Print Inspection: XG3Z

The findings of the re-licensure survey, conducted 04/22/24 through 04/24/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 04/22/24, conducted 10/01/24 through 10/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 second revisit to the re-licensure survey of 04/24/24, conducted 03/03/25 through 03/04/25, 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 third revisit to the re-licensure survey of 04/24/24, conducted 04/30/25, 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 interview and record review, it was determined the facility failed to ensure complete and accurate records were maintained and records were not falsified for 1 of 1 sampled resident (#8) whose records were reviewed.  Findings include, but are not limited to:

Resident 8 moved into the memory care community in 04/2024 with diagnoses including dementia.

Review of Resident 8's records including 09/01/24 through 10/01/24 MARs were reviewed during the survey and interviews with staff were conducted. Observations of the resident during the survey identified s/he required meal assistance from staff for all nutrition and hydration.

Review of the MARs instructed unlicensed staff to give protein shakes and ice water four times per day after meals and at bedtime for weight gain with administration times at 9:00 am, 1:00 pm, 5:00 pm, and 8:00 pm.

Observations and interviews with multiple staff throughout the survey from 10/01/24 through 10/03/24 identified staff were not consistently providing the protein shakes and ice water as ordered however, the MARs were being initialed that protein shakes and ice water were being given.

During an interview on 10/02/24 at 1:30 pm with Staff 1 (ED) and Staff 28 (Regional RN) the above concerns were discussed.

During an interview on 10/03/24 at 8:50 am with Staff 1 and Staff 28 it was reported they interviewed staff, provided education and wrote a TSP for staff to do the following:

* Make sure the resident drinks water approximately every two hours; and

* "Offer protein drinks as ordered. Don't sign off that boost was consumed if the resident does not drink it."

The need to ensure accurate resident records were kept and were not falsified was discussed with Staff 1 and Staff 28 on 10/02/24 at 1:30 pm. They acknowledged the findings.

1. Executive Director and Health and Wellness Director interviewed staff, provided education, and wrote a TSP to ensure the resident drinks water approximately every two hours, protien drinks as ordered, and not to sign off that the protein drink was consumed if the resident did not drink it. Staff will accurately document in Emar.

2. Staff will receive additional education on how to assist the resident to drink water and consume protein beverages.

3. The MAR will be reviewed on a weekly basis and inbetween as needed.  The staff will be interviewed daily on the resident's consumption of water and protein beverages.

4. Health and Wellness Director, Executive Director, or designee.   

Based on interview and record review, it was determined the facility failed to ensure investigations into physical injuries of unknown cause were documented to include that the physical injury was not the result of abuse for 2 of 3 sampled residents (#s 1 and 4) with injuries of unknown cause. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia with mood disturbance. The resident was noted to require the assistance of two staff for ADL cares.

Review of the resident's 01/25/24 through 04/22/24 progress notes showed the following:

* 01/31/24 "[Resident] is on alert charting for skin tear to the right hand middle and pointer fingers...doesn't remember how it happened."

In a 04/24/24 interview with Staff 2 (RN, Health and Wellness Director), she stated an immediate investigation into the injuries concluded the injuries were not the result of abuse or neglect to Resident 1, however there was no documentation to support the conclusion.

The need to ensure investigations into physical injuries of unknown cause were documented to include the injuries were not the result of abuse or neglect was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations). They acknowledged the findings.

2. Resident 4 moved into the memory care community in 09/2021 with diagnoses including Alzheimer's disease.

Review of the resident's 01/21/24 through 04/22/24 progress notes and review of hospice orders showed the following:

* 01/31/24: A hospice order documented there was a wound to the anterior left knee.

During an interview on 04/24/24 at 1:00 pm, Staff 2 (RN, Health and Wellness Director) stated she was aware of the wound and consulted with hospice weekly, and the wound was healed. She stated an immediate investigation into the injury concluded it was not the result of abuse or neglect to Resident 4. However, there was no documented evidence to support the conclusion.

The need to ensure an investigation into physical injuries of unknown cause was documented to include the injury was not the result of abuse or neglect was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1) The incidents identified during the survey: Resident 1 incident on 1/31/2024 was reported to APS on 5/13/24 and RN Alert Charting has been completed.  Resident 4 incident on 1/31/2024 was reported to APS on 5/13/2024 and RN Alert Charting note has been completed.

2) Community associates will receive training on "Elder Abuse Prevention, Investigation and reporting" provided by Oregon Care Partners online education series.  Community management will be re-educated on Brookdale policies and procedures related to investigating and reporting incidents.

3) Incidents will be reviewed 4-5 days a week during  scheduled clinical meetings. This review will confim that incidents have been properly investigated and reported to APS as appropriate.

4) The Executive Director, Health and Wellness Director, and Health and Wellness Coordinator, or designees.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of an injury of unknown cause to rule-out abuse or report the injury as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 1 sampled resident (#8) with a documented injury of unknown cause. This is a repeat citation. Findings include, but are not limited to:

Resident 8 moved into the facility in 04/2024 with diagnoses including dementia.

Review of the resident's 06/23/24 through 10/01/24 progress notes and incident reports for the same time frame identified the following:

On 07/04/24 "[Resident] is on alert charting for skin tear to the right forearm."

This represented an injury of unknown cause. There was no documented evidence the facility immediately investigated and documented the injury was not the result of abuse. The facility did not report the injury to the local SPD office as required.

At the request of survey, the facility was asked to report the injury to the local office. The facility reported the injury to the local adult protective services office and verification was received on 10/03/24 at 4:37 pm.

The need to ensure investigations into physical injuries of unknown cause were completed and documented to include the injuries were not the result of abuse was discussed with Staff 1 (ED), Staff 5 (District Director of Operations) and Staff 28 (Regional RN) on 10/03/24 at 2:26 pm. They acknowledged the findings.

1. A report of injury of unknown cause was sent to APS on 10/3 to report a skin tear from 7/4.  The Health and Wellness Director immediately reviewed additional education on the expecation of complete documentation, investigaton, and reporting of injuries of unknown causes.

2. Health and Wellness Director received reeducation on the expectations of investigating skin concerns and reporting skin concerns to APS.  Health and Wellness Director will report skin investigations to APS within 24 hours of discovery.  This will be reviewed daily by Health and Wellness Director, Resident Care Coordinator, and Executive Director.

3. Skin concerns will be investigated and documented daily as they appear.  Incidents will be reviewed 4-5 days a week during scheduled clinical meetings. This review will confim that incidents have been properly investigated and reported to APS as appropriate.

4. The Executive Director, Health and Wellness Director, and Health and Wellness Coordinator, or designees.

Based on observation, interview, and record review, it was determined the facility failed to provide services to assist residents in activities of daily living for 1 of 1 sampled resident (#8) who required staff assistance. Findings include, but are not limited to:

Resident 8 moved into the memory care community in 04/2024 with diagnoses including dementia. The resident was observed to need staff assistance for all nutrition and hydration, required assistance from two care staff for transfers and mobility including repositioning, and bowel and bladder management.

The resident's service plan dated 08/18/24, subsequent temporary service plans (TSP's) and 09/01/24 through 10/01/24 MARs instructed staff to perform the following ADL tasks:

* Reposition every two hours if s/he was unable to self-adjust in the geri-chair;

* Use a gait belt for all transfers;

* Please check and provide incontinent care every two to three hours;

* Please add butter and gravy to puree food;

* Push fluids- water, juice, broth, tea, etc.;

* Provide a high calorie dessert, sweets and ice cream; and

* Give protein shakes and ice water four times per day after meals and at bedtime for weight gain with administration times at 9:00 am, 1:00 pm, 5:00 pm, and 8:00 pm.

Observations made during the survey from 10/01/24 through 10/03/24 identified the following:

* The resident was not observed to be able to self-adjust in the geri-chair;

* The resident was unable to use the call light system;

* The resident did not request food or fluids unless prompted by staff;

* Staff were not observed to provide a protein shake, protein supplement added to any fluids, a high calorie dessert such as ice cream or sweets were not offered, per the service planned weight loss interventions;

* Staff were not observed to provide any fluids on 10/02/24 from 8:39 am until 12:17 pm when lunch was served;

* Staff were not observed to use a gait belt for safety when transferring the resident;

* Staff were not observed to reposition the resident every two hours; and

* Staff were not observed to provide incontinent care every two to three hours as instructed.

During an interview on 10/02/24 at 10:54 am with Staff 13 (Kitchen Manager) it was reported Resident 8 was not receiving a protein powder shake with fresh fruit from the kitchen. Staff 13 stated "we don't prepare that for any residents. I don't even have protein powder. I usually put extra gravy on the mechanical soft diets, I don't do that for puree diet. I only have a TSP for Resident 8 to receive a puree diet, that is it."

During an interview on 10/02/24 at 1:30 pm with Staff 1 (ED) and Staff 28 (Regional RN) the above findings were discussed. Staff 1 provided survey with a TSP that clarified ADL instructions for care staff to follow.

1. Resident 8's service plan and TSP's were reviewed and updated on 10/14/24 to be consistent with her current needs including: reposition every two hours, resident is unable to use the call light system, offer food and beverages as listed on the MAR in addition to scheduled meal/snack times, offering high calorie desserts, and providing incontinece care every 2-3 hours. Kitchen Manager ordered and received protein powder for protein shakes.  Kitchen Manager received all TSP's for dietary changes.  

2. Kitchen Manager and Health and Wellness Director will meet on a weekly basis to discuss resident diet changes. Staff were reeducated on the expectations that all ADL's are completed as listed on the service plan.  Health and Wellness Director or designee will review current needs as listed on the service plan and collaborate with the staff to ensure the service plan is accurate in all areas.  

3. Resident needs will be reviewed on a monthly basis at Collaborative Care Review, or sooner if needed.  Kitchen Manager and Health and Wellness Director will meet on a weekly basis to discuss resident diet changes.

4. Health and Wellness Director, Resident Care Coordinator, Executive Director, or designee.   

2. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia.

The resident's 02/22/24 service plan was reviewed, observations made of the resident and interviews with staff occurred throughout the survey.

The service plan was not implemented in the following areas:

* Assistance with and use of hearing aids; and

* Transfer assistance including use of a gait belt.

The need to ensure Resident 1's service plan was implemented was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.

3. Resident 4 moved into the memory care community in 09/2021 with diagnoses including Alzheimer's disease.

The resident's 02/22/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Dressing assistance;

* Positioning in Geri chair;

* When staff were to offer a Mighty Shake;

* Who and how shower assistance was provided;

* Orientation status;

* How the resident communicates needs and preferences;

* History of skin issues;

* History of weight loss; and

* Use of heel protectors.

The need to ensure service plans were reflective of residents' current needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's current status and care needs, provided clear instruction regarding the delivery of services and were implemented for 3 of 5 sampled residents (#s 1, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia.

A review of the resident's clinical record, including a review of the service plan dated 01/25/24, temporary service plans, interviews with staff and observations of the resident's care was conducted during the survey.

The following areas were not reflective of the resident's current status and care needs and did not provide clear instructions for staff:

* One-to-two person transfers and use of a gait belt;

* Mobility;

* Cognitive/Psychosocial;

* Reluctance to accept care;

* Nutrition including meal refusals and meal assistance needed;

* History of weight loss and weight loss interventions;

* Behavior Management including exit seeking;

* Hospice and services that were provided;

* Use of a variable pressure mattress; and

* Use of a foam wedge while in bed.

The need to ensure service plans were reflective of the resident's current status and care needs, provided clear instruction regarding the delivery of services was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. Resident 1, 4, and 5 service plans were updated on 5/14/2024 to reflect resident's current needs and provide clear direction to care staff.  Additionally, service plans will be reviewed for the other residents by 6/15/24 to confirm they provide clear direction to staff regarding how assistance will be provided and who is responsible to provide it.

2. Service plans will be reviewed and updated as required. Additionally, other residents service plans will be reviewed at care conferences with the care planning team to verify the services align with resident's personal preferences. Signatures will be obtained from care planning team members at that meeting acknowledging service plans are reflective of resident's current needs/preferences.  We will review Colaborative Care Review notes and will use the 24 hour report for the last three months.  

3. Care Plans will be updated at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition.  In the clinical meeting, update current care plans with changes that have been observed and documented.

4. Executive Director, Health and Wellness Director and/or Designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition, had actions or interventions determined and communicated to staff on each shift and the conditions monitored with weekly progress noted until resolution for 3 of 6 sampled residents (#1, 4, and 5) who experienced short term changes of condition. Findings include, but are not limited to:

1.  Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia with mood disorder.

a. Review of the 01/22/24 through 04/22/24 progress notes, 02/22/24 service plan, and Temporary Service Plans (TSP's) revealed Resident 1 experienced the following short-term changes of condition:

* 02/21/24 - Medication order, increase sertraline (for depression) to 50 mg once daily;

* 03/05/24 - Medication order, start cephalexin (for leg ulcer) 500 mg four times per day; and

* 04/07/24 - Fall.

The facility lacked documented evidence actions or interventions were developed and communicated to staff on each shift for the 04/07/24 fall and changes of condition were monitored, with progress noted at least weekly through resolution, for the 02/21/24 and 03/05/24 medication changes.

The need to ensure each of Resident 1's short term changes of condition had interventions developed, communicated to staff on each shift and the conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

3. Resident 4 moved into the memory care community in 09/2021 with diagnoses including Alzheimer's disease.

A review of the resident's clinical record, including progress notes dated 01/21/24 through 04/22/24, temporary service plans for the same time period and interviews with staff were conducted during the survey.

a. Resident 4 had the following changes of condition that lacked documentation of what action or intervention was needed, the determined action or intervention communicated to staff on each shift, and the condition monitored with weekly progress noted until the condition resolved:

* 02/09/24 - Raised, red area to scalp; and

* 04/14/24 - Temporary increase of hydrochlorothiazide medication.

b. Resident 4 had the following change of condition that lacked documentation of what action or intervention was needed and that the determined action or intervention was communicated to staff on each shift:

* 01/31/24 - Wound to left knee.

The need to ensure the facility determined and documented what action or intervention was needed for a resident following a change of condition, communicated the actions or interventions to staff and ensured weekly progress noted until the condition resolved was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

2. Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia.

A review of the resident's clinical record, including charting notes dated 01/25/24 through 04/15/24, temporary service plans for the same time period and interviews with staff were conducted during the survey.

Resident 5 had the following changes of condition that lacked documentation of what action or intervention was needed, the determined action or intervention communicated to staff on each shift, and the condition monitored with weekly progress noted until the condition resolved:

* 03/11/24 - Discontinue Donepezil and Namenda medications; and

* 03/11/24 - Right leg pain.

The need to ensure the facility determined and documented what action or intervention was needed for a resident following a change of condition, communicated the actions or interventions to staff and ensured weekly progress noted until the condition resolved was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. Resident 1, 4, 5 nursing notes were reviewed and the Health and Wellness Director completed Temporary Service Plans for residents 1, 4, 5 with interventions.  The interventions from incident reports and Temporary Service Plans were communicated to staff and written on the current service plan.  These notes will be included on future service plans. This was completed by 5/13/2024.  HWD also reviewed nursing notes and completed Temporary Service Plan for residents  

2. Changes in condition including, but not limited to weight changes, changes in Activities of Daily Living, skin changes, will be discussed at clinical meetings and communicated to staff via Temporary Service Plans.  Alert Charting will be completed at least once per day by community staff and then closed by Executive Director, Health and Wellness Director, Health and Wellness Coordinator, or designee and updated on resident's serivce plan per policy.

3. Temporary changes will be monitored on at clinical meeting, daily charting to be completed, and service plan changes to be made as needed by resident changes.

4. Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee.  

3. Resident 11 moved into the facility in 12/2017 with diagnoses including dementia and chronic obstructive pulmonary disease.

The current service plan dated 08/01/24, temporary service plans, and progress notes dated 07/01/24 through 09/29/24 were reviewed. Observations and interviews with staff were completed between 10/02/24 and 10/03/24.

The facility failed to determine what action or intervention was needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:

* 07/12/24 - New diagnosis, COVID;

* 07/13/24 - Hospital visit for lethargy and tachycardia;

* 07/24/24 - Significant weight loss (5.6%); and

* 09/12/24 - New medication.

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (ED), Staff 5 (District Director of Operations) and Staff 28 (Regional RN) at 12:34 pm on 10/03/24. They acknowledged the findings.

2. Resident 9 was admitted to the MCC in 08/2021 with diagnoses including Alzheimer's disease.

The resident's clinical record was reviewed and noted the resident was at risk for falls having experienced the following falls and instances where s/he was found on the floor between 06/28/24 and 09/15/24:

* 06/28/24 - Found on floor. Interventions: "check on resident every 30 minutes if in room, give PRN if agitated, keep in wheelchair";

* 06/29/24 - Found on floor. Interventions: "remind to ask for help, encourage use of wheelchair, push fluid and food";

* 07/01/24 - Found on floor three times. Interventions: "remind to ask for help, have wheelchair ready for use, encourage fluids and food while sitting in wheelchair, staff to be near resident";

* 07/02/24 - Found on floor. Interventions: "encourage non-skid socks, offer wheelchair";

* 07/09/24 - Fall with abrasion to forehead. Interventions: "monitor for anxiety and agitation";

* 08/05/24 - Found on floor. Interventions: "encourage wheelchair use, monitor for anxiety and agitation";

* 08/20/24 - Found on floor with skin tear to left elbow. Interventions: "encourage him/her to sit in wheelchair and push fluids";

* 08/28/24 - Found on floor. Interventions: "encourage fluids and snacks, make sure s/he is wearing non-skid socks";

* 08/30/24 - Found on floor. Interventions: "encourage wheelchair use, push fluids and food";

* 09/02/24 - Found on floor. Interventions: "encourage him/her to ask for help, push fluids and snacks while sitting, ensure s/he has  non-skid socks at all times";

* 09/14/24 - Found on floor. Interventions: "encourage fluids and snacks"; and

* 09/15/24 - Fall. Interventions: "monitor anxiety and agitation, monitor position in wheelchair."

There was no documented evidence the facility consistently monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident after each fall. The resident continued to fall and sustained multiple injuries.

During the survey on 10/01/24 through 10/03/24, Resident 9 was observed to self propel his/her manual wheelchair and received escorting assistance from staff via wheelchair.

On 10/02/24 during an interview with Staff 20 (MT) she stated Resident 9 would fluctuate between ambulating on his/her own and using the manual wheelchair.

The lack of monitoring existing fall interventions to determine if in place and appropriate and the lack of developing new actions/interventions with each fall represented a situation that placed the resident at risk for additional falls. The situation was discussed with the facility who conducted and submitted an evaluation of the resident and new interventions to minimize further falls prior to survey exit.

The need to ensure resident-specific instructions or interventions were reviewed for effectiveness was discussed with Staff 1 (ED), Staff 5 (District Director of Operations), and Staff 28 (Regional RN) on 10/03/24 at 1:24 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short term changes of condition, communicated resident-specific instructions and interventions to staff on each shift, and monitored the change of condition at least weekly until resolved and the facility failed to monitor each resident consistent with his or her evaluated needs and service plan for 3 of 4 sampled residents (#s 8, 9 and 11) who experienced changes of condition. Resident 8 experienced ongoing and severe weight loss. Resident 9 experienced ongoing falls with injuries. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 04/2024 with diagnoses including dementia and chronic kidney disease stage 4 (severe).

a. The current service plan dated 08/18/24, temporary care plans (TSP's), progress notes dated 06/23/24 through 10/01/24 and 09/01/24 through 10/01/24 MARs were reviewed. Observations and interviews with staff and Resident 8 were conducted during the survey.

Resident 8 had the following significant change of condition:

Observations from 10/01/24 through 10/03/24 identified the resident was dependent on staff for all nutrition and hydration and was not able to independently hold and bring any utensils or cups to his/her mouth.

Resident 8's service plan, dated 08/18/24, noted the following:

* Provide 3 ounces of fluid with each meal and 6 ounces with most snacks;

* Please make sure s/he is offered dessert as s/he likes sweets and ice cream;

* Likes protein water and ice water; and

* On 09/17/24 a TSP instructed staff to increase protein drink and/or calorie snacks and add butter and gravy to pureed food.

Review of the 09/01/24 through 10/01/24 MAR identified the following:

* Give protein shakes and ice water four times per day after meals and at bedtime for weight gain. Give at 9:00 am, 1:00 pm, 5:00 pm and 8:00 pm.

Observations on 10/01/24 from 11:30 am -1:27 pm identified the following:

* Resident was assisted to eat lunch from 11:58 am -12:24 pm. The resident ate 100% of the meal which consisted of pureed rice, chicken, vegetables, pea soup and applesauce. At the end of the meal s/he was offered apple juice without a protein additive and drank approximately 4.5 ounces before the care staff removed the food tray and remaining apple juice.

* At 1:08 pm care staff escorted the resident to his/her apartment to provide ADL care. Upon completion of care at 1:27 pm the resident asked to remain in bed.

There was no ice water, or a protein drink provided prior to care or after care. The 10/01/24 MAR was initialed that a protein shake and ice water was given at 1:00 pm.

On 10/02/24 from 8:39 am to 12:41 pm the following was observed:

Resident 8 was seated in a geri-chair in the activity lounge. No fluids were observed.

At 9:41 am Staff 18 (CG) brought the resident a water bottle with lid and straw. The caregiver stated "it's just ice water, s/he really likes it. Oh, s/he is sleepy, I'll come back later." Without attempting to rouse the resident to give fluids, the care staff placed the water on the activity table and walked away."

From 8:39 am - 11:56 am prior to the lunch meal there were no observations that water, snack, protein shake or other supplement was given during this time as ordered on the MAR.

During an interview with Staff 7 (MT) on 10/02/24 at 10:40 am it was reported "we have vanilla boost but s/he is not a fan of them, so we have the kitchen staff prepare a shake with protein powder and fresh fruit. S/he really likes them."

During an interview on 10/02/24 at 10:54 am with Staff 13 (Kitchen Manager) it was reported Resident 8 was not receiving a protein powder shake with fresh fruit from the kitchen. Staff 13 stated "we don't prepare that for any residents. I don't even have protein powder. I usually put extra gravy on the mechanical soft diets, I don't do that for puree diet. I only have a TSP for Resident 8 to receive a puree diet, that is it."

During an interview on 10/02/24 at 11:56 am with Staff 7, it was reported that he found one liquid gel protein packet in the kitchen, and he thought s/he had two more of them in the med room. Staff 7 stated MT's would mix the liquid gel in the residents drink; however Staff 7 was unaware of the instructions to only use one to four ounces of fluid to ensure the proper ratio delivered the instructed 16 grams of protein. Staff 7 was unaware of who was responsible to ensure the stock of liquid protein gel was available to give the resident.

From 11:56 am - 12:21 pm Staff 32 (CG) assisted the resident to eat lunch. The resident ate 100% of the meal, was offered and ate 100% of applesauce and a Jello dessert and drank approximately two ounces of apple juice and had one sip of water.

There was no observations that a protein shake and ice water was given after the meal and there was no gravy and butter added to the puree meal as ordered, or no high calorie dessert such as ice cream was offered.

Resident 8's weight records identified the following:

* Residents initial weight on 04/18/24 was 118.2 lbs;

* 05/28/24 - 112.7 lbs;

* 06/18/24 - 107.2 lbs;

* 06/25/24 - 103.8 lbs;

* 07/16/24 - 101.8 lbs;

* 08/20/24 - 101.2 lbs; and

* 09/24/24 - 101.4 lbs.

* 10/03/24 - 97 lbs (observed weight taken during survey).

From 04/18/24 - 05/28/24 the resident lost 5.5 pounds or 4.65% total body weight within one month. From 04/18/24 - 06/18/24 the resident lost 11 pounds or 9.30% total body weight in two months. From 04/18/24 - 07/17/24 Resident 8 continued to lose weight and experienced a severe weight loss of 16.41 pounds or 13.87% of total body weight within three months.

There was no documented evidence the weight loss interventions were reviewed for effectiveness, new interventions attempted and documented and resident-specific instructions communicated to staff or the service plan updated with interventions when the resident continued to have severe weight loss. That put the resident at risk for continued weight loss.

During an interview with Staff 1 (ED) and Staff 28 (Regional RN) on 10/02/24 at 1:30 pm the concern that staff were not following weight loss interventions, the lack of staff knowledge regarding the weight loss interventions, staff signing the MAR indicating protein supplements were provided when they were not and the resident's ongoing severe weight loss was discussed. They acknowledged the findings.

b. Resident 8 had the following short term changes of condition:

* On 06/23/24 - Skin tear on legs;

* On 7/01/24 - Left skin tear on forearm; and

* On 07/04/24 - Right forearm skin tear.

The facility failed to determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved.

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were monitored for effectiveness, the interventions were communicated to staff on all shifts, and were monitored at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (RN/Health and Wellness Director), Staff 5 (District Director of Operations) and Staff 28 (Regional RN) on 10/03/24 at 3:05 pm. They acknowledged the findings.

1. Resident 8 nursing notes were reviewed for significant change of condition due to weight loss and temporary change of condition for skin tears. Health and Wellness Director created TSPs for weight loss interventions and educated the staff on how to provide nutrition and hydration support.  Health and Wellness Director was re-educated on the expectations of documentation and investigation for temporary change of conditions.  Resident 9 incident reports and nursing notes were reviewed for root cause analysis regarding their falls.  A TSP was created with new interventions and staff were educated on the interventions. Resident 11 nursing notes were reviewed for change of condition and interventions. The interventions were communicated to the staff and a change of condition service plan was completed.

2. Changes in condition including, but not limited to weight changes, falls, hospital visit, new medicatons, etc, will be discussed at clinical meetings and communicated to staff via Temporary Service Plans and updated Service Plans as needed.  Alert Charting will be completed at least once per day by community staff and then closed by Health and Wellness Director, Health and Wellness Coordinator, or designee and updated on resident's serivce plan per policy.

3. Temporary changes will be monitored on at clinical meeting 4-5 days per week, daily charting to be completed by staff, and change of condition service plans will be made as needed.

4. Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee.  

4.  Resident 2 moved into the  memory care community in 04/2022 with diagnoses including dementia and Type II diabetes.

Observations of the resident from 04/22/24 to 04/24/24 revealed the resident required staff assistance for bathroom use.

The resident's clinical record showed the resident had the second toe on the left foot amputated on 03/29/24.

During the survey, Staff 14 (CG) and Staff 16 (CG) reported the resident had an overall decline in status after the toe amputation in the following areas:

* The resident ambulated independently without using an assisted device before the amputation, but currently the resident required a wheelchair for mobility; and

* The resident was independent with shower, bladder and bowel management, but currently the resident required staff assistance in those care areas.

The overall decline in multiple ADL's represented a significant change of condition.

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

On 04/24/24, Staff 2 (RN, Health and Wellness Director) confirmed she did not complete a RN assessment for Resident 2.

The failure to conduct an RN assessment following a significant change in status was discussed with Staff 1 (ED), Staff 2, Staff 5 (District Director of Operations) and Staff 22 (RN, District Director of Clinical Operations) on 04/24/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia.

The resident's clinical record was reviewed and revealed the resident experienced bilateral weeping ulcers on 03/05/24.

During a 04/24/24 interview, Staff 2 (RN, Director of Health and Wellness) acknowledged an RN assessment was not completed for Resident 1's bilateral weeping ulcers. No further documentation was provided.

The need for an RN to conduct an assessment when a resident experienced a significant change of condition which included documentation of findings, resident status, and interventions made as a result of the assessment was reviewed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

3. Resident 4 moved into the memory care community in 09/2021 with diagnoses including Alzheimer's disease and Type 2 diabetes.

The resident's clinical record was reviewed and revealed Resident 4 experienced weight fluctuations between 01/02/2024 through 04/17/24. Weight records showed the following:

* 01/02/24: 126.7 pounds;

* 01/24/24: 123.6 pounds;

* 02/02/24: 113.4 pounds;

* 03/02/24: 115.0 pounds;

* 04/02/24: 120.8 pounds; and

* 04/17/24: 120.3 pounds.

Resident 4 was documented to experience a weight loss of 13.3 pounds in one month, or 10.5% of his/her body weight.  This constituted a significant change of condition requiring an RN assessment.  

There was no documented evidence the RN completed an assessment which included findings, resident status, and interventions made as a result of the assessment related to weight loss.

The resident was observed during to the survey to require assistance with eating and ate approximately 100% of his/her noon meal on 04/22/24 and 04/23/24.

During an interview on 04/23/24 at 1:00 pm, Staff 2 (RN, Health and Wellness Director) stated she was aware of the weight fluctuations, and acknowledged there was no RN assessment conducted.

The need to ensure an RN conducted an assessment that included findings, status and interventions when a resident experienced a significant change of condition was reviewed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24 at 2:30 pm.  No additional information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 4 of 4 sampled residents (#s 1, 2, 4 and 5) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia.

During the entrance acuity interview on 04/22/24, review of the resident roster identified Resident 5 was receiving hospice services.

A review of the resident's clinical record, including charting notes dated 01/25/24 through 04/15/24, temporary service plans for the same time period and interviews with staff was conducted during the survey and identified the following:

Resident 5 had a decline in ADL ability which included an admission to hospice on 02/29/24. This constituted a significant change of condition that required an RN assessment.

There was no documented evidence a significant change of condition assessment was completed by an RN, including findings, resident status and interventions made as a result of the assessment.

On 04/23/24, Staff 2 (RN, Director of Health and Wellness) reported she was aware of the resident's decline and hospice admission however, she did not document an assessment of the resident's significant change in condition.

The need to ensure an RN assessed all significant changes of condition, including findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. Significant change in condition assessment was completed on 5/14/2024 for Residents 1, 2, 4, 5.  Additionally, weekly RN progress notes were added.   Changes in instructions for staff were communicated via Temporary Service Plan.  Service plan was updated with resident's current needs and staff instruction.   

2. When a change of condition is identified, Heath and Wellness Director or nurse designee will complete a nursing assessment and observe resident changes. Staff instruction or ongoing monitoring needs will be communicated to staff with Temporary Service Plans, on the Medication Administration Record, and with Service Plan updates as needed. Executive Director will review a significant change in condition with Health and Wellness Director to verify each step is completed.

3. The assessment will be completed with each significant change in condition as needed.

4. Executive Director, Health and Wellness Director, and/or Designee  

2. Resident 9 was admitted to the MCC in 08/2021 with diagnoses including Alzheimer's disease.

a. Resident 9's weight records were reviewed and revealed the following:

* 04/03/24 - 216.2 pounds;

* 05/03/24 - 212.4 pounds;

* 06/03/24 - 202 pounds;  

* 07/02/24 - 188 pounds; and

* 09/03/24 - 184.6 pounds.

From 04/03/24 to 07/02/24, Resident 9 had a weight loss of 28.2 pounds or 12.96% of his/her total body weight in three months. The severe weight loss indicated a significant change of condition and required an RN assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.  

Observations of the resident were made during lunch on 10/01/24 and breakfast on 10/02/24. The resident ate approximately 75% of his/her lunch and approximately 90% of his/her breakfast.

On 10/02/24 at 1:56 pm, an RN assessment for the resident's severe weight loss was requested. Staff 2 (RN, Health and Wellness Director) confirmed there was no documented evidence a facility RN completed an assessment of Resident 9's severe weight loss.

On 10/03/24, the surveyor requested the facility obtain the weight for Resident 9. The facility was unable to obtain the current weight for the resident due to resident preference.

The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 5 (District Director of Operations), and Staff 28 (Regional RN) on 10/03/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 8 and 9) who experienced significant weight loss. Resident 8 experienced ongoing severe weight loss. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 04/2024 with diagnoses including dementia and chronic kidney disease stage 4 (severe).

The current service plan dated 08/18/24, temporary care plans (TSP's), progress notes dated 06/23/24 through 10/01/24 and 09/01/24 through 10/01/24 MARs were reviewed. Observations and interviews with staff and Resident 8 were conducted during the survey.

Review of Resident 8's weight records identified the following:

* Residents initial weight on 04/18/24 was 118.2 lbs;

* 05/28/24 - 112.7 lbs;

* 06/18/24 - 107.2 lbs;

* 06/25/24 - 103.8 lbs;

* 07/16/24 - 101.8 lbs;

* 08/20/24 - 101.2 lbs; and

* 09/24/24 - 101.4 lbs.

* 10/03/24 - 97 lbs (observed weight taken during survey).

From 04/18/24 -05/28/24 the resident lost 5.5 pounds or 4.65% total body weight within one month. From 04/18/24 - 06/18/24 the resident lost 11 pounds or 9.30% total body weight in two months. From 04/18/24 - 07/17/24 Resident 8 continued to lose weight and experienced a severe weight loss of 16.41 pounds or 13.87% of total body weight within three months.

This constituted a significant change of condition that required an RN assessment.

There was no documented evidence the RN completed an assessment which documented resident condition, status, findings and interventions made as a result of the assessment. The resident continued to have subsequent weight loss in August 2024 and September 2024 to which the facility failed to have an RN assessment, which put the resident at risk for further weight loss.

During the survey on 10/03/24 at 10:05 am, the resident weight was observed to 97 pounds, which was an additional weight loss of 4.4 pounds from the last weight taken on 09/24/24.

The need to ensure an RN completed an assessment for the resident's severe weight loss was discussed with Staff 1 (ED) and Staff 28 (Regional RN) on 10/02/24 at 1:30 pm. They acknowledged the findings.

Refer to C 270.

1. Resident 8 & 9 weight notes and nursing notes were reviewed.  TSPs for weight loss interventions were put into place on 10/3.  RN assessment for weight loss was completed on 10/14 and Significant Change of Condition Service Plan was completed on 10/14.  

2. Health and Wellness Director was re-educated on expecations and documenation of Significant Change of Condition and Change of Condition. Heath and Wellness Director or nurse designee will observe resident changes, complete a nursing assessment, communicate and educate the changes/interventions via TSPs to staff. Health and Wellness Director will complete weekly notes until the condition is resolved or requires a Significant Change of Condition or Change of Condition Service Plan to be created. Executive Director will review a significant change in condition with Health and Wellness Director weekly and as needed to verify each step is completed.

3. Significant Change of Condition and Change of Condition nursing notes and service plan updates will be monitored weekly and as needed.

4. Executive Director, Health and Wellness Director, and/or Designee    

2. Resident 1 was admitted to the facility in 10/2023 with diagnoses including dementia. The resident was noted to require two persons to assist with transfers and incontinence care. Observations of incontinence care on 04/22/24 revealed the following:

Staff 18 (CG) and Staff 21 (MT/CG) were observed at 11:46 am. Both staff entered the common area rest room with Resident 1, wearing single use gloves. Staff assisted the resident with transferring to the commode. Immediately afterward, Staff 21 removed the resident's soiled brief with his right gloved hand and placed the brief in the waste receptacle. As the resident completed toileting, Staff 21 did not remove gloves or perform hand hygiene. Both staff then assisted the resident in transferring to a standing position with Staff 21 touching the right sleeve of the resident's sweater with his right hand. Staff 8 provided perineal care using her left gloved hand and assisted the resident in pulling up the clean brief and pants and pulling the resident's sweater down using the same hand. Staff 8 then touched the door handle and the handle of the resident's manual wheel chair using her left hand without removing the glove or performing hand hygiene. While in the hallway, Staff 8 doffed her gloves and began donning another glove to the left hand. At this time, the surveyor asked both Staff 8 and Staff 21 to perform hand hygiene before beginning new tasks. They agreed and did so.

The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure establishment and maintenance of infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 2 of 2 sampled residents (#s 1 and 4) related to incontinence care. Findings include, but are not limited to:

1. Resident 4 moved into the memory care community in 09/2021 with diagnoses including Alzheimer's Disease. Observations and interviews with staff during the survey identified s/he relied on two staff for transfers and incontinence care needs.

On 04/23/24 at 11:23 am, Staff 7 (MT) and Staff 14 (CG) were observed providing ADL incontinence care for Resident 4. Staff 7 and Staff 14 donned gloves without first performing hand hygiene. Staff 7 and Staff 14 assisted in transferring Resident 4 from Geri chair to bed, and then doffed his/her pants and brief. Staff 14 identified the resident's brief was soiled with urine, removed the brief, and placed it into a trash bag. Staff 7 provided perineal care and placed a new brief without performing hand hygiene or a glove change between tasks. Staff 14 changed gloves without performing hand hygiene and assisted Staff 7 in dressing Resident 4. Both staff transferred Resident 4 back to the Geri chair, and Staff 14 placed a blanket on Resident 4. Both staff doffed gloves after assisting Resident 4 and were not observed to perform hand hygiene at the completion of providing assistance. The surveyor requested the staff perform hand hygiene prior to exiting Resident 4's apartment, which was completed.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24 at 2:30 pm.

1. Re-education on infection control policies was completed with staff on 5/8/24.  Staff also reviewed supply levels and reordered supplies as necessary.

2. Staff were reeducated on how to perform hand hygiene before, during, and after all cares.  Staff will be re-educated at the next monthly staff meeting on how to perform hand hygene and infection control.  They will be instructed and observed on the following items:  when to wash their hands, with what product, how long, how often, and how often to change gloves.

3.  For the next month, hand hygiene will be reviewed daily at clinical meeting. For the next month, the HWC, RCC, and/or HWD will observe staff hand hygiene by randomly shadowing cares as they are performed.

4. Responsible Parties: HWD, ED, or designee.   

Based on observation and interview, it was determined the facility failed to ensure establishment and maintenance of infection prevention and control protocols to provide a safe, sanitary and comfortable environment for 1 of 1 sampled resident (#8) related to incontinence care and multiple unsampled residents during meal service. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the memory care community in 04/2024 with diagnoses including dementia. Observations and interviews with staff during the survey identified s/he relied on two staff for transfers and incontinence care needs.

With permission from the resident on 10/01/24 at 1:08 pm, Staff 18 (CG) and Staff 25 (CG) were observed providing ADL incontinence care for Resident 8.

Staff 18 donned gloves in the common area, proceeded to touch the back of the geri chair to escort the resident to his/her apartment. Staff 18 stopped to go into the housekeeping closet to retrieve a clean chucks pad before entering the apartment. Staff 18 failed to doff potentially contaminated gloves and perform hand hygiene prior to beginning incontinent care. Staff 25 donned clean gloves without first performing hand hygiene. Staff 18 and Staff 25 assisted in transferring Resident 8 from geri chair to bed, and then doffed his/her pants and brief. Staff 18 identified the resident's brief was soiled with urine, removed the brief, and placed it into a trash bag. Staff 18 provided perineal care, applied barrier cream, placed a clean brief on the resident, adjusted the resident in bed, placed pillows on areas of bony prominence, and placed a wedge under the mattress without performing hand hygiene or a glove change between tasks. Staff 18 then proceeded to touch the resident's blankets, clean clothing, closet door, geri chair and radio without taking off the soiled gloves and performing hand hygiene. Both staff doffed gloves after assisting Resident 8. Staff 25 was not observed to perform hand hygiene prior to exiting the resident's apartment.

2. The lunch meal service on 10/02/24 at 11:56 am in the Clare neighborhood the following was observed:

a. Staff 32 (CG) provided meal assistance for Resident 8 in the hallway outside of the dining room. Staff 32 donned gloves without performing hand hygiene or have an apron or other barrier between their potentially contaminated clothing and the resident during meal assistance.

Staff 32 was observed to touch another resident's walker and then return to provide meal service with Resident 8. Staff 32 failed to doff potentially dirty gloves, perform hand hygiene and don clean gloves. Staff 32 was observed to hand over a bowl of Resident 8's food to Staff 31 (CG) who proceeded to provide the remainder of the meal assistance. Staff 31 failed to wash her hands prior to the meal service, was not wearing gloves and an apron or other barrier between their potentially contaminated clothing and the resident during meal assistance.

b. Care staff provided meal assistance for an unsampled resident seated at the dining room table. The care staff was not observed to perform hand hygiene, wear gloves or have an apron or other barrier between their potentially contaminated clothing and the resident during meal assistance.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) and Staff 28 (Regional RN) on 10/02/24 at 1:30 pm. They acknowledged the findings.

1. Re-education on infection control policies was completed with staff on 10/3/24 and 10/9/24.  By Oct 31 all staff will receive Infectious Disease Training by the Executive Director and/or District Director of Clinical Services.   

2. Staff were reeducated on how to perform hand hygiene before, during, and after all cares.  Staff were reeducated to wear aprons and gloves while serving meals, snacks, or helping a resident to eat.  Staff will be re-educated at the next monthly staff meeting on how to perform hand hygene and infection control.  They will be instructed and observed on the following items:  when to wash their hands, with what product, how long, how often, and how often to change gloves.

3.  For the next month, hand hygiene will be reviewed daily at clinical meeting. For the next month, the HWC, RCC, and/or HWD will observe staff hand hygiene by randomly shadowing cares as they are performed.

4. Responsible Parties: HWD, ED, or designee.   

3. Resident 3 moved into the  memory care community in 09/2023 with diagnoses including dementia.

Resident 3's record indicated s/he had orders for PRN quetiapine 25 mg for "agitation".

Resident 3's 04/01/24 through 04/22/24 MAR was reviewed during the survey and revealed the following:

* The PRN medication was administered two occasions;

* There was no instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation for which staff could consider administering the medication; and

* There was no documented evidence of non-drug interventions had been attempted with ineffective results prior to administering the medication.

On 04/24/24, Resident 3's record was reviewed with Staff 1 (Executive Director), Staff 2 (RN, Health and Wellness Director), Staff 5 (District Director of Operations) and Staff 22 (RN, District Director of Clinical Operations).  Attempting non-pharmacological interventions prior to administering psychoactive medications was discussed. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the MAR had written resident-specific parameters, non-pharmacological interventions for PRN psychotropic medications and failed to ensure non-pharmacological interventions had been tried and documented with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 3, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia.

a. A review of the MAR dated 04/01/24 through 04/21/24 and progress notes for the same time period identified the following:

Resident 5 was prescribed lorazepam 2mg/0.5ml (1mg) by mouth every four hours as needed for anxiety. Unlicensed staff administered the PRN psychotropic medication on 04/02/24, 04/04/24 and 04/08/24.

There was no documented evidence non-pharmacological interventions had been tried with ineffective results prior to administering the medication.

b. Resident 5 was prescribed risperidone 0.25mg tablet, give one tablet by mouth, twice daily as needed for agitation.

The MAR lacked written resident specific non-pharmacological interventions to attempt prior to administration of the PRN medication.

The 04/01/24 through 04/21/24 MAR identified unlicensed staff did not administer the risperidone medication to the resident.

The need to ensure the MAR had non-pharmacological interventions for unlicensed staff to attempt prior to administering a PRN psychotropic and the need to ensure staff documented non-pharmacological interventions were attempted with ineffective results prior to administering a PRN psychotropic was reviewed with Staff 2 (RN, Health and Wellness Director) on 04/23/24 and Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

2. Resident 6 moved into the memory care community in 04/2024 with diagnoses including unspecified dementia.

A review of the MAR dated 04/09/24 through 04/21/24 and progress notes for the same time period identified the following:

Resident 6 was prescribed olanzapine 2.5 mg tablet, give one tablet, twice daily, as needed for agitation. On 04/10/24 an unlicensed staff administered the PRN medication.

There was no documented evidence for the reason staff administered the PRN medication or that non-pharmacological interventions had been tried with ineffective results prior to administering the medication.

The need to ensure non-pharmacological interventions were attempted and documented with ineffective results prior to administering a PRN psychotropic medication was discussed with Staff 2 (RN, Health and Wellness Director) on 04/23/24 and Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. Staff were re-educated on how to administer PRN medication.  Intervientions were included for individual behaviors.

2. At one clinical meeting each week, the HWD, HWC or nurse designee will audit medication records to confirm proper documentation of PRN medications.  PRN medication administration will be reviewed again with the Medication Technicians at the next monthly Med Tech meeting.  Staff will continue to be educated on behaviors at the monthly all staff meeting, daily huddle, and as needed.

3. PRN medcation reviews will be conducted during  clinical meetings and ongoing.

4. Executive Director, Health and Wellness Director or designee.   

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

The facility's ABST was reviewed on 04/23/24.

There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST used by the facility.

The need to use an ABST which addressed all of the 22 activities of daily living for each resident and the amount of staff time needed to provide care was discussed with Staff 1 (ED) on 04/24/24. She acknowledged the findings.

1. Community is in process of working with Corrective Action Team on reviewing Brookdale's Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified.

2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale's tool.

3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly.

4. Executive Director or designee.

Based on interview and record review, it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:

During an interview on 10/03/24, Staff 1 (ED) and Staff 5 (District Director of Operations) stated the facility was using the "Brookdale ABST".

A review of the facility's Acuity Based Staffing Tool (ABST) identified the following:

1. The ABST tool failed to include all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide each task.

2. The ABST had multiple ADLs grouped together in subcategories. For example, dressing was grouped together with grooming.

3. The tool failed to address the following ADL's, individually:

* Personal hygiene;

* Transfer in and out of bed or a chair;

* Repositioning in bed or chair;

* Assisting with leisure activities;

* Assisting with communication, assistive devices for hearing, vision, speech;

* Responding to call lights; and

* Safety checks, fall preventions.

The ABST tool was reviewed and discussed with Staff 1 and Staff  5 on 10/03/24. They acknowledged the findings.

1. Community is in process of working with Corrective Action Team on reviewing Brookdale's Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified.

2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale's tool.

3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly.

4. Executive Director or designee.

Based on interview and record review, it was determined the facility failed to maintain documentation regarding each direct care staff's demonstrated competency and maintain written documentation of all training's completed by each employee. Findings include, but are not limited to:

During a review of staff training records on 04/23/24 and 04/24/24, Staff 4 (Business Office Coordinator) was unable to provide documented evidence that sampled staff administering medications and providing personal care had completed pre-service dementia training and demonstrated competency in all duties they were assigned before working independently with residents including:

* Staff 9 (Med Tech) was hired on 09/15/2021 and administered medications to residents. There was no documented evidence of Staff 9's demonstrated competency in medication administration until requested by the survey team on 04/23/24.

* Staff 8 (Med Tech/Caregiver) was hired on 01/08/24 and provided personal care to residents on the MCC independently. Staff 8 did not document demonstrated competency in providing care until 04/09/24.

The requirement to maintain written documentation of training completed by each employee, to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing before working independently and/or administering medications to residents was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. The ED reviewed training program and checklists with the BOC and designee.  The BOC or designee audited staff training documentation and check lists to identify past due training.  The ED, HWD or designee will scheduled past due training sessions to be completed by no later than 6/15/24.

2. Community will implement and follow Brookdale onboarding policies and proceedures.  The BOC or designee will review associate files to confirm their required trainings are completed in the appropriate time frame.  

3. Training documents will be audited on a monthly basis by the ED, BOC, or designee.

4. Executive Director, Business Office Coordinator, or designee.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month, ensure a complete written fire drill record was kept and provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

Fire drill and fire and life safety training records were reviewed with Staff 3 (Maintenance Technician) and Staff 1 (ED) on 04/23/24 at 11:00 am. The following were identified:

a. The facility had not provided staff with life safety instruction at least every other month;

b. The fire drill records from 10/01/24 to 4/22/24 failed to document one or more of the following required components:

* Location of the simulated fire;

* Evidence alternate routes were used; and

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills.

The requirements for providing and documenting fire drills and fire and life safety training for staff was discussed with Staff 1 and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.

I. Fire drills will be completed every month on rotating shifts and documented with the neccesary information such as location of the fire, alternate routes, and any problems encountered. Maintenance Technician received additional training on fire drills and accompanying documentation including the requirement to identify the location of the simulated fire and any problems that were encountered during the drill.

2. Maintenance Technician will receive additional training on documentation regarding the location of the simulated fire and any problems that were encountered during the drill.  Staff will receive additional training on fire drill routes and options for any residents who resisted or failed to participate in the drill.  

3. The fire drill reports will be reviewed by the ED or designee each month.

4. Responsible Parties: ED, Maintenance Technician or designee.

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

Facility fire and life safety records were reviewed on 04/23/24. The facility lacked documented evidence residents were instructed on general safety procedures, evacuation methods, and responsibilities within 24 hours of admission and annually.

The need for residents to be instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. New residents will be inserviced on Fire and LIfe Safety instruction with 24 hours of move in and anually thereafter.  Fire and Life Safety procedures will be reviewed with current residents at a resident meeting in June 2024.  A sign up sheet will be used to document their attendance.

2. New moves in wil be reviewed at Daily Stand Up meeting and Maintenance Director will arrange inservice within 24 hours. Fire and Life Safety inservice will be added to Move in Checklist. Annual inservice will be calendered for scheduled care conference closest to annual inservice date.

3. Within 24 hours of move in and annually thereafter with a monthly review to idenitfy residents approaching annual inservice date.

4. Maintenance Director, Executive Director, Health and Wellness Director, and Business Office Coordinator to monitor.     

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 C 231, C 270, C 280, C 295, C 361, and Z 163.

1. The community team will create and implement a revised plan of correction for C155, C231, C243, C270, C280, C295, C361, C455, Z142, Z162, Z163.

2. The District Director of Operations, Distric Director of Clinical Service and Brookdale Clinical Specialists will connect with the community team a minimum of once weekly via in person visits, training/support calls, and/or remote documentation review.  This additional monitoring will continue for the next 30 days, and then monthly for the next 30 days.

3.  Will be reviewed with District Team as described above.

4.The community has entered into an agreement with a department-approved Registered Nurse Consultant.  The District Director of Operations, Distrcit Director of Clinical Services and their designees will be responsible for veriffying tha the corrections are completed.  

Based on observation and interview, it was determined the facility failed to ensure there was locked storage for all poisons, chemicals, and other toxic materials. Findings include, but are not limited to:

Observations of the facility on 04/22/24 identified the following:

* The beauty shop directly off the Towne Square activity area was unlocked and accessible to residents. In the beauty shop an unlocked drawer contained sharp scissors, wood glue and other toxic materials.

* The Clare unit activity kitchen had unlocked clear glass cabinets with dermal wound cleanser, disinfectant wipes, and disinfectant spray.

* The Bridge unit activity kitchen had unlocked clear glass cabinets with disinfectant spray and wipes.

The need to use locked storage for all poisons, chemicals, and other toxic materials was discussed with Staff 1 (ED) and Staff 4 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. Chemicals were removed or locked in the following areas: Beauty shop, Clare Activity Kitchen, Bridge Activity Kitchen.  Additionally the rest of the building was reviewed for any unlocked chemicals.  Staff were informed to secure chemicals for the safety of the residents.   

2. The ED or designee will re-educate staff the Brookdale policy on the storage of chemicals.

3. The ED, HWD, Maintenance Technician or designee will inspect the common areas daily to confirm chemicals are stored properly.

4. Executive Director, Health and Wellness Director, Maintenance Technician, or designee.   

Based on observation and interview, it was determined the facility failed to ensure interior surfaces and equipment necessary for the health, safety, and comfort of residents were kept clean and in good repair. Findings include, but are not limited to:

The interior of the building was toured on 04/22/24 and again on 04/23/24. The following areas were observed to need cleaning and/or repair:

* The resident use bathroom directly off the Towne Square activity area:

  a. A bucket was placed underneath the toilet water inlet to contain a leaking connection.

  b. Ceramic sink base mounted to the wall was dislodged and loosely hanging.

* Persistent urine odors were noted on 04/22/24 and 04/23/24 outside the Bridge unit laundry room;

* Carpet in both the Clare and Bridge units television rooms had red carpet stains in front of the chairs;

* On 04/24/24 the Bridge unit laundry room had a washing machine water drain pipe connected with black duct tape, it was observed to leak water onto the floor of the laundry room.

* Interior courtyards in both Clare and Bridge units had wood shingles and siding detached from the exterior walls, and multiple areas of rotted wood in the window and door frames, exposing the underlayment.

On 04/24/24 the areas were shown to and discussed with Staff 3 (Maintenance Technician), Staff 1 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. The following areas were repaired: bathroom in Town Square - leaking connection to the toilet and ceramic sink base has been remounted.  Persistent urine odors in F Hall - increased carpet cleaning from monthly to weekly. Carpet in both Clare and Bridge television rooms - removed red carpet stains.  Bridge laundry room washing machine - repaired drain pipe connection. Interior courtyards on both Clare and Bridge units - repaired wood shingles so they are attached to the exterior walls and obtained a quote to repair the dry rot.  Dry rot repair will be completed by 6/23/24.

2. Items from repairs that were completed will be put away immediately.  The building will be reviewed regularly for any items that need repair.  Proper cleaning agents will be used to remove stains.  Windows, door frames, and other wood items on the exterior of the building will be reviewed and/or repaired in a timely fashion.

3. The interior and exterior of the building will be checked weekly for any aspect in need of repair.

4. Executive Director, Maintenance Technician, or designee.  

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

a. Observations of the Clare Street Unit on 03/03/25 and 03/04/25 revealed the following:

* Resident rooms A5, A6, B4, B5, C3, C4, C6, C7, C8, entry door to unit, and common bathroom in B-hall had scraped doors and/or jambs;

* The common activity kitchen had an approximate 24 inch scraped area on the wall by the television;

* The common bathroom in B-hall had several scraped areas on the wall next to the toilet, and discolored caulking around the toilet base;

* Furniture in the activity room and television room was discolored with stains on the seats and arms, and urine odors were evident; and

* Pervasive urine odors were noted in halls and common areas during the survey.

b. Observations of the Bridge Street Unit on 03/03/25 and 03/04/25 revealed the following:

* Resident room D5, medication room, housekeeping room, activity room, and solace room had scraped doors and/or jambs;

* The common bathroom on E-Hall had discolored caulking around the toilet base, and scraped areas on the door and/or jamb;

* The television room had a scraped area on the wall behind a blue recliner;

* Furniture in the activity room, television room, and hallway was discolored with stains on the seats and arms, frayed/scratched corners, and urine odors were evident;

* The dining room had a section of missing paint on the wall underneath the windows; and

* Pervasive urine odors were noted in halls and common areas during the survey.

c. Observations of the common areas in the entrance of the facility on 03/03/25 and 03/04/25 revealed the following:

* Scraped areas to both entrance doors of facility; and

* Discolored caulking around the toilet base in the common bathroom.

The surveyor toured the environment with Staff 1 (Administrator) on 03/04/25. She acknowledged the findings.

1. Executive Director and Regional Maintenance Technican reviewed doors, odors, furniture, caulking.  Damaged furniture was removed, plan for carpet cleaning and door/wall/caulking repair was created.  

2. Staff will receive education on how to use cleaning equipment so carpets and furniture can be cleaned.  Correct paint will be used on doors and trim.  Caulk will be replaced around toilets where needed. New furniture will be ordered.

3. This will be reviewed on a weekly basis and in between as needed.  Staff will communicate building concerns to Maintenance Technician and Executive Director.  

4. Maintenance Technician and Executive Director, or designee.  

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1511 Individual Rights Settings: OAR 411-004-0020 (1)(d)

(1) Residential and non-residential HCB settings must have all of the following qualities:

(d) The setting ensures the individual the right to freedom from restraints, except in accordance with the standards set forth in ORS

443.739, OAR chapters 309 and 411, 1915(c) HCBS Waivers, 1915(i) State Plan HCBS, or 1915(k) Community First Choice (K State Plan Option). When the right to freedom from restraints must be limited due to a threat to the health and safety of an individual or others, an individually-based limitation as described in OAR 411-004-0040 must apply in any residential or non-residential setting.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1515: Physical Setting: Individual Accessible OAR411-004-0020(2)(b)

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

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

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1518 Individual Door Locks: Key Access OAR 4110004-0020(2)(e)

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

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

During the survey, concerns were identified in the following area and the facility was provided with technical assistance:

H 1521 Individual Vistors: Any Time OAR 411-004-0020 (2)(h)

(h) Each individual may have visitors of his or her choosing at any time.

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

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

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 231, C 361, C 365, C 420, C 422, C 510 and C 513.

Refer to the plans of corrections submitted for C231, C361, C365, C420, C422, C510, C513  

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

Refer to C 155, C 231, and C 361.

Refer to plans of corrections submitted for C155, C231, C361

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

Refer to: C 513.

Refers to C513

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly-hired staff (#s 8 and 15) completed all required pre-service orientation prior to providing care; 1 of 3 sampled staff (#8) failed to demonstrate competency before providing personal care, 3 of 3 long term staff (#s 9, 15, and 16) completed annual training as required, and that one of two sampled staff (#9) demonstrated competency prior to providing medication pass independently.  Findings include but are not limited to:

Staff training records were reviewed with Staff 4 (Business Office Coordinator) on 04/23/24 and 04/24/24. The following was identified:

1. The following staff did not have documented evidence of completing the following pre-service training prior to providing personal care independently:

a. Staff 8 (Med Tech/Caregiver) hired on 01/08/24:

* Environmental factors important to a resident's well being; and

* Family support and the role family may have in the care of the resident.

b. Staff 15 (Caregiver) hired on 11/19/21:

* How to provide care to a resident with dementia including an orientation to the resident's service plan.

2. There was not documented evidence the following staff demonstrated competency in the following areas within 30 days of hire or prior to providing care independently:

a. Staff 8 (Caregiver) hired on 01/08/24:

* Providing assistance with ADL's;

* Changes associated with normal aging; and

* Conditions that require assessment, treatment, observation and reporting.

b. Staff 9 (Med Tech) hired on 09/15/21:

* Medication Pass

3. There was no documented evidence Staff 9 (Med Tech) hired 09/15/21,  Staff 16 (Caregiver) hired on 11/01/12, and Staff 15 (Caregiver) hired on 11/19/21 had completed the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training related to dementia care.

The need to ensure the required pre-service and annual training was completed by staff in the time frames specified in the rules, as well as the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 4 (Business Office Coordinator) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. Staff 8 completed training on the required pre-serivce oriatnation and dementia training. Staff 9, 15, 16 have completed annual training and will be upto date with all annual trianing by 6/23/24.

2. Community will follow policies and proceedures for onboarding and annual education, this will ensure all required trainings are completed in the appropriate time frame.  

3. Training documents will be audited on a monthly basis.

4. Executive Director, Business Office Coordinator, or designee.

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 260, C 270, C 280, C 295 and C 330.

Refer to the plans of correction for C260, C270, C280, C295, C330

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

Refer to  C 243, C 270, C 280, and C 295.

Refer to the plans of corrections submitted for C243, C270, C280, C295

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutritional plan for each resident was developed and included in the resident's service plan for 1 of 3 sampled residents (# 5) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to:

Resident 5 moved into the memory care community in 03/2023 with diagnoses including Alzheimer's disease with late onset and dementia.

The resident's clinical record was reviewed, interviews with care staff and meal observations were conducted during the survey and the following was identified:

* The service plan offered the following staff instruction: "will want coffee with [his/her] meals ...will have at least three six oz [ounce] glasses of fluids with most meals." There was no additional information regarding resident specific food or fluid preferences.

* The MAR dated 04/01/24 through 04/21/24 instructed staff to provide a Mighty Shake with each snack twice daily and give with any meal that [s/he] eats less than 50% of the meal, twice daily. The MAR indicated staff were only giving the Mighty Shake twice daily at the scheduled times of 10:00 am and 2:00 pm.

On 04/22/24 at 11:44 am, the resident was served a plate of mashed potatoes and gravy, chopped chicken, a dinner roll, a small bowl of soup, small bowl of mandarin oranges, a bowl of cake and one glass of apple juice.

* The resident pushed the plate of food away into the middle of the table where it remained for the duration of the meal;

* The resident used a spoon and ate 100% of the soup, mandarin oranges and cake that was served in a bowl.;

* The resident drank half the glass of apple juice;

* Surveyor observed the resident had eaten 0% of the mashed potatoes and gravy, chopped chicken, and dinner roll that was served on the plate; and

* There was no coffee provided during the meal.

During the breakfast meal observation on 04/23/24 at 8:24 am, the resident was observed with his/her head bowed down and arms crossed at the dining room table.

S/he had a plate of scrambled eggs, bacon, canned fruit, half of an english muffin and one glass of apple juice. There was a fork laying on the plate and it appeared that s/he had eaten a couple bites of egg and fruit, approximately 15 %. The bacon and muffin were untouched.

There was no coffee provided, there was no observation of cueing the resident to eat or assistance to help the resident eat and a mighty shake wasn't given to the resident.

During the lunch meal observation on 04/23/24 at 11:45 am, the resident was served a plate of mashed potatoes and gravy, a slice of meat loaf, green beans, a dinner roll and one glass of red colored juice. There was no coffee provided.

At 12:06 pm, Staff 16 chopped the resident's meat loaf into 4 pieces, stating "ok, lets eat [resident name]" and then placed the fork on the plate and walked away from the resident. The resident crossed his/her arms and bowed his/her head.

At 12:10 pm, Staff 16 approached the resident and stated "are you falling asleep, are you tired? Come on take a bite" and then walked away. No bite was taken, and the resident again crossed his/her arms and bowed his/her head.

At 12:25 pm, Staff 16 physically assisted and offered a bite of meat loaf. The resident took the bite. Then the caregiver stated, "you don't like it, what do you like, do you like the bread, the beans, the mashed potatoes, PBJ, do you like that? The resident replied, "no." Staff 16 stated, "ok, I will take it for you" and removed the plate at 12:29 pm.

During an interview on 04/23/24 at 2:45 pm, Staff 26 (CG) reported the resident "doesn't really eat much at dinner time. I try to offer him/her another snack or extra dessert. We are not asked to monitor snacks, meals or fluids. We do for some [residents], but not [him/her]."

During an interview on 04/24/24 at 1:07 pm, Staff 27 (CG) reported the resident ate approximately 45 % of the lunch meal, had a pudding for dessert and was given a Boost, however she could not recall how much of the Boost the resident had consumed.

There was no documented evidence the facility developed a daily meal program for nutrition and hydration that was based upon the resident's preferences, ability to eat independently or need for adaptive utensils in order to maintain eating ability. Additionally, the facility failed to ensure an individualized nutrition plan was developed and documented in the resident's service plan.

The need to develop individualized nutritional plans addressing residents' nutrition and hydration preferences and needs was discussed with Staff 1 (ED), Staff 2 (RN, Health and Wellness Director), and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. Resident 5's serivce plan was updated to include specific beverage preferences, nutrition plan, and how staff are to assist this resident.

2. Management will observe meal service to confirm the residents are getting the support they need and are offered the food they prefer.

3. The ED, HWD, HWC or designee will observe one meal service each day for the next month.

4. Executive Director, Health and Wellness Director, Health and Wellness Coordinator, or designee.

Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 4 sampled residents (#s 8 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 and 10's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.  

The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED) and Staff 5 (District Director of Operations ) on 10/03/24. They acknowledged the findings.

1. Resident 8 & 10 service plans were updated to include specific beverage preferences, nutrition plan, and how staff are to assist the residents.

2.  Health and Wellness Director will collaborate with staff and families to know the nutrition and beverage preferences, status, and hydration needs.  When serivce plans are being developed the Health and Wellness Director will include specifics on what types of food and beverages each resident prefers, and how the staff should assist the residents.  

3. The nutrition and hydration will be reviewed upon move-in and at each service plan update.  Changes will be made to the service plan as needed to update preferences and instruction for staff.  

4. Health and Wellness Director, Resident Care Coordinator, Executive Director, or designee.  

Based on observation, interview, and record review, it was determined the facility failed to develop individualized activity plans for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose evaluations and service plans were reviewed. Findings include, but are not limited to:

Observations and interviews were completed between 04/22/24 and 04/24/24. Service plans and evaluations were reviewed for Residents 1, 2, 3, 4, 5 and 6. The following were identified:

During an interview on 04/23/24 at 1:35 pm, Staff 1 (ED) reported the facility had a "Life Story" that was completed when the resident moved into the facility however; the information obtained on the "Life Story" did not meet regulation.

There was no documented evidence activity evaluations were completed that reflected each resident's activity preferences and needs and individualized activity plans were developed based on the residents' activity evaluation.

The need to ensure the facility developed individualized activity plans for each resident was discussed with Staff 1 and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings.

1. Activity Evaluations and Service Plans for Residents 1, 2, 3, 4, 5, 6 were updated to include specific activity preferences and information from their "Life Story".

2. For new residents the activity evaluation and "Life Story" will be documented and added to their initial service plan.  For current residents, the activity evaluation and "Life Story" will be reviewed quarterly or as needed with their current interests and preferences.

3. Upon move-in, and at each assessment and service plan update.

4. Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator, or designee.  

Based on observation, interview, and record review, it was determined the facility failed to ensure behavioral symptoms, which negatively impacted the resident and others in the MCC, were evaluated and included in the service plan, for 1 of 2 sampled residents (# 3) whose behavioral issues were reviewed. Findings include but are not limited to:

Resident 3 moved into the  memory care community in 09/2023 with diagnoses including dementia.

During the acuity interview on 04/22/24, the resident was identified to have verbal aggression and received as needed medication to address the aggression.

On 04/22/24, the resident was observed to push a female resident's wheelchair to the dining room for lunch.

An interview, 04/23/24 at 12:45 pm, Staff 14 (CG) and Staff 16 (CG) reported Resident 3 tended to be upset when male residents were present around female residents. The resident was noted to be very protective when female residents were present. They further stated the resident could be agitated with showering and refused shower assistance.

Review of the resident's clinical records indicated the resident was involved in a resident to resident altercation on 03/29/24 that the resident was standing over another resident "who was laying on [his/her] back...". Further record review including the 04/01/24 through 04/22/24 MAR, noted the resident refused showers on seven occasions.

There was no documented evidence the facility evaluated Resident 3's behaviors which could negativity impact other residents. Also, there was no specific interventions and instructions in the service plan to guide caregiving staff in responding to Resident 3's behavioral symptoms.

On 04/24/24, the above findings were shared with Staff 1 (ED), Staff 2 (RN, Health and Wellness Director), Staff 5 (District Director of Operations) and Staff 22 (RN, District Director of Clinical Operations) and discussed to ensure behavioral symptoms which negatively impact the resident and others were evaluated and included in the service plan. They acknowledged the findings.

1. Resident 3's service plan was updated to include behaviors that could negatively impact other residents and what interventions to use.  

2. Health and Wellness Director will collaborate with staff to determine if the interventions are working.  If the interventions are not successful, new non-pharmacological interventions will need to be developed.  

3.  Monthly and as needed.

4. Executive Director, Health and Wellness Director, Health and Wellness Coordinator, or designee.  

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to:

Observations of the Clare and Bridge memory care units, from 04/22/24 through 04/23/24, revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time.

On 04/24/24 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 (ED) and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings and stated they would unlock the doors from dawn to dusk except during severe weather.

1. The doors to Clare and Bridge interior courtyards were immediately unlocked and staff were re-educated on the policy regarding locking/unlocking interior courtyard doors.  A sign was posted at both entrances to the courtyard on the policy of outdoor use, and what might constitute the temporary closure of that area.

2. Staff were re-educated on the policy regarding courtyard doors.  The signs explaining the policy will remain posted.

3. For the next thirty days, the interior courtyard doors will be checked daily by the ED or designee to verify the doors are unlocked.

4. Executive Director or designee.  

Based on observation and interview, it was determined the memory care community failed to ensure a keyed lock was not placed between residents and the emergency exit, and the outside perimeter fencing allowed for egress in the event of an emergency. Findings include, but are not limited to:

The facility's interior and outdoor areas were toured on 04/22/24. The facility was divided into two units, Clare and Bridge, which had the same layout and features.  Both unit's emergency exit to the outdoors was through two doors leading to a fenced outdoor area.

Both emergency exit doors on both units were observed with keyed locks.  The outdoor areas each had one emergency exit, which were secured with  combination padlocks.

In interview with Staff 1 (ED) and Staff 3 (Maintenance Technician) on 04/22/24, they confirmed the exit doors that were locked were the designated emergency exits, could only be opened with a key, and the outdoor areas only exit were the gates locked with padlocks.

The requirement for memory care communities to not have entrance and exit doors that are closed with non-electronic keyed locks were discussed with Staff 1 and Staff 5 (District Director of Operations) on 04/24/24. They acknowledged the findings and stated the keyed and combination locks would be immediately removed leaving only electronic locks that released in case of an emergency.

1. Emergency exit doors from each of the television rooms were unlocked and a sign posted. Keys to those locks of the exit doors were removed from staff key chains. New gates were installed without a keyed lock.

2. Community staff were re-educated on the rules regarding exit doors and locking devices.  

3. The ED or designee will inspect the exit doors monthly or as needed to verify the doors and locks are maintained properly.

4. Executive Director or designee.