resident's service plan was not reflective in the following areas:

* Fall history;

* Level of meal assistance needed;

* Frequency of safety checks;

* Need for finger foods;

* Significant weight loss; and

* Hospice report resident was "possibly transitioning."

In addition, the service plan which was available to care staff was not the most  updated version.

The need for service plans to accurately reflect residents' current status and care needs, and for caregivers to have access to the most current service plan, was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC). They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) The most up to date care plan will be made available and accessible to care staff, located in the chart room.

    b) Service plans for Residents 1 & 3 were updated to reflect their current status including intervention, incident history, and changes in condition.

2. The system will be corrected so that the violation will not occur again by:

    a) The License Nurse will complete resident service plans at move in, within 15-30 days of move in, quarterly, and with any change of condition.

    b) The Licensed Nurse will review all current resident records and ensure that any short-term change or change in condition is addressed with appropriate interventions accordingly.

3. The area needing correction will be evaluated by the Licensed Nurse weekly by auditing all current residents service plans and charts ensuring they reflect the current physical and mental needs of the resident. The licensed nurse will ensure all change of conditions are complete and reflective of resident changes. A clinical meeting will occur daily with the Interdisciplinary team  and any other applicable parties for additional oversight on completion and timeliness.

4. The Administrator  will be responsible to ensure that corrections are completed and monitored.

2. Resident 5 was admitted to the MCC in 04/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the current service plan, temporary service plans, progress notes from 10/30/23 through 12/06/23, and incident reports showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Level of care/assistance needed for ADLs with instructions on determining how many staff were needed to assist related to behaviors;

* Continence of bowel and bladder;

* Unable to use call light;

* Behaviors, to include visual hallucinations and physical aggression;

* Mechanical soft diet texture;

* Regular dinnerware;

* History of weight loss; and

* Fall interventions implemented.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 27 (Interim ED), Staff 28 (ED in Training), and Staff 29 (RN/Health and Wellness Director) by telephone on 12/07/23. The staff acknowledged the findings.

3. Resident 7 was admitted to the facility in 11/2023, with diagnoses including dementia, Parkinson's Disease, and hypertension.

Resident 7's initial service plan, dated 11/01/23, was not reflective of the resident's current status and care needs or lacked clear direction to staff regarding the delivery of service in the following areas:

* wheel chair use;

* weight loss risk; and

* meal refusals.

The service plan lacked any information regarding wheel chair use by Resident 7. However, on both days of the survey the resident was observed sitting in a wheel chair during the noon meal.

In an interview on 12/07/23, Staff 33 (CG) stated Resident 7 was considered at risk for weight loss, and often refused meals. The service plan lacked any information about these concerns.

On 12/07/23, the need to ensure service plans were reflective of current resident care needs and provided clear directions to staff was discussed with Staff 27 (Interim ED) and Staff 28 (ED in Training). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services for 3 of 3 sampled residents (#s 5, 6, and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease and visual hallucinations.

The resident's 11/03/23 service plan, 10/30/23 through 12/05/23 progress notes, and interim service plans were reviewed. Staff were interviewed and observations were made of the resident. The resident was observed to be in his/her bed each time s/he was observed on 12/06/23 and 12/07/23.  Records revealed the resident experienced a significant change of condition and was admitted to hospice on 10/31/23. The following areas of the service plan were not reflective of the resident's current care needs and/or did not provide clear direction to staff:

* Frequency of safety checks;

* Ensuring apartment door left open;

* Fall history and risk;

* Hospice assistance with bathing;

* Oral care;

* Ability to use call light;

* Type of diet;

* Level of meal assistance required; and

* Choking and swallowing concerns.

The need for service plans to accurately reflect residents' current needs and provide clear instructions to staff was discussed with Staff 27 (Interim ED), Staff 28 (ED in Training), Staff 29 (RN/Health & Wellness Director) by telephone, and Staff 30 (RN Consultant) on 12/07/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

a) Service plan for Residents 6 was updated to reflect their current needs including frequency of safety checks, ensureing apartment door is left open, fall history and risk, hospice assistance with bathing, oral care, abiltiy to use call light, type of diet, level of meal assistance required and choking and swallowing concerns.

b) Service plan for resident 5 was updated to reflect their currenct needs including Level of care/assistance needed for

ADLs with instructions on determining

how many staff were needed to assist

related to behaviors; Continence of bowel and bladder;  Unable to use call light; Behaviors, to include visual

hallucinations and physical aggression; Mechanical soft diet texture; Regular dinnerware; History of weight loss; and Fall interventions implemented.

c) Service plan for resident 7 has been closed resident is no longer in the facility.

2. The system will be corrected so that the violation will not occur again by:

a) The License Nurse in collaboration with the Resident Care Coordinator will complete resident service plans at

move in, quarterly, and with any change of condition. This will be reviewed daily in clinical meeting to ensure they are not missed.

b) The Licensed Nurse will record and ensure that any short-term change or change in condition is addressed with appropriate interventions accordingly.  LN and RCC will review for acute/changes in condition during the clinical team meetings.

3. The area needing correction will be evaluated by the LN and administrator.  Audit of resident charts who have an admission /30-days, quarterly, and chang in condition functional evaluation/SP due to ensure interventions reflect the current physical and mental needs of the resident.  The policy and procedure for review/updating ISP has been reviewed and updated. A clinical meeting will occur daily with the Interdisciplinary team and any other applicable parties for additional oversight on completion and timeliness.  

a)Staff education will completed by onsite inservices and collaboration with nurse consultants regarding how to be resident specific, including direction for staff on mobility, nutrition, behaviors, bowel and bladder, diet textures as well as fall interventions to be reflective of current care needs.

4. The Administrator will be responsible to ensure that corrections are completed and monitored.  Nurse consultant to review service plans of residents who have had changes of condition/new move-ins/30 days/completed 90 day reviews during the nurse consultant visits.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 2, and 3). As applicable, the Service Planning Team must also include local APD or AAA Case Managers and family invited by the resident, and a licensed nurse if the resident needed or was receiving nursing services or experienced a significant change of condition. Findings include, but are not limited to:

Current service plans for Residents 1, 2, and 3 were reviewed during the survey.

The service plans lacked documented evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) The service plans for Residents 1,2, and 3 were updated to reflect that a service planning team participated in the development of the service plans.

2. The system will be corrected so that this violation does not occur again by:

    a) The Licensed Nurse will review all current residents evaluations and conduct service plans reviews including all applicable parties such as: Resident, Resident Legal Representative, any person of Resident's choice, Administrator, Licensed Nurse, and at least one other person who is familiar with the resident such as dietary team, and Life Enrichment team.

3. The Administrator or designee will conduct weekly audits to ensure compliance to the plan. Areas of non-compliance will be addressed immediatley. Results of findings will be reviewed at monthly QA meetings to identify need to modify plan.

4. The Administrator  will be responsible to ensure that corrections are completed and monitored.   

2. Resident 1 was admitted to the MCC in 03/2022 with diagnoses including dementia and bipolar disorder.

Observations of the resident, interviews with staff, and review of the resident's 03/02/23 service plan, 01/18/23 through 05/23/23 progress notes, incident investigations, and physician communications were completed.

The resident experienced multiple short-term changes without evaluation of interventions for effectiveness, documented progress noted weekly until resolution, and/or resident-specific actions or interventions developed and communicated to staff on each shift  in the following areas:

* Non-injury falls on 03/09/23, 03/11/23, 03/14/23, 03/22/23, 03/28/23, and 05/15/23;

* Injury fall on 03/28/23 with skin tear to the right elbow and bruising to both arms;

* Injury fall on 05/07/23 with bruising, swelling, and pain to the right eye, temple, and right forehead area;

* 03/03/23 Significant weight loss;

* 03/11/12 Vomiting;

* 03/15/23 COVID positive;

* 03/27/23 Hospital return; and

* 04/10/23 Hospice admit.

The need to ensure short-term changes of condition had an evaluation which included effectiveness of interventions, documentation of weekly progress until resolution, and resident-specific actions or interventions developed and communicated to staff on each shift was discussed with Staff 3 (RN) and Staff 2 (Wellness Director/LPN) on 05/24/23 and Staff 1 (Executive Director), Staff 2, Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. The staff acknowledged the findings.

3.  Resident 2 was admitted to the memory care community in 02/2023 with diagnoses including Alzheimer's Disease, hypertension, and anxiety.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 04/03/23, progress notes dated 02/22/23 through 05/23/23, incident reports, and interim service plans revealed the following:

Resident 2 was involved in the following resident-to-resident altercations:

* 02/27/23 - Resident 2 roughly grabbed a caregiver in a "wrist lock", which led to a physical altercation with another resident;

* 03/25/23 - Resident 2 swung at another resident, grazing his/her nose;

* 04/30/23 - Resident 2 approached another resident in a wheelchair, then struck the resident on the head and pulled his/her hair; and

* 05/20/23 - Resident 2 grew upset in a common area and struck another resident in the back.

Resident 2's clinical records documented the following interventions for agitation and aggressive behavior:

* Avoid crowding; give [him/her] space when agitated;

* Remove fellow residents from the area, or remove [Resident 2] from the area;

* Be aware of any items which may be used as a weapon or could be viewed as a threat;

* Watch for [Resident 2] entering other residents' rooms;

* Keep hallway noise and lighting to a minimum;

* Redirect to a quiet place, while offering toileting, soothing music, snack, or a back rub; and

* Resident was placed on 1:1 monitoring by staff on swing shift, starting on 03/15/23. This was increased to 24 hour supervision on 04/10/23.

There was no documented evidence these interventions were evaluated for effectiveness.

On 05/25/23 the need to ensure short-term changes of condition had an evaluation which included effectiveness of any interventions was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 3 (RN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC). The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated to determine and document what actions or interventions were needed, to communicate the actions or interventions to staff on each shift, to provide written resident-specific instructions or interventions to staff on each shift, to monitor residents consistent with their evaluated needs, and to note weekly progress until resolution for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including dementia and spinal stenosis.

The resident's current service plan updated 04/07/23, temporary service plans dated 04/03/23 through 05/16/23, and progress notes dated 03/05/23 through 05/22/23, were reviewed, and staff were interviewed. The following changes of condition were identified:

* 03/23/23 - transported to emergency department, who reported s/he had experienced vision loss;

* 03/24/23 - return to the facility from the emergency department;

* 04/02/23 - non-injury fall;

* 04/21/23 - resident found on the floor;

* 04/29/23 - report of a "nickel size" wound on the resident's [genital];

* 05/02/23 - resident found on the floor;

* 05/13/23 - resident found on the floor; and

* 05/16/23 - resident experienced difficulty "feeding himself."

There was no documented evidence resident-specific actions or interventions were developed and communicated to staff on each shift and/or progress was noted at least weekly until resolution for these changes.

The need to determine, document, and communicate to staff specific actions or interventions for short-term changes of condition and to monitor progress and document at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct this rule violation are:

    a) The Service Plans for sample residents 1,2, and 3 were updated to ensure that all short term changes of condition were documented and communicated to staff. These service plans and resident's progress will be evaluated at least weekly until resolution.

2. The system will be corrected so that the violation will not occur again by:

    a) The Licensed Nurse will review all current resident service plans to ensure service plans are descriptive of the residents' current health and functional status. During the record review, the Licensed Nurse will also ensure the service plans provide a clear description and directon of the care needs for care associates.

    b) The Licensed Nurse will review all current resident records to ensure that all significant and short-term changes of condition are reflected in an updated service plan or temporary service plan respectively. The Licensed Nurse will document instructions and interventions that are specific to each change of condition.

   c) The Licensed Nurse will monitor residents daily for any changes of condition. Any change will be monitored at least weekly with a minimum of a progress note and communitcated to staff.

   d)  The care staff will receive in-service training on policies and procedures related to care and management of resident changes of condition.

3. The Registered Nurse or designee will conduct weekly audits of required clinical documentation and service plans of residents who experienced a change of condition. Areas of non-compliance will addressed immediately. Results of these audits will be discussed at the monthly QA meetings for review and revisions to the plan as needed.

4.  The Administrator  will be responsible to ensure that corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to ensure changes of condition had determined and documented what actions or interventions were needed, had communicated the actions or interventions to staff on each shift, provided written resident-specific instructions or interventions to staff on each shift, monitored residents consistent with their evaluated needs, and noted weekly progress until resolution for 2 of 3 sampled residents (#s 5 and 6) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2023 with diagnoses including dementia.

The resident's current service plan, updated 10/22/23, temporary service plans dated 10/30/23 through 12/06/23, and progress notes dated 10/30/23 through 12/06/23 were reviewed, and staff were interviewed. The following changes of condition were identified:

* 10/30/23 - Non-injury fall;

* 11/03/23 - Fall with head strike;

* 11/10/23 - Non-injury fall

* 11/15/23 - Non-injury fall;

* 11/16/23 - Non-injury fall;

* 11/27/23 - Fall with skin tear to right knee;

* 11/28/23 - Fall with skin tear to left knee and left elbow;

* 11/28/23 - Two Non-injury falls; and

* 12/03/23 - Resident-to resident altercation.

There was no documented evidence the changes of condition were evaluated to determine what resident-specific actions or interventions were needed, interventions were documented and communicated to staff on each shift, and/or progress consistent with evaluated needs was monitored at least weekly until resolution.

The need to determine, document, and communicate to staff specific actions or interventions for short-term changes of condition, and to monitor progress and document at least weekly through resolution, was discussed with Staff 27 (Interim ED), Staff 28 (ED in Training), and Staff 29 (RN/Health and Wellness Director) by telephone on 12/07/23. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease and visual hallucinations.

Review of the 11/03/23 service plan, 10/30/23 through 12/05/23 progress notes, interim service plans (ISPs), and incident reports was completed, and staff were interviewed. The following was identified:

a. On 10/30/23 the resident was sent to the emergency department due to a sudden cognitive decline. The hospital referred the resident to hospice and discontinued several of the resident's medications. An ISP was created on 10/30/23 which included monitoring instructions for staff. There was no documented evidence the medication changes were monitored through resolution, with at least weekly documentation.

b. Resident 6 experienced falls on 10/30/23 and 11/14/23. There was no documented evidence interventions were evaluated for effectiveness or new interventions were developed, implemented, and communicated to staff.

The lack of documented monitoring and evaluations of fall interventions for effectiveness was discussed with Staff 27 (Interim ED), Staff 28 (ED in Training), Staff 29 (RN/Health & Wellness Director) via telephone, and Staff 30 (RN Consultant) on 12/07/23. They acknowledged the findings.

1. The actions that will be taken to correct this rule violation are:

a) The Service Plans for sample residents 5,6, were updated to ensure that all short term changes of condition were documented and communicated to staff. These service plans and resident's progress will be evaluated at least weekly until resolution.  Resident 7 is no longer in facility.

2. The system will be corrected so that the violation will not occur again by:

a) The Licensed Nurse in collaboration with the Resident Care Coordinator will ensure service plans for new admissions/30-day/quarterly/change in condition  are descriptive of the residents' current health and functional status. During the record review, the Licensed Nurse in collaboration with the Resident Care Coordinator will also ensure the service plans provide a clear description and directon of the care needs for care associates.

b) The Licensed Nurse will review new admissions/30 days/quarterly/change in condition to ensure that all significant and short-term changes of condition are reflected in an updated in service plan or temporary service plan respectively. The Licensed Nurse will document instructions and interventions that are specific to each change of condition.

c) The Licensed Nurse will monitor residents for any changes of condition upon onset and monitor effectiveness of temporary plans put in place and discuss at interdisciplinary meetings with a minimum of a progress note and communitcation to staff at a minimum of at least weekly.

d) Staff education will be provided by nurse consultants to Administrator, Resident Care Coordinator as well as LN on when to complete change of condition and how to evaluate the effectiveness of interventions.

3. The Administrator/nurse consultant or designee will conduct weekly audits of required clinical documentation and service plans of residents who experienced a change of condition. Areas of non-compliance will be addressed immediately. Results of these audits will be discussed at the monthly QA meetings for review and revisions to the plan as needed.

4. The Administrator will be responsible to ensure that corrections are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed to include documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled residents (#s 1 and 3) who experienced significant changes of condition related to weight loss. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 03/2022 with diagnoses including dementia and bipolar disorder.  

Weight records, dated 12/12/22 through 05/06/23, and progress notes, dated 01/18/23 through 05/23/23, were reviewed and indicated the resident experienced significant and then severe weight loss as follows:

* 12/12/22 = 104.4 lbs.;

* 01/04/23 = 94.4 lbs.;

* 02/13/23 = 92.4 lbs.;

* 03/03/23 = 92.8 lbs.;

* 04/05/23 = 73.2 lbs.; and

* 05/06/23 = 77.6 lbs.

Between 12/12/22 and 03/03/23 the resident lost 10 lbs., or 7.5% of total body weight in 90 days. This weight loss constituted a significant change of condition.  There was no RN assessment documented for the weight loss.

Between 03/03/23 and 04/05/23 the resident lost a total of 19.6 lbs., or 21% of total body weight in one month. On 03/28/23 a facility-contracted nurse practitioner wrote a comprehensive assessment of the resident's condition, including contributing factors for weight loss, expectation for future weight loss, and interventions in place and interventions to be implemented.

The facility RN wrote a progress note on 04/10/23 indicating Resident 1 would be admitted to hospice related to continued weight loss and decline.

A weight of 77 lbs was obtained on 05/25/23, at the request of the surveyor.

Multiple observations of the resident between 05/23/23 and 05/25/23 showed the resident had attended meals in the dining room. The resident was observed to eat less than 50% of the observed lunch meals, without staff assistance.

The facility failed to ensure an RN assessment was completed for the weight loss from 12/2022 to 03/2023, which included documented findings, resident status, and interventions made as a result of the assessment.

On 05/25/23 Staff 3 presented survey with an RN assessment of Resident 1's significant and ongoing weight losses between 12/2022 and 05/2023.

The need to ensure an RN assessment was completed for a significant change of condition, which documented findings, resident status, and interventions made, was discussed with Staff 3 (RN) and Staff 2 (Wellness Director/LPN) on 05/24/23 and Staff 1 (Executive Director), Staff 2, Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on on 05/25/23. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 10/2022 with diagnoses including dementia and spinal stenosis.

The resident's current service plan updated 04/07/23, temporary service plans dated 04/03/23 through 05/16/23, progress notes dated 03/05/23 through 05/22/23, and 10/21/22 through 05/09/23 weight records were reviewed, and staff were interviewed.

The following was identified:

* 12/06/22 = 164.4 lbs.;

* 01/08/23 = 160.6 lbs.;

* 02/02/23 = 154.3 lbs.;

* 03/04/23 = 148.4 lbs.;

* 04/06/23 = 140.4 lbs.; and

* 05/08/23 = 127.6 lbs.

Between 12/06/23 and 03/04/23, the resident lost 16 lbs., or 9.73% of his/her total body weight, in 90 days. This constituted a significant change of condition. There was no RN assessment documented for the weight loss. In a progress note dated 03/13/23, the RN wrote they implemented health shakes and protein pudding three times a day, cueing and assisting with meals as needed, and alert charting which was resolved 04/10/23.

The resident was admitted to hospice on 04/05/23. On 05/15/23 hospice noted " ... [the resident] is likely transitioning to dying process  ..."

Between 04/06/23 and 05/09/23, the resident lost an additional 12.8 lbs., or 9.1% of his/her total body weight in one month. There was no RN assessment for this significant change of condition.

A current weight was not obtained during survey because the resident was largely non-responsive and observed to be in bed throughout the survey, from 05/23/23 through 05/25/23.

The facility failed to ensure RN assessments were completed for the weight loss between 12/2022 and 05/2023, which included documented findings, resident status, and interventions made as a result of the assessments.

On 05/25/23 Staff 3 (RN) presented survey with an RN assessment of Resident 3's significant weight loss between 12/2022 and 03/2023.

The need to ensure an RN assessment was completed for significant changes of condition, which documented findings, resident status, and interventions made, was discussed with Staff 2 (Wellness Director/LPN) and Staff 3 on 05/24/23 and Staff 1 (Executive Director), Staff 2, Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a)  The Licensed Nurse conducted an RN Note/Assessment for sample Residents 1 and 3.

    b) The Licensed Nurse conducted a significant change in condition service plan adjustment with a current nutrition and hydration plan for Residents 1 and 3 as well as implement resident specific interventions.

2. The system will be corrected to avoid future violations by:

    a) The Registered Nurse (RN) will complete training on the role of the RN in CBC settings by July 3, 2023.

    b)  The Licensed Nurse will notify the RN of all significant changes of condition promptly. The RN will complete a full or problem-focused assessment and will document findings and interventions to address the problem area(s) timely.

3. The Regional Clinical Operations Lead or designee will conduct weekly audits of clinical documentation and service plans for  Resident significant changes of condition. Areas of non-compliance will be addressed immediately. Results of these audits will be discussed at the monthly QA meetings for review and revisions to the plan as needed.

4.  The Administrator  will be responsible to ensure that corrections are completed and monitored.  

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

1. Resident 1 was admitted to the MCC in 03/2022 with diagnoses including dementia and bipolar disorder.

Review of the resident's 05/01/23 through 05/23/23 MAR and physician orders revealed the resident had multiple PRN bowel care and PRN pain medications. These PRN medications lacked clear direction to staff regarding the timing and sequence for administration.

The need to ensure there were clear instructions/parameters for staff when administering PRN medications was discussed with Staff 2 (Wellness Director/LPN) and Staff 3 (RN) on 05/24/23, and Staff 1 (Executive Director), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 10/2022 with diagnoses including dementia and spinal stenosis.

A review of the resident's 05/01/23 through 05/23/23 MAR and physician orders revealed the following:

* The resident had a physician order for PRN oxycodone (a narcotic pain reliever) 0.25 ml every hour as needed for pain.

* The resident had an order for PRN acetaminophen (a pain reliever) 325 mg, 2 tabs every six hours as needed for "mild pain/fever."

There were no instructions on the MAR regarding the sequence in which to administer the PRN pain medications.

The need to have clear parameters on the MAR was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule vioaltion include:

    a) The PRN (as needed) medications for sampled Residents 1 and 3 were reviewed and updated to include resident specific instructions and parameters on how and when to administer.

2. The system will be corrected so that the violation will not occur again by:

    a) Associates who administer medications will receive training on establishing and following specific instructions and/or parameters for PRN medications.

    b) Licensed Nurse will review orders for residents with PRN medications to ensure they have specific instructions or parameters on how and when to administer. Orders will be clarified with the attending physician or provider to ensure accuracy.

3. The Registered Nurse or designee will conduct weekly audits of PRN medications for required instructions or parameters for administration.  Areas of non-compliance will addressed immediately. Results of these audits will be discussed at the monthly QA meetings for review and revisions to the plan as needed.

4.  The Administrator  will be responsible to ensure that corrections are completed and monitored.    

2. Resident 1 moved into the MCC in 03/2022 and had diagnoses which included dementia and bipolar disorder.

Review of the resident's service plan, physician orders, and 05/01/23 through 05/23/23 MAR revealed the following:  

a. Resident 1 was prescribed lorazepam 0.5 mg (anti-anxiety medication) one tablet every four hours as needed for anxiety.

The facility failed to ensure the resident's MAR and clinical record included the following required information:

* Documentation of how Resident 1 exhibited anxiety;

* Documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 1; and  

* Staff administered the PRN lorazepam on eight occasions without documentation that non-pharmacological interventions were attempted and were ineffective, prior to administration of the medication.

b. Resident 1 was prescribed olanzapine 5 mg (anti-psychotic medication) every six hours as needed for agitation.

The facility failed to ensure the resident's MAR and clinical record included the following required information:

* Documentation of how Resident 1 exhibited agitation; and

* Staff administered the PRN olanzapine on 13 occasions without documentation that non-pharmacological interventions were attempted and were ineffective, prior to administration of the medication.

During an interview with Staff 14 (MT) on 05/24/23 at 09:55 am, she reviewed the resident's record and confirmed there was no documentation as to how Resident 1 exhibited anxiety or agitation and that staff had not documented that non-pharmacological interventions had been attempted prior to administering the medications.

The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. The staff acknowledged the findings. No further information was provided.

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

1. Resident 2 was prescribed olanzapine 10 mg (a psychotropic medication) as needed every eight hours for agitation.

The facility administered the olanzapine to the resident on four occasions between 05/01/23 and 05/23/23.

The facility failed to ensure there were specific parameters for staff describing how Resident 2 exhibited symptoms of agitation. There were no non-pharmacological interventions on the MAR for staff to attempt prior to administering the medication.

The need to ensure there were resident-specific descriptions of how residents expressed agitation and non-pharmacological interventions for staff to attempt prior to the administration of psychotropic medications was reviewed with Staff 1 (Executive Director), Staff 2 (Wellness Director), Staff 3 (RN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC). They acknowledged the findings.

3. Resident 3 was admitted to the facility in 10/2022 with diagnoses including dementia and depression.

A review of the resident's 05/01/23 through 05/23/23 MAR and physician orders revealed the following:

* The resident had a physician order for lorazepam (a psychotropic medication) 0.5 mg every four hours as needed for anxiety.

* The facility administered the lorazepam to the resident on two occasions between 05/01/23 and 05/23/23.

There was no documented evidence staff were attempting non-pharmacological interventions  and documenting they were ineffective prior to administering the PRN psychotropic medication.

The need to attempt non-pharmacological interventions and document which interventions were tried and whether they were effective was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) The eMAR for sampled Residents 1,2 and 3 were updated to ensure PRN psychotropic medications have written, resident-specific parameters and to include instructions to attempt resident specific non-pharmacological interventions prior to medication administration.

2. The system will be corrected so that the violation will not occur again by:

    a) The Licensed Nurse will review medication orders for residents receiving PRN psychotropic medications to ensure each psychotropic medication has resident specific parameters as well as non-pharmacutical interventions prior to administration. The resident's attending physician will be notified for orders needing clarification.

    b) All direct care staff as well as associates who are trained to administer medication will receive additional training on administering psychotropic medication such as understanding reasons for pyschotropic medications, medication side effects, parameters, and when to contact a healthcare professional.

3. The Registered Nurse or designee will conduct weekly audits of required clinical documentation for PRN psychotropic medications. Areas of non-compliance will addressed immediately. Results of these audits will be discussed at the monthly QA meetings for review and revisions to the plan as needed.

4.  The Administrator  will be responsible to ensure that corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat residents' behavior had written, resident-specific parameters and staff were documenting non-pharmacological interventions attempted prior to administering the medication for 2 of 2 sampled residents (#s 5 and 6) who were prescribed PRN medication to address behaviors. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 moved into the MCC in 04/2023 and had diagnoses which included dementia.

Review of the resident's service plan, physician orders, 11/01/23 through 11/30/23 MAR, and progress notes revealed the following:

Resident 5 was prescribed lorazepam 1 mg (anti-anxiety medication) daily as needed for agitation.

Staff administered the PRN lorazepam on four occasions without documentation that non-pharmacological interventions were attempted and were ineffective, prior to administration of the medication.

The need to ensure non-pharmacological interventions were attempted with ineffective results prior to administration of  PRN psychotropic medications, and were documented on the MAR or in the clinical record was discussed with Staff 27 (Interim ED), Staff 28 (ED in Training), and Staff 29 (RN/Health and Wellness Director) by telephone on 12/07/23. The staff acknowledged the findings. No further information was provided.

2. Resident 6 was admitted to the facility in 07/2023 with diagnoses including Alzheimer's disease and visual hallucinations.

A review of the residents 11/2023 MAR revealed s/he was prescribed two PRN psychotropic medications:

* Lorazepam 0.5 mg, 1 tab every four hours as needed for anxiety, restlessness, shortness of breath, or nausea; and

* Haloperidol 5 mg, 0.5 tablet (2.5 mg) every four hours as needed for restlessness, agitation, or nausea.

There were no resident-specific parameters on the MAR for either medication to indicate symptoms for which these medications would be administered or non-pharmacological interventions to attempt prior to administration of either medication.

In an interview on 12/07/23, Staff 40 (Staffing Care Coordinator) reviewed the electronic MAR and confirmed there were no resident-specific parameters for the resident's PRN psychotropic medications.

The need to include resident-specific parameters on the MAR for all PRN psychotropic medications was reviewed with Staff 27 (Interim ED), Staff 28 (ED in Training), Staff 29 (Health & Wellness Director) via telephone, and Staff 30 (RN Consultant). They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

a) The eMAR for sampled Residents 5 and 6 were updated to ensure PRN psychotropic medications have written, resident-specific parameters to include instructions to attempt resident specific non-pharmacological interventions prior to medication administration and the EMAR has been configured to allow documentation of non-pharmiculical interventions to be documented prior to administering PRN psychotorpic medication.

2. The system will be corrected so that the violation will not occur again by:

a) The LN will review medication orders for residents receiving PRN psychotropic medications to ensure each psychotropic medication has resident specific parameters as well as non-pharmacutical interventions prior to administration. The resident's attending physician will be notified for orders needing

clarification.

b) All direct care staff as well as associates who are trained to administer medication will receive additional training from nurse consultant on administering psychotropic medication such as understanding reasons for pyschotropic medications, medication side effects, parameters, how to document and when to contact a healthcare professional.

3. Required clinical documentation for PRN psychotropic medications and documention of non pharmacutical interventions will be reviewed daily in clinical meetings. Areas of non- compliance will be addressed immediately. Results of these audits will be discussed at the monthly QA meetings for review and revisions to the plan as needed.

4. The Administrator will be responsible to ensure that

corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation for 1 of 3 sampled residents (# 3) whose records were reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed on 05/24/23. The following was identified:

1. During a review of sampled residents' service plans, it was determined the ABST failed to accurately reflect the following areas for Resident 3:

* Repositioning;

* Meal assistance needed; and

* Safety checks.

2. The facility did not have a system in place for updating the ABST for each resident whenever there was a significant change of condition and no less than quarterly, preferably at the same time the resident's service plan was updated.

* Resident 3's ABST had not been updated since 11/30/22.

The need to ensure the ABST accurately reflected residents' current needs and was updated as required was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff  4 (VP of Clinical Operations), and Staff 7 (RCC) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) The ABST was reviewed and revised for Resident 3 to ensure it reflects the resident's current care needs and level of assistance specifically on the areas noted in the findings.

     b) At a minimum, the ABST will be updated quarterly by the Licensed Nurse for each resident following completion of the quarterly evaluation. Likewise, the ABST will also be updated with any resident changes of condition to ensure it reflects the current care needs and level of assistance for the resident.

2. The system will be corrected so that the violation will not occur again by:

    a) At a minimum, the ABST will be updated quarterly by the Licensed Nurse for each resident following completion of the quarterly evaluation. Likewise, the ABST will also be updated with any resident changes of condition to ensure it reflects the current care needs and level of assistance for the resident.

3. The Administrator will conduct weekly audits of the ABST to ensure proper and timely updates are completed.

4. The Administrator will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to:

ABST data was reviewed on 12/06/23.

Resident 6 experienced a significant change of condition on 10/31/23. There was no documented evidence the ABST data had been updated after the significant change.

The need to ensure the ABST was updated whenever a resident experienced a significant change of condition was discussed with Staff 27 (Interim ED), Staff 28 (ED in Training), Staff 29 (RN/Health & Wellness Director) via telephone, and Staff 30 (RN Consultant) on 12/07/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

a) The ABST was reviewed and revised for Resident 3 to ensure it reflects the resident's current care needs and level of assistance specifically on the areas noted in the findings.

2. The system will be corrected so that the violation will not occur again by:

a) At a minimum, the ABST will be updated quarterly by administrator of designee for each resident following completion of the quarterly evaluation. Likewise, the ABST will also be updated with any resident changes of condition to ensure it reflects the current care needs and level of assistance for the resident.

3. The Administrator or designee will conduct weekly audits of the ABST to ensure proper and timely updates are completed.

4. The VP of Process Improvement, will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 new staff (#s 14, 16, and 20) demonstrated competency in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 05/24/23 and 05/25/23.

There was no documented evidence Staff 14 (MT), Staff 16 (MT), or Staff 20 (CG), hired 04/24/23, 04/03/23, and 03/30/23, respectively, demonstrated competency in abdominal thrust within 30 days of hire.

The need to ensure all training requirements were met within the required time frames was discussed with Staff 1 (Executive Director) and Staff 4 (VP of Clinical Operations) on 05/24/23 and 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violations include:

    a) Sample staff # 13, 14 and 20's training records were reviewed to ensure training requirements were met including abdominal thrust training.

2. The system will be corrected so that the violation will not occur again by:

    a) The RCC will review staff training files to ensure that all direct care staff have completed all required including how to perform abdominal thrust.

    b) All newly hired care staff will complete required pre-service dementia training as well as courses required within 30 days of hire.

3. The RCC will audit training files weekly and areas of non-compliance will be addressed immediately. Results of the audits will be brought to the monthly QA meeting for review and recommendations.

4. The Administrator will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to document all required elements on fire drill documentation, per the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records dated 12/29/22 through 05/23/23 were reviewed on 05/24/23 and 05/25/23. The following was identified:

Fire drill documentation did not include the following required elements:

* Escape route used;

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

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

The need to follow OFC requirements pertaining to fire drills and documentation was discussed with Staff 1 (Executive Director) and Staff 8 (Maintenance Director) on 05/25/23. They acknowledged the findings. No additional information was provided.

1. The actions that will be taken to correct the violations include:

    a) There were no corrective actions taken since no specific Resident (s) were identified.

2. The system will be corrected so that this violation does not occur again by:

    a) The community has modified the current documentation system to include the missing required Oregon (i.e. escape route utilized, any potential problems encountered, comments relating to residents who refused to participate, number of occupants evacuated, and evidence that an alternate route was utilized) on fire drill evacuation documentation to ensure all OFC requirements are being followed.

    b) The Maintenance Director will ensure throrough and complete reporting documentation for each evacuation drill conducted.

3. The evacuation drill documentation will be reviewed monthly during the QA or safety meeting to ensure compliance. Revisions to the plan will be made accordingly.

4. The Administrator will be responsible for monitoring.

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

Refer to C260, C270, C330, C361, and Z164.

See POC for all Citations.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes and to alert staff when residents exited the RCF. Findings include, but are not limited to:

On 05/25/23, it was observed the four exit doors residents used to access outdoor courtyards did not have an effective system to alert staff when a resident exited the unit.

In an interview on 05/25/23, Staff 1 (Executive Director) stated the facility had an alarm system for the doors. Staff 7 (RCC) then demonstrated how the opening of these doors sent alerts to tablets carried by floor staff. However, the system was found inadequate, as evidenced by the following:

The tablets required a shoulder strap for staff to carry. Observations were made throughout the three day survey of multiple floor staff performing their duties without having the tablets with them.

In an interview on 05/25/23, Staff 24 (Agency CG) stated s/he did not wear the tablet, because the size and weight of the unit hindered the performance of job duties in the MCC.

On 05/25/23 the need to maintain an effective system for alerting staff when a resident exited the building was discussed with Staff 4 (VP of Clinical Operations). She acknowledged the deficiency in the alerting system.

1. The actions that will be taken to correct the rule violation include:

    a) The iPads from which the doors leading to the outdoor courtyards alerts staff will be installed in the common areas with an audible alarm sounding off to alert staff when a resident exits to the outdoor area.

2. The system will be corrected so that this violation does not occur again by:

    a) The Manager on Duty will be responsible for observing that all staff are carrying their portable call system device every shift through daily observation.

3. The area needing correction will be evaluated daily by the Licensed Nurse, Maintenance Director, and Administrator to ensure the system is working properly.

4. The Administrator and Licensed Nurse will be responsible for monitoring.  

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

Refer to C150, C200, C231, C361, C372, C420, and C555.

See POC for all Citations.

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

Refer to C361.

See POC for all Citations.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff completed all required pre-service orientation and dementia training topics prior to beginning job duties, 3 of 4 new staff demonstrated competency in all job duties within 30 days of hire, and 1 of 3 long-term staff completed the required number of hours of annual in-service training. Findings include, but are not limited to:

Staff training records were review on 05/24/23.

a. There was no documented evidence Staff 10 (CG), Staff 16 (MT), Staff 17 (CG), or Staff 20 (CG), hired 02/01/23, 04/03/23, 04/03/23, and 03/30/23, respectively, completed one or more of the following pre-service orientation topics prior to beginning their job duties:

* Infectious Disease Prevention; and

* Written job description.

b. There was no documented evidence Staff 10, Staff 16, Staff 17, or Staff 20 completed the following dementia care training topics prior to providing resident care and services independently:

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

* Environmental factors which are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); and

* How to recognize behaviors which indicate a change in the resident's condition and report behaviors which required on-going assessment.

c. There was no documented evidence Staff 10, Staff 16, or Staff 20 demonstrated competency in one or more assigned duties within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation, and reporting changes of condition;

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

* General food safety, serving, and sanitation; and

* Other duties as applicable (e.g., med pass, treatments).

d. There was no documented evidence Staff 19 (MT), hired 08/17/15, completed 10 hours of annual in-service training related to the provision of care in CBC.

The need to ensure all staff training was completed in the required time frames was discussed with Staff 1 (Executive Director) and Staff 4 (VP of Clinical Operations) on 05/25/23. They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) The required training for Staff 10, 16, 17 and 20 was completed.

    b) Job Descriptions for Staff 10, 16, 17, and 20 were signed.

    c) Staff 10, 16, and 20 completed the required competencies.

    d) Staff 10 completed 10 hours of required annual training related to provisions of care in CBC settings.

2. The system will be corrected so that the violation will not occur again by:

     a) All newly hired direct care staff will sign job descriptions and complete the required pre-service orientation and dementia training prior to beginning job duties. They will also complete the required training topics and competencies within 30 days of hire. The Business Office Manager (BOM) will assign these courses or schedule the required training.

      b) Long-term care staff will also complete all required number of hours of annual in-service training.

3 The RCC will conduct audits of training files on a weekly basis to ensure that staff completes required training.

4. The Administrator will be responsible to see that the corrections are completed and or monitored.

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

Refer to C252, C260, C262, C270, C280, C310, and C330.

See POC for all Citations.

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

Refer to C260, C270, and C330.

See POC for all Citations.

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 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, and 3'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.  

On 05/25/23 the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 3 (RN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC). They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) Residents 1, 2, and 3's service plans were updated to ensure that they have an individualized nutrition and hydration plan that includes but is not limited to food preferences, including favorite dishes, favorite drink, likes/dislikes preferences, and utensils needed if any.

2. The system will be corrected so that this violation does not occur again by:

    a) The residents service plans will be reviewed and updated to ensure they have an individualized nutrition and hydration plan specific to meet their needs and preferences.

     b) All newly admitted residents will be evaluated by the Licensed Nurse prior to admission to ensure an individualized hydration and nutrition plan is developed. This plan will be evaluated within 30 days of move-in, quaterly, or with changes of condition to reflect the active preferences and adaptations for the resident as well as ensure there are proper staff instructions for residents daily meal program.

3. The Registered Nurse or designee will conduct weekly audits of service plans to ensure hydration and nutrition plans are individualized and reflective of resident's needs and preferences. Areas of non-compliance will be addressed immediately. Audit results will be discussed at monthly QA meetings to evaluate effectivenss of corrections or plan.

4. The Administrator will be responsible to see that corrections are completed or monitored.   

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation for 1 of 3 sampled residents (# 2) whose records were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 02/2023 with diagnoses including Alzheimer's Disease, anxiety, and hypertension.

The resident's current service plan and evaluations were reviewed. There was no documented evidence the facility had evaluated the resident's:

* Past and current interests;

* 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.

During the survey, Resident 2 was observed spending most waking hours in the common area outside his/her apartment, with the resident on 1:1 staff monitoring. The only activities observed were watching TV, resting, or talking with staff.

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

On 05/25/23 the failure to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 3 (RN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC). They acknowledged the findings.

1. The actions that will be taken to correct the rule violations include:

    a) Sample Resident 2's service plan was updated to include an activity plan that reflects the residents past and current interests, abilities and skills, physical abilities, adaptations necessary and activities that could be used as a behavioral intervention.

2. The system will be corrected so that the violation will not occur again by:

    a) The Life Enrichment Director will ensure that all residents are evaluated and have a documented person-centered activities plan to engage them in meaningful activities. The evaluation and plan development will involve the service plan team. The plan will be updated at least quarterly or with changes of condition to reflect the residents current needs, preferences, and abilities.

3. The Licensed Nurse or designee will conduct monthly audits of activity plans to ensure accuracy and compliance. Areas of non-compliance will be addressed immediately. Audit results will be discussed at monthly QA meetings to evaluate effectivenss of corrections or plan.

4. The Administrator will be responsible to see that corrections are completed or monitored.   

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 5, 6 and 7) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5, 6 and 7's service plans, assessments, and evaluations were reviewed. There was some information included, but the records lacked documented evidence the facility had fully evaluated the residents':

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

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

There was no documented evidence of specific activity plans which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities.

On 12/07/23, the need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 27 (Interim ED) and Staff 28 (ED in Training). They acknowledged the findings.

1. The actions that will be taken to correct the rule violations include:

a) Resident 5 and 6's service plan was updated to include an activity plan that reflects the residents past and current interests, abilities and skills, physical abilities, adaptations necessary and activities that could be used as a behavioral intervention.

2. The system will be corrected so that the violation will not occur again by:

a) The Life Enrichment Director will ensure that all residents have a documented person-centered activities plan to engage them in meaningful activities. The evaluation and plan development will involve the service plan team. The plan will be updated at least quarterly or with changes of condition to reflect the residents current needs, preferences, and abilities.

3. The Administrator or designee will conduct monthly audits of activity plans to ensure accuracy and compliance. Areas of non-compliance will be addressed immediately. Audit results will be discussed at monthly QA meetings to evaluate effectivenss of corrections or plan.

4. VP of Process Improvement will audit 5 resident charts monthly for compliance.

Based on observation, interview, and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the memory care community and update the resident's service plan for 1 of 2 sampled residents (#2) who displayed negative behaviors. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 02/2023 with diagnoses including Alzheimer's disease, hypertension, and anxiety.

Review of Resident 2's progress notes, interim service plans, and incident reports identified four resident-to-resident altercations, with Resident 2 identified as the aggressor in each case. These incidents were listed as follows:

* 02/27/23 - Resident 2 roughly grabbed a caregiver in a "wrist lock", which led to a physical altercation with another resident;

* 03/25/23 - Resident 2 swung at another resident, grazing his/her nose;

* 04/30/23 - Resident 2 approached another resident in a wheelchair, then struck the resident on the head and pulled his/her hair; and

* 05/20/23 - Resident 2 grew upset in a common area and struck another resident in the back.

In an interview on 05/24/23, Staff 24 (Agency CG) stated Resident 2 had "been involved in several resident-to-resident altercations, and had even assaulted staff members on a few occasions." When asked about safety measures to manage those behaviors, Staff 24 said, "We just keep a close eye on [him/her], and try to re-direct [him/her] if a conflict arises."

Resident 4 was observed on multiple days in the MCC. There were no aggressive or threatening behaviors observed during the survey. Resident 2 spent most of his/her time seated on a couch in the common area, watching TV, resting, or chatting with a 1:1 caregiver.

There was no documented evidence the facility evaluated the resident's negative behaviors and included them in the resident's service plan.

On 05/25/24 the need for evaluation and service planning for behavioral symptoms which negatively impacted the resident and others was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/LPN), Staff 3 (RN), Staff 4 (VP of Clinical Operations), and Staff 7 (RCC). They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) Resident 1's behavioral care plan was reviewed and updated to include the behavioral symptoms that negatively impact the resident and others as well as the specific interventions to manage these symptoms. The updated plan was then made accessible to the staff.

2. The system will be corrected so that this violation does not occur again by:

    a) The Licensed Nurse will be responsible for updating the Residents' Service Plans to include any resident specific behavioral interventions when residents display negative behaviors.

    b) The Licensed Nurse will include any interventions or incidents in the residents service plan and made available to direct care staff.

3. The Registered Nurse or designee will conduct weekly audits of service plans of residents manifesting behavioral symptoms to ensure the behavioral plan is individualized and addresses potential negative impacts to the resident and others. Areas of non-compliance will be addressed immediately. Audit results will be discussed at monthly QA meetings to evaluate effectivenss of corrections or plan.

4. The Administrator will be responsible to see that corrections are completed or monitored.   

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to:

During a tour of the facility grounds on 05/23/23, it was observed the two exit doors leading to an outdoor courtyard area, on both units in the building, were locked.

It was observed the exit doors remained locked throughout the first two days of the survey. On the third day of survey, the doors were unlocked.

Interviews with staff during the survey confirmed the doors were "always locked."

On 05/25/23 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (Executive Director) and Staff 8 (Maintenance Director). They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) The outdoor courtyard doors were immediately unlocked.

2. The system will be corrected so that this violation will not occur again by:

    a) The Maintenance Director, RCC or designee will conduct daily rounds and/or observations to ensure that the outdoor courtyard doors are unlocked and accessible for residents per company policy.

    b) Staff will be notified via call system when the outside courtyard doors are opened, so the outside area can be supervised.

3. The Licensed Nurse will conduct random and weekly audits to ensure outdoor courtyards are accessible per company policy. Areas of non-compliance will be addressed immediately. Audit results will be discussed at monthly QA meetings to evaluate effectiveness of corrections or plan.

4. The Administrator will be responsible to see that corrections are completed or monitored.  

Based on observation and interview, it was determined the facility failed to ensure doors to secure outdoor recreation area were only locked during nighttime hours or during severe weather per facility policy. Findings include, but are not limited to:

During a tour of the facility grounds on 05/23/23, it was observed the two doors leading to an outdoor courtyard area, on both units of the building, were locked.

In an interview on 05/23/23 Staff 1 (Executive Director) stated the facility had a written policy for why the doors were locked. The surveyor requested and received a copy of this document, which stated the following:

"Doors to the outside courtyard will be locked during nighttime hours, during inclement weather, and at any time deemed appropriate by the administrator."

The current weather was clear and dry, with moderate temperature. When asked why the doors were locked, Staff 1 stated they were following the written policy. It was observed the exit doors remained locked throughout the first two days of the survey. On the third day of survey, the doors were unlocked.

On 05/25/23 the need to provide access to secured outdoor recreation area, except during nighttime hours or during severe weather was discussed with Staff 1 (Executive Director) and Staff 8 (Maintenance Director). They acknowledged the findings.

1. The actions that will be taken to correct the rule violation include:

    a) The outdoor courtyard doors were immediately unlocked.

2. The system will be corrected so that this violation will not occur again by:

    a) The Maintenance Director, RCC or designee will conduct daily rounds and/or observations to ensure that the outdoor courtyard doors are unlocked and accessible for residents per company policy.

    b) Staff will be notified via call system when the outside courtyard doors are opened, so the outside area can be supervised.

3. The Licensed Nurse will conduct random and weekly audits to ensure outdoor courtyards are accessible per company policy. Areas of non-compliance will be addressed immediately. Audit results will be discussed at monthly QA meetings to evaluate effectiveness of corrections or plan.

4. The Administrator will be responsible to see that corrections are completed or monitored.