Print Inspection: XHAR

The findings of the initial survey, conducted 08/30/22 through 09/01/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 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 revisit to the re-licensure survey of 09/01/22, conducted 05/23/23 through 05/25/23 date, 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 09/01/22, conducted 11/27/23 through 11/29/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third revisit to the re-licensure survey of 09/01/22, conducted 04/02/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

During a tour of the environment at 2:30 pm on 08/31/22, the following was observed:

The memory care unit had two kitchenettes which were accessible to residents.

Three countertop food warmers were observed in one of the kitchenettes. Each of the food warmers had approximately one inch of water in the bottom. Electrical outlets were located directly behind the appliances.

A countertop electric soup warmer, full of a tomato-based soup, was observed to be on the counter in the same kitchenette. Staff 23 (CG) reported the soup stayed in the warmer from breakfast through dinner, and staff did not take the temperature of the soup during the day. The temperature of the soup registered 170 degrees Fahrenheit on the surveyor's thermometer.

At 2:40 pm, Staff 3 (Memory Care Administrator/RN) was apprised of the dangers those findings presented, including the risk of residents sustaining burns from the soup and the warmers, electrocution, and food-borne illness related to the lack of monitoring of the temperature of the soup throughout the day. Staff 3 was instructed to discard the soup and either remove the appliances or ensure residents did not have access to them. The administrator immediately removed the appliances.

At 2:50 pm, a popcorn machine was observed on the countertop of the other kitchenette. The risk of residents sustaining burns from the popcorn machine was brought to the attention of Staff 3, who had it removed from the kitchenette.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 3 on 08/30/22. She acknowledged the findings.

1. Food warmers, soup pot, and popcorn machine have all been removed from the MC Kitchens. Gates for our MC Kitchens will be installed in a manner to not create a fall hazard.

2. MC Admin and Memory Care Staff will be trained to look for any conditions that may pose a safety risk to the residents. MC Staff who are members of the Safety Committee will also be asked to bring suggestions/concerns to the Safety Meetings so that they can be addressed and corrected. Safety Committee members will also be encouraged to obtain suggestions/concerns from their co-workers.

3. Areas of Safety Concern will be brought before the Safety Committee on a monthly basis. MC Admin, MCC, and MC Staff will be encouraged to continually look for items that may pose a safety risk to residents.

4. Responsible Party: Administrator

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. This is a repeat citation. Findings include, but are not limited to:

a. Observations of incontinent care for Resident 5 were completed on 05/24/23 and showed the following:

Staff 20 (Memory Care RCC) assisted Resident 5 to the restroom. The resident's soiled brief was removed and placed directly on the bathroom floor. The resident was provided perineal care, a new brief was placed on, and the resident's pants were changed. Staff 20 picked up the soiled brief and placed it into the bag and removed it from the resident's room when care was completed.

After returning the resident to the dining room, Staff 20 was asked to disinfect the floor where the soiled brief had been placed.

The need to ensure appropriate infection control measures were implemented by staff was discussed with Staff 1 (Campus Administrator) and Staff 26 (Memory Care Administrator) on 05/24/23 and 05/25/23. The staff acknowledged the findings.

b. Observations of the lunch meal on 05/24/23 were completed and showed the following:

The insulated cart with Resident's lunches was delivered to the Maple neighborhood kitchenette at 11:15 am. The cart sat parked inside the kitchenette until 11:45 am when Staff 20 began to unload resident plates. Staff 20 began to check temperatures of hamburgers, microwave the sandwiches and then recheck the temperatures.

The first resident plate was delivered at 11:50 am which consisted of one of the hamburgers. The remaining plates sat on the counter and the resident lunches for the Aspen neighborhood remained in the insulated cart.

At noon (45 minutes later), Staff 20 was asked to check temperatures of the remaining resident lunches which consisted of a cold shrimp salad. The shrimp salads were measured at 74 degrees Fahrenheit or above. Staff 20 stated the temperatures were too hot and the surveyor asked Staff 20 to get fresh items from the kitchen. The plates for the residents located in the Aspen neighborhood were also removed, as they were still located on the insulated cart in the Maple kitchenette.

On 5/24/23, Staff 26 (Memory Care Administrator) provided a plan of correction for holding and delivering lunches at a safe temperature for residents.

The need to ensure meals were served at a safe temperature for residents was discussed with Staff 1 (Campus Administrator) and Staff 26 (Memory Care Administrator) on 05/24/23. The staff acknowledged the findings.

A) 1. Trash cans will be properly placed in each residents bathrooms. Trash bags will be properly placed within each trash can to prevent soiled items from touching the floor.

2. Memory Care Staff will be trained on disposal of soiled items in a healthcare setting.

3. A building task will be added to check 3 times daily for placement of trash can and trash bags.

4. Responsible Party: Memory Care Staff

B)1. If insulated cart is brought to Memory Care and is not expected to be immediately served, staff is to put all cold items in the fridge until ready. All hot food will be temped before serving and reheated as necessary, if not served immediately.

2. Memory Care Staff will be trained on properly using thermometers.

3. Thermometers will be checked monthly for accuracy.

4. Responsible Party: Administrator

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

During the survey, 08/30/22 through 09/01/22, there were no observations of individual or group activities being provided for residents.

During an interview with Staff 3 (Memory Care Administrator/RN) on 09/01/22, she stated the activity coordinator quit and the facility was working to fill the position.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 3 on 09/01/22. She acknowledged the findings.

1. MC Life Enrichment Director has been hired and has been creating more enriching activities for our residents to participate in. Activities Evaluation shall be performed to plan activities based upon the personal interest of the Residents.

2. We have hired a new MC Life Enrichment Director. She will be documenting the interests and participation of our MC Residents for activities. She will be using an Activities Evaluation Form to evaluate each resident's needs, personal interests, and abilities to plan her monthly Activities Calendar.

3. This area will be evaluated quarterly to make sure Evaluations are being performed and Residents are actively participating.

4. Responsible Party: MC Life Enrichment Director and Administrator

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. This is a repeat citation. Findings include, but are not limited to:

During the survey, 05/23/23 through 05/25/23, observations of the unit showed coloring was offered twice and no group activities were conducted inside the memory care unit.

In an interview on 05/24/23, Staff 26 (Memory Care Administrator) indicated the activity coordinator quit and the facility was working to fill the position.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 (Campus Administrator) and Staff 26 on 05/25/23. They acknowledged the findings.

1.The Landing is currently doing interviews for the MC Life Enrichment Director. Once hired the MC Life Enrichment Director will be creating more enriching activities for our residents to participate in. Activities Evaluation shall be performed to plan activities based upon the personal interest of the Residents.

2. We are doing interviews for the MC Life Enrichment Director. They will be documenting the interests and participation of our MC Residents for activities. They will be using an Activities Evaluation Form to evaluate each resident's needs, personal interests, and abilities to plan her monthly Activities Calendar.

3. This area will be evaluated quarterly to make sure Evaluations are being performed and Residents are actively participating.

4. Responsible Party: MC Life Enrichment Director and Administrator

Based on interview and record review, it was determined the facility failed to ensure a new move-in evaluation was completed prior to admission for 1 of 1 sampled resident (#3) who had recently moved into the facility. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 07/2022 with diagnoses including vascular dementia.

During an interview with Staff 3 (Memory Care Administrator/RN) on 08/31/22, she stated the facility had completed a service plan upon admission, but not an evaluation.

The need to ensure an initial evaluation which addressed all required elements was completed prior to move-in, and served as the basis for the development of the service plan, was discussed with Staff 3. She acknowledged the findings.

1. Resident #3 shall be reevaluated as per OAR 411-054-0034 and administrator shall review for all elements.

2. Move In Evaluations will follow template that corresponds to OAR 411-054-0034. Evaluations will be reviewed by at least 1-2 other people (RCC, MCC, Wellness Director, Admin, or a delegate) to assure that all elements of the Evaluation have been completed.

3. Upon admission each residents evaluation and chart shall be reviewed by no less than two individuals to ensure completion. Quarterly chart reviews shall be completed to ensure all elements of OAR 411-054-0034 are met.

4. Responsibly parties include Wellness Director and Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure a new move-in evaluation was completed prior to admission and addressed all elements for 1 of 1 sampled resident (#7) who had recently moved into the facility. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 02/2023 with diagnoses including Alzheimer's disease.

Review of the resident's record revealed the new move-in evaluation was completed after the resident's move-in date. Additionally, the new move-in evaluation lacked the following elements:

* Customary routines, including eating and bathing;

* Mental health issues, including history of treatment;

* Pain, including pharmaceutical and non-pharmaceutical interventions and how the resident expresses pain or discomfort;

* Fluid preferences;

* Emergency evacuation ability; and

* Environmental factors that impact the resident's behavior, including, but not limited to: noise, lighting, and room temperature.

The need to ensure new move-in evaluations were completed prior to resident admission and addressed all required elements was discussed with Staff 1 (Campus Administrator) and Staff 2 (Memory Care Administrator) on 05/25/23. They acknowledged the findings.

1. Before residents move in, the facility will conduct a proper initial screening. Resident #7 shall be reevaluated as per OAR 411-054-0034 and administrator shall review for all elements.

2. Move In Evaluations will follow template that corresponds to OAR 411-054-0034. Evaluations will be reviewed by at least 1-2 other people (RCC, MCC, Wellness Director, Admin, or a delegate) to assure that all elements of the Evaluation have been completed.

3. Upon admission each residents evaluation and chart shall be reviewed by no less than two individuals to ensure completion. Quarterly chart reviews shall be completed to ensure all elements of OAR 411-054-0034 are met.

4. Responsibly parties include Wellness Director and Administrator to ensure compliance

2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including vascular dementia.

Review of the resident's 07/23/22 service plan and interviews with staff revealed the service plan was not reflective of the resident's current status, care needs and did not provide clear direction to staff in the following areas:

* Hearing loss;

* Edema;

* Dentures;

* Incontinence; and

* ADL assistance.

The need to ensure the service plan was reflective of the resident's current status and provided clear direction to staff was discussed with Staff 3 (Administrator) on 09/01/22. She acknowledged the findings.

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

1. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia and chronic obstructive pulmonary disease (COPD).

Observations of the resident were made on 08/31/22 and 09/01/22, the resident's clinical record was reviewed, and staff were interviewed.

The service plan was not reflective of the resident's current status and care needs and/or did not provide clear instruction to staff in the following areas:

* Use of an ambulatory device;

* Oxygen use;

* Ability to use call system;

* Eyeglasses; and

* Hearing aids.

On 09/01/22, the need to ensure service plans accurately reflected residents' current status and care needs, as well as provided clear instructions to staff, was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN). They acknowledged the findings.

1. Residents #1 and #3 will be re-evaluated and an up-to-date Care Plan will be developed to reflect their current status. This will include a Service Planning Team.

2. Care Plans will be updated upon Changes of Condition and quarterly evaluations to reflect current status of the Resident. This includes when a resident is placed on Hospice or under the care of Home Health. Service Planning Teams will be used to ensure Care Plans are reflective of Resident needs.

3. This process will be evaluated on an ongoing basis by the Service Planning Team and quarterly to make sure it is still meeting the needs of our residents.

4. Responsible Party: Wellness Director and Administrator

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, followed by staff and provided clear direction to staff regarding care and services for 5 of 5 sampled residents (#s 2, 5, 6, 7 and 8). This is a repeat citation. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2021 with diagnoses including chronic pain and dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 03/23/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not consistently followed by staff in the following areas:

* Transfer assistance;

* Incontinence and toileting assistance;

* Behaviors including crying, anxiety and agitation with other residents; and

* Grooming assistance.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and was followed was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 09/2020 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 02/20/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not consistently followed by staff in the following areas:

* Side rail use;

* 1 vs 2 person transfer and gait belt use;

* Incontinence and toileting assistance;

* Behaviors and activity adaptations;

* Cut up foods, meal assistance and health shakes;

* Food likes and dislikes; and

* Nonskid footwear and tab alarm use.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and was followed was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

3. Resident 8 was admitted to the facility in 09/2020 with diagnoses including post traumatic stress disease and dementia.

Observations of the resident, interviews with staff and review of the service plan, dated 01/27/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not consistently followed by staff in the following areas:

* Edema and elevating of legs;

* Ted hose and leg wounds;

* Anxiety, agitation and post traumatic stress disease;

* Confusion and toileting in inappropriate areas; and

* Sleeping in recliner.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff and was followed was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

4. Resident 6 was admitted to the facility in 12/2020 with diagnoses including Alzheimer's disease.

Observations of the resident were made on 05/23/23 and 05/24/23, the resident's clinical record was reviewed, and staff were interviewed.

The service plan was not reflective of the resident's current status and care needs, staff were not following instructions and/or did not provide clear instruction to staff in the following areas:

* Hospice status;

* Use of a Foley catheter;

* Assistive devices including side rails, sling, hospital bed and fall mat;

* Swabbing resident's mouth before and after meals;

* Transfer status;

* Mobility status;

* Activity participation; and

* Sleep pattern.

The need to ensure service plans accurately reflected resident's current status and care needs, provided clear instructions to staff and was followed by staff was discussed with Staff 1 (Campus Administrator) and Staff 26 (Memory Care Administrator) on 05/25/23. They acknowledged the findings.

5. Resident 7 was admitted to the facility in 02/2023 with diagnoses including Alzheimer's disease and history of dehydration.

Chart notes reviewed revealed a recent weight loss.

Observations of the resident were made from 05/23/23 to 05/25/23, the resident's clinical record was reviewed, and staff were interviewed.

The service plan was not reflective of the resident's current status and care needs, staff were not following instructions and/or did not provide clear instruction to staff in the following areas:

* Staff instructions regarding resident's cat;

* Dressing assistance;

* Elopement risk;

* Care refusals and interventions for redirection; and

* Nutrition and hydration plan, including portion sizes, offering alternatives, serving resident food dislikes and favorite beverages.

The need to ensure service plans accurately reflected resident's current status and care needs, provided clear instructions to staff and was followed by staff was discussed with Staff 1 (Campus Administrator) and Staff 26 (Memory Care Administrator) on 05/25/23. They acknowledged the findings.

1. Residents #2, #5, #6, #7 and #8 will be re-evaluated and an up-to-date Care Plan will be developed to reflect their current status. This will include a Service Planning Team.

2. Care Plans will be updated upon Changes of Condition and quarterly evaluations to reflect current status of the Resident. This includes when a resident is placed on Hospice or under the care of Home Health. Service Planning Teams will be used to ensure Care Plans are reflective of Resident needs.

3. This process will be evaluated on an ongoing basis by the Service Planning Team and quarterly to make sure it is still meeting the needs of our residents.

4. Responsible Party: Wellness Director and Administrator

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

Current service plans for Residents 1, 2, 3, and 4 were reviewed during the survey. There was no documented evidence a Service Planning Team reviewed and participated in the development of the service plans.

On 09/01/22 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN). They acknowledged the findings.

1. For residents #1, #2, #3 and #4 a Service Planning Team to be established for any re-evaluations to be completed upon Change of Condition or at a minimum Quarterly. This action also applies to any other residents of The Landing.

2. Service Planning Team will be gathered to develop Care Plans after Change of Condition or Quarterly reviews. The team will consist of Resident and/or Representative, Residents Physician, Member of Wellness Team and Administrator or delegate.

3. Quarterly evaluations to be completed and documented that Service Planning Team is in place.

4. Responsible parties include Wellness Director and Administrator.

Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and the condition was monitored to resolution at least weekly for 3 of 3 sampled residents (#s 1, 3, and 4) who experienced changes of condition. Findings include, but are not limited to:

1.  Resident 4 was admitted to the facility in 05/2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 06/06/22 service plan, 05/23/22 through 08/30/22 progress notes, incident investigations, and physician communications were completed.

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

* Left heel blister; and

* Fall with head strike and bruising.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including vascular dementia.

Review of the resident's 07/23/22 service plan, 07/23/22 through 08/29/22 progress notes, temporary service plans, MARs, incident investigations, and skin monitoring sheets revealed the following:

a. Two progress notes dated 08/09/22 indicated the resident's right thumbnail was "red, inflamed, infected" with "yellowish fluid under skin."

b. Skin logs completed on 07/23/22, the date of move-in, indicated the resident had a bruise on his/her mid-back and redness on the inside of his/her left leg. Skin logs completed on 08/13/22 and 08/27/22 indicated the resident continued to have redness on the back of his/her left leg.

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident when s/he experienced the short-term changes of condition or monitored the changes to resolution.

b. An 08/15/22 progress note indicated the resident fell and sustained "golf-ball sized bump on the back of [his/her] head." The resident was sent to the emergency room and returned the same day.

There was no documented evidence the facility monitored the bump on the resident's head at least weekly through resolution.

The need to determine and document what actions or interventions were needed for the resident when s/he experienced short-term changes of condition, and monitor the changes at least weekly through resolution, was discussed with Staff 3 (Memory Care Administrator/RN) on 09/01/22. She acknowledged the findings.

3. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia.

The resident's current service plan and 05/31/22 through 08/30/22 progress notes, incident reports and investigations, and interim service plans, and staff interviews were conducted.

The resident experienced the following short-term changes of condition:

* 05/31 - a "skin sheer" on his/her right shin;

* 06/25 - an unwitnessed fall with no injuries noted;

* 07/01 - return from a hospital stay;

* 08/02 - an unwitnessed fall with head strike; and

* 08/18 - a medication change.

There was no documented evidence those short-term changes were evaluated, interventions were developed and monitored for effectiveness, and/or progress was documented at least weekly through resolution.

On 09/01/22, the need to evaluate, develop actions and interventions, communicate interventions to staff, and monitor the effectiveness of the interventions, as well as documenting progress at least weekly through resolution, all short-term changes of condition was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN). They acknowledged the findings.

1) Residents #1, #3, #4: Current/Identified Change of Conditions will be documented and monitored per 24 Hour Log Book. Staff will be notified of COCs and trained on how to care for the resident with accepted interventions and how to identify any complications that may arise due to COC. Weekly progress notes will be documented by the Wellness Director.

2) The Wellness Director will be responsible for evaluating and documenting COCs. COCs will be communicated to the Wellness Team using a 24 hour log, which will also track the monitoring of COCs. Wellness Director and/or MCC will train the Team how to identify complications and what interventions should be used for COCs. The Wellness Director will monitor and document weekly findings.

3) The process being used for COCs will be evaluated initially on a monthly basis until the Administrator and Wellness Director both feel the process is working and in compliance with OAR 411-054-0040. After the initial monthly evaluations, the process will be evaluated every semester.

4) Responsible Party: Wellness Director

2. Resident 2 was admitted to the facility in 10/2021 with diagnoses including chronic pain and dementia.

Observations of the resident, interviews with staff, review of the resident's 03/23/23 service plan, 04/01/23 through 05/23/23 progress notes, interim service plans and physician communications were completed.

.

The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Behaviors including agitation with other residents;

* Missed insulin doses;

* Emotional distress over decline of sibling;

* Medication changes; and

* GI upset.

The need to ensure resident short-term changes had resident specific interventions and showed documented progress until resolved was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

3. Resident 5 was admitted to the facility in 04/2022 with diagnoses including edema.

Observations of the resident, interviews with staff and Resident 4, review of the resident's 02/20/23 service plan, 03/01/23 through 05/23/23 progress notes, interim service plans and physician communications were completed.

The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Medication changes and missed medications;

* Falls and emergency room visits;

* Circulation issue with purple feet and legs;

* Torn toe nail and pain;

* Skin issues including scabs to thigh creases;

* Genital itching; and

* Waking the resident with a sternal rub and discomfort.

The need to ensure resident short-term changes had resident specific interventions and showed documented progress until resolved was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

4. Resident 8 was admitted to the facility in 09/2020 with diagnoses including post traumatic stress disorder and dementia.

Observations of the resident, interviews with staff and Resident 4, review of the resident's 01/27/23 service plan, 03/01/23 through 05/23/23 progress notes, interim service plans and physician communications were completed.

The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Missed medications and new medications;

* Cellulitis, red perineal area, drainage from the legs;

* Resident verbal altercations;

* Increased confusion and hallucinations;

* Left elbow pain;

* Anxiety; and

* Loose stools.

The need to ensure resident short-term changes had resident specific interventions and showed documented progress until resolved was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific actions or interventions were determined, interventions were communicated to staff and conditions were monitored at least weekly to resolution for 4 of 5 sampled residents (#s 2, 5, 6 and 8) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 12/2020 with diagnoses including Alzheimer's disease.

The resident's current service plan and 03/01/2023 through 05/23/2023 progress notes, incident reports, physician communications and interim service plans were reviewed and staff interviews were conducted.

a. The resident experienced the following short-term changes of condition:

* 03/05/23: bruise on left inner wrist; and

* 03/15/2023: "open wound on left upper buttock".

There was no documented evidence the facility noted weekly progress until the conditions resolved.

b. The resident experienced the following short-term changes of condition:

* "[Y]ellow thick discharge" from his/her genitals; and

* A skin tear on the left forearm observed by survey for which no documentation existed.

There was no documented evidence actions or interventions were determined, interventions communicated to staff, and progress was documented weekly through resolution for the short term changes of condition.

The need to ensure residents who experienced short-term changes of condition were evaluated, resident-specific actions or interventions were determined, interventions were communicated to staff and conditions were monitored at least weekly to resolution was discussed with Staff 1 (Campus Administrator) and Staff 26 (Memory Care Administrator) on 05/25/23. They acknowledged the findings.

1) Residents #2, #5, #6, and #8: Current/Identified Change of Conditions will be documented and monitored per 24 Hour Log Book. Staff will be notified of COCs and trained on how to care for the resident with specifice interventions and how to identify any complications that may arise due to COC. Weekly progress notes will be documented by the Wellness Director.

2) The Wellness Director will be responsible for evaluating and documenting COCs. COCs will be communicated to the Wellness Team using a 24 hour log, which will also track the monitoring of COCs. Wellness Director and/or MCC will train the Team how to identify complications and what interventions should be used for COCs. The Wellness Director will monitor and document weekly findings.

3) The process being used for COCs will be evaluated initially on a monthly basis until the Administrator and Wellness Director both feel the process is working and in compliance with OAR 411-054-0040. After the initial monthly evaluations, the process will be evaluated every semester.

4) Responsible Party: Wellness Director

Based on interview and record review, it was determined the facility failed to evaluate changes of condition, refer to the facility RN if needed, determine and document interventions needed, and communicate the interventions to staff for 1 of 3 sampled residents (#1) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia and chronic obstructive pulmonary disease (COPD).

Review of the resident's clinical record, including progress notes dated 09/05/23 through 11/28/23, weight records dated 06/23/23 through 11/24/23, and temporary service plans was completed, and staff were interviewed.

Weight records revealed the following:

* 08/04/23 - 125.8 pounds; and

* 09/06/23 - 115.8 pounds.

The resident lost 10 pounds in 30 days, or 7.9% of his/her total body weight, which constituted a significant change of condition. There was no documented evidence this weight loss was referred to facility nursing staff for assessment.

In an interview on 11/28/23, Staff 29 (Memory Care Administrator) confirmed the resident's weight loss was not referred to the facility RN for assessment.

On 11/29/23, the need to have a system in place to evaluate changes of condition and refer changes to the facility RN when needed was discussed with Staff 29 (Memory Care Administrator), Staff 31 (Assistant Wellness Director/RCC), Staff 32 (Campus Administrator), Staff 33 (RN Consultant), Staff 34 (Operations Specialist), and Staff 35 (Regional Director of Operations). They acknowledged the findings. No additional information was provided.

See C280.

1) Daily Clinical meeting with Med-

tech, RCC, RN,ADMIN to review all medication errors, changes in condition, Weights

2) Administrator will check weights weekly to ensure there are no significant weight changes

3)Weekly compliance audit conducted by Admin and RN on documentation, weights, ECP

and Daily clinical meeting with nursing staff

4)Med-techs, RCC, RN, ADMIN all responsible for ensuring that these tasks are completed and documented in full detail.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for all residents who had significant changes of condition, with interventions communicated to staff and service plans updated for 2 of 2 sampled residents (#s 1 and 4) who experienced a significant change of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 05/2021 with diagnoses including dementia.

Review of the resident's clinical records indicated that on 07/06/22, Resident 4 was identified to have an intact blister to the left heel (pressure ulcer).

The development of the blister to the left heel constituted a significant change of condition.

There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia and COPD.

The resident's clinical record was reviewed, including progress notes dated 05/31/22 through 08/29/22, 07/01/22 through 08/31/22 MARs, interim service plans, and outside provider notes, and staff were interviewed. The following was identified:

* A progress note dated 06/25/22 indicates the resident was admitted to the hospital for hypoxia and COVID-19; and

* On 07/01/22 staff documented the resident returned to the facility from the hospital with an order to be admitted to hospice, was minimally responsive, and required a two person assist to get him/her into bed.

There was no documented evidence the RN had assessed the resident, documented findings or the resident's status, or developed interventions as a result of the assessment.

In an interview on 08/31/22, Staff 2 (Wellness Director/RN) stated she had updated the resident's service plan with hospice information but had not completed a significant change of condition assessment.

The need for an RN to assess all significant changes of condition was discussed with Staff 1 (Campus Administrator), Staff 2, and Staff 3 (Memory Care Administrator/RN). They acknowledged the findings.

1. Resident 4: Body charts will be used to document skin changes. RN will document any Significant COCs following all COC procedures and update Service Plan accordingly.

Resident 1: RN will assess residents returning from the hospital for COCs. RN will document any Significant COCs, following all COC procedures and update Service Plan accordingly.

2. RN will complete an assessment following a Significant COC and update the Care Plan accordingly. All COC procedures will be followed, including: documenting in 24 hour log, communicating to staff about interventions and things to look for, etc.

3. This process will initially be evaluated on a monthly basis until the Admin and Wellness Director both feel the processes are working and in compliance with the corresponding OARs. After the initial monthly evaluations, the process will be evaluated every semester to ensure compliance and that we are meeting the needs of the residents.

4. Responsible Party: Wellness Director

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and included documented findings, resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#6) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 12/2020 with diagnoses including Alzheimer's disease.

Resident 6's weight records were reviewed and revealed the following:

* 03/01/23 - 131.6 pounds;

* 03/15/23 - 122.4 pounds;

* 03/22/23 - 124.2 pounds;

* 04/01/23 - 128 pounds;

* 05/01/23 - 129.4 pounds; and

* 05/24/23 - 125.4 pounds (taken during the re-licensure survey).

From 03/01/23 to 03/15/23, Resident 6 had a weight loss of 9.2 pounds or 6% of his/her body weight in 14 days. This constituted a severe weight loss and indicated a significant change of condition which required an RN assessment.

On 05/24/23 at 11:35 am, an RN assessment for the significant change of condition was requested. The facility RN confirmed there was no RN assessment completed for Resident 6's severe weight loss.

The need to ensure significant changes of condition were assessed by an RN and included findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Campus Administrator) and Staff 26 (Memory Care Administrator) on 05/25/23. They acknowledged the findings, and no additional documentation was provided.

1. Resident 6: Will be weighed and charted weekly. RN will document any Significant COCs following all COC procedures and update Service Plan accordingly. RN will document any Significant COCs, following all COC procedures and update Service Plan accordingly. RN will also report any Significant COCs to primary physicians.

2. RN will complete an assessment following a Significant COC and update the Care Plan accordingly. All COC procedures will be followed, including: documenting in 24 hour log, communicating to staff about interventions and things to look for, etc.

3. This process will initially be evaluated on a monthly basis until the Admin and Wellness Director both feel the processes are working and in compliance with the corresponding OARs. After the initial monthly evaluations, the process will be evaluated every semester to ensure compliance and that we are meeting the needs of the residents.

4. Responsible Party: Wellness Director and Facility RN

Based on observation, interview, and record review, it was determined the facility failed to ensure significant changes of condition were assessed by the facility RN in a timely manner for 1 of 1 sampled resident (#1) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia and chronic obstructive pulmonary disease (COPD).

Review of the resident's clinical record, including progress notes dated 09/05/23 through 11/28/23, weight records dated 06/23/23 through 11/24/23, and temporary service plans, and staff were interviewed.

Weight records revealed the following:

* 08/04/23 - 125.8 pounds; and

* 09/06/23 - 115.8 pounds.

The resident lost 10 pounds in 30 days, or 7.9% of his/her total body weight, which constituted a significant change of condition. A significant change of condition assessment was noted in the progress notes on 11/09/23.

In an interview on 11/28/23, Staff 29 (Memory Care Administrator) confirmed an RN assessment was not completed until two months after the resident's severe weight loss.

Progress notes revealed Staff 29 had contacted the resident's family and physician on 10/17/23 and had implemented interventions, including providing supplemental health shakes three times a day, weekly weights, and meal intake monitoring. Weight records indicated the resident had gained weight since 09/06/23. Observations on 11/28/23 revealed the resident ate 100% of breakfast and lunch.

On 11/29/23, the need to have a system in place to evaluate changes of condition and refer changes to the facility RN when needed was discussed with Staff 29 (Memory Care Administrator), Staff 31 (Assistant Wellness Director/RCC), Staff 32 (Campus Administrator), Staff 33 (RN Consultant), Staff 34 (Operations Specialist), and Staff 35 (Regional Director of Operations). They acknowledged the findings. No additional information was provided.

1) All weights reviewed for the month of December by RCC and RN. RN to complete all significant changes of condition within 48 hours of review. Interventions implemented utilizing a TSP and alert charting per RN assessment.

2) Retrain all care staff on difference between short-term change of condition versus significant change of condition utilizing the DHS interpretive guidelines.  Also provide education as to when the RN should be notified of any change of condition.

3)Daily Clinical meetings

4) Med techs, Rcc, RN, Admin

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.

During the acuity interview on 08/30/22, Resident 2 was identified to be administered insulin injections daily by non-licensed staff.

a. Resident 2's MARs, reviewed from 08/01/22 through 08/30/22, revealed insulin had been given by Staff 21 (MT/CG) and Staff 22 (MT/CG) on multiple occasions.

The initial delegation for Staff 21, completed 03/28/22, and for Staff 22, completed 04/19/22, lacked documentation in the following areas:

* A nursing assessment to determine if the resident's condition was stable and predictable;

* Rationale that the task could be safety delegated to the CG;

* That the delegated task was client-specific and not transferable;

* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; and

* That the RN takes responsibility for delegating task and ensures supervision will occur for as long as the RN is supervising performance.

Additionally, there was no documentation that Staff 2 (Wellness Director/RN) re-evaluated Staff 21 within 60 days of the initial delegation, and no RN assessment to determine Resident 2 remained stable and predicable prior to completing the re-evaluation of the delegation for Staff 22 on 06/03/22.

b. There were four delegated staff who Staff 2 reported were no longer employed at the facility. There was no documentation the delegations were rescinded when the staff left employment at the facility.

On 08/31/22, Staff 2 presented a plan which included only the RN's were to administer insulin to residents receiving insulin injections until all staff delegations were reviewed and completed according to the OSBN Division 47 Administrative rules.

The need to ensure staff who administered insulin injections were delegated, re-evaluated, and delegation rescinded in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Campus Administrator), Staff 2, and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings. No further information was provided.

1. Resident 2: An assessment of the Resident's stability will be performed by the RN to ensure that the task can be safely delegated to non-licensed staff. The RN will reassess the Resident's stability according to regulations. RN will train, delegate, and supervise non-licensed staff to ensure the safety of the Resident. All documentation will be appopriately documented to show compliance to OAR 411-054-0045.

2. An assessment of the Resident's stability will be performed by the RN to ensure that the task can be safely delegated to non-licensed staff. The RN will reassess the Resident's stability according to regulations. RN will train, delegate, and supervise non-licensed staff to ensure the safety of the Resident. All documentation will be appopriately documented to show compliance to OAR 411-054-0045. Delegation will be rescinded for staff who are no longer delegated.

3. This process will be evaluated during every Delegation Assessment and quarterly to ensure compliance.

4. Responsible Party: Wellness Director

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.

During the acuity interview on 05/23/23, Resident 2 was identified to be administered an insulin injection once daily by non-licensed staff.

a. Resident 2's MARs, reviewed from 04/01/23 through 05/23/23, revealed insulin had been given by Staff 13 (MT/CG), Staff 21 (MT/CG) and Staff 24 (MT/CG) on multiple occasions.

The initial delegation for Staff 13, completed 05/17/23; Staff 21, completed 05/17/23, and Staff 24, completed 04/19/23 lacked documentation in the following areas:

* A current nursing assessment to determine if the resident's condition was stable and predictable;

* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; and

* How frequently the staff should be supervised and reevaluated by the RN, including rationale for the frequency; and

* That the RN takes responsibility for delegating task and ensures supervision will occur for as long as the RN is supervising performance.

Additionally, the delegation for Staff 13 and Staff 21 indicated both were completed on 05/17/23 when the resident only received one injection per day.

The reevaluation dates for the staff were documented as 180 days for Staff 13 and Staff 24 and 90 days for Staff 21.

In interviews on 05/23/23, 05/24/23 and 05/25/23, Staff 30 (RN) was asked to update the reevaluation dates for the staff to reflect a 60 day timeframe from initial delegation. The update to the dates would put the staff delegation reevaluation in June for Staff 24 and July for Staff 13 and Staff 21. Staff 30 (RN) provided no documentation that the updates were made as requested.

b. Resident 2 received a weekly injection of Ozempic for his/her diabetes.

Resident 2's MARs, reviewed from 04/01/23 through 05/23/23, revealed insulin had been given by unlicensed staff on seven occasions.

Review of the delegation binder showed no documentation delegations were completed for any staff related to the Ozempic injection.

In an interview on 05/23/23, Staff 30 (RN) indicated she was unaware the resident was on the Ozempic injection and that it required delegation. On 05/23/23 and 05/24/23, Staff 30 was asked to provide a plan for administration of the resident's weekly Ozempic injection while getting unlicensed staff delegated.

On 05/25/23, Staff 1 (Campus Administrator) provided a plan which indicated facility LPN staff would administer the weekly injections until unlicensed staff were delegated over the next two months according to the OSBN Division 47 Administrative rules.

The need to ensure staff who administered insulin injections were delegated and re-evaluated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator) and Staff 30 (RN) on 05/25/23. They acknowledged the findings. No further information was provided.

1. Resident 2: An assessment of the Resident's stability will be performed by the RN to ensure that the task can be safely delegated to non-licensed staff. The RN will reassess the Resident's stability according to regulations. RN will train, delegate, and supervise non-licensed staff to ensure the safety of the Resident. All documentation will be appopriately documented to show compliance to OAR 411-054-0045.

2. An assessment of the Resident's stability will be performed by the RN to ensure that the task can be safely delegated to non-licensed staff. The RN will reassess the Resident's stability according to regulations. RN will train, delegate, and supervise non-licensed staff to ensure the safety of the Resident. All documentation will be appopriately documented to show compliance to OAR 411-054-0045. Delegation will be rescinded for staff who are no longer delegated.

3. This process will be evaluated during every Delegation Assessment and quarterly to ensure compliance.

4. Responsible Party: Wellness Director and Facility RN

Based on interview and record review, it was determined the facility failed to ensure recommendations made by outside providers were implemented, communicated to staff, and the service plan updated for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia and chronic obstructive pulmonary disease (COPD).

The resident's clinical record, including outside provider notes dated 07/02/22 through 08/25/22, the current service plan, interim service plans, and the 07/01/22 through 08/31/22 MARs were reviewed.

The resident was hospitalized on 06/25/22 and diagnosed with hypoxia (lack of oxygen) and COVID-19. S/he returned to the facility on 07/01/22 with an order for hospice, who admitted him/her on 07/02/22. The following recommendations for ordered medications were noted:

* On 07/05/22, the hospice RN recommended administering 0.5 tab of the 1 mg Ativan "at dinner time x 1 wk [sic] to see if it helps" with agitation;

* A note dated 07/08/22 recommended administering "MOM today and if ineffective administer suppository on 07/09/22"; and

* On 08/25/22 instructions were left on when to use the concentrator and not the oxygen tanks.

There was no documented evidence those recommendations were implemented, interventions were communicated to staff, or the service plan updated with the changes.

Coordination of care and following up on recommendations from outside providers was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

1. Resident 1: All recommendations from Outside Agency will be reviewed by RN and implemented if found to be in agreeance with the wishes of the Resident and/or Resident Representative and PCP. The review, findings, and decision will be documented and added to the Care Plan accordingly. Instructions and interventions will be communicated to staff.

2. All recommendations from Outside Agency will be reviewed by RN and implemented if found to be in agreeance with the wishes of the Resident and/or Resident Representative and PCP. The review, findings, and decision will be documented and added to the Care Plan accordingly. Instructions and interventions will be communicated to staff.

3. This Process will be evaluated quarterly to ensure compliance.

4. Responsible Party: Wellness Director

Based on observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers, ensure outside providers left written information in the facility that addressed on-site services being provided, and reviewed and updated the resident's service plan with new interventions, for 1 of 1 sampled resident (#8) who received home health services. This is a repeat citation. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2020 with diagnoses including dementia and leg wounds.   

During the acuity interview on 05/23/23, Resident 2 was identified as receiving outside provider services related to wound care nursing services.  

Observations of the resident, interviews with staff, review of the service plan dated 01/27/23, progress notes and outside provider notes dated 02/08/23 through 05/22/23 were completed. The resident's lower extremities had varying levels of edema from moderate to significant, drainage was noted intermittently, and the resident was started on an antibiotic for cellulitis.

Facility documentation was unclear when the resident started, stopped and restarted nursing services and wound treatment from the outside agency.

Recommendations from the outside provider included the following:

*  A nursing visit note dated 02/15/23 indicated the resident had some flaking skin on the lower left extremity, no open skin or signs of infection were noted. Recommendation to gently wipe both legs with dry wash cloth to exfoliate flaky skin off at next shower.

* A Registered Dietitian visit note dated 03/22/23 indicated staff were to encourage the resident to consume three meals and one snack daily with at least 75% intake, consume Ensure Plus health shakes twice a day with at least 75% intake over the next one to two months.

* A nursing visit note signed by the nurse practitioner and dated 05/08/23 indicated staff were to repeatedly advise the resident to elevate his/her legs, wear compression stocking in the morning until bedtime and to sleep at night in his/her bed. The facility was to add Cephalaxin 250 mg (antibiotic) one tablet four times a day for seven days and acetaminophen 500 mg scheduled three times a day.

The resident's antibiotic was not started until 05/17/23.

There was no indication the remaining recommendations were communicated with staff and implemented.

In an interview on 05/25/23, Staff 26 indicated she requested additional notes and documentation for the resident's outside provider visits. The documentation provided was all the information the facility had. Staff 26 had not received any additional documentation of visits as of survey exit.

The need to ensure on-going coordination of care recommendations were implemented was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

1. Resident 2: All recommendations from Outside Agency will be reviewed by RN and implemented if found to be in agreeance with the wishes of the Resident and/or Resident Representative and PCP. The review, findings, and decision will be documented and added to the Care Plan accordingly. Instructions and interventions will be communicated to staff. Memory Care Staff will ensure Outside Agency Forms are completed with every Outside Agency visit.

2. All recommendations from Outside Agency will be reviewed by RN and implemented if found to be in agreeance with the wishes of the Resident and/or Resident Representative and PCP. The review, findings, and decision will be documented and added to the Care Plan accordingly. Instructions and interventions will be communicated to staff.

3. This Process will be evaluated quarterly to ensure compliance.

4. Responsible Party: Wellness Director, Facility RN, and Memory Care Staff

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

Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

C 282: Delegation;

C 303: Systems: Medication and Treatment Orders;

C 310: Systems: Medication Administration; and

C 330: Psychotropic Medication.

The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

1. Administrator will perform a quarterly evaluation and review of the Medication system to ensure safety and compliance.

2. Administrator will perform a quarterly evaluation and review of the Medication system to ensure safety and compliance. The following areas will be part of the evaluation: Delegation, Medication and Treatment Orders, Medication Administration, and Psychotropic Medication.

3. This process will be evaluated quarterly.

4. Responsible Party: Administrator

2. Resident 4 was admitted to the facility in 05/2021 with diagnoses including hypertension, atrial fibrillation, and diabetes.

A review of the resident's 08/01/22 through 08/30/22 MARs and physician orders revealed the following medications were being administered without a signed physician's order:

* Digoxin (heart medication);

* Docusate Sodium (stool softener);

* Jardiance (for diabetes);

* Metoprolol (for blood pressure);

* Omeprazole DR (for stomach acid);

* Rosuvastatin (for cholesterol); and

* Telmisartan (for blood pressure).

The need to have signed physician orders in the resident chart was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and all medication and treatment orders were documented in the resident's facility record for 2 of 4 sampled residents (#s 1 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia.

The resident's 07/01/22 through 08/31/22 MARs and physician orders were reviewed, and staff were interviewed. There were no physician orders in the resident's chart for the following medications on the 08/2022 MAR:

* Polyethylene Glycol OTC powder (a stool softener);

* Docusate Sodium (a stool softener); and

* Aspercream (for pain).

The resident had a 07/13/22 order for oxygen "2-4 Liter" which was not transcribed to the 07/2022 or 08/2022 MARs.

The need to have physician orders in the resident's record and to follow them as written was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

1) Resident 1 and 4: Wellness Director or MCC will review Physician's Orders and confirm the appropriate prescriptions. MAR will be updated to reflect current Physician's Oders. Signed Physician's Orders will be gathered for the appropriate medications. Parameters and Adverse Effects will be added to the MAR.

2) A Triple-Check Process will be used to ensure accuracy of MAR and Physician's Orders - Med Tech, MCC, Wellness Director. Parameters and Adverse Effects will be added to the MAR.

3) This process will be evaluated for every Medication addition/change/discontinuation for every resident - Triple Check.

4) Responsible Party: Wellness Director and Administrator

2. Resident 2 was admitted to the facility in 10/2021 with diagnoses including insulin dependent diabetes.

The resident's 03/01/23 through 05/23/23 progress notes, 12/26/22 physician orders, 03/01/23 through 05/23/23 physician communications and the 04/01/23 through 05/23/23 MAR/TAR were reviewed and showed the following:

* On 04/06/23 Tresiba 60 units, for diabetes, was not signed it was administered as ordered;

* On 04/11/23 Letrozole 2.5 mg, for hormone therapy, was not signed it was administered as ordered; and

* On 04/12/23 Tresiba 55 units, for diabetes, was not signed it was administered as ordered.

The need to ensure the facility administered all medications as ordered by the physician was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

3. Resident 8 was admitted to the facility in 09/2020 with diagnoses including dementia.

The resident's 03/01/23 through 05/23/23 progress notes, 05/24/23 physician orders, 03/01/23 through 05/23/23 physician communications and the 04/01/23 through 05/23/23 MAR/TAR were reviewed and showed the following:

* An order for Cetirizine 5 mg tablet, give daily PRN for allergy symptoms.

The MARs reflected Cetirizine 5 mg, give daily at 8 am. The medication was signed as administered daily with one refusal noted.

* An order for Zinc Oxide 20% topical paste, apply to reddened areas twice daily and PRN for skin protection.

The MAR/TARs reflected only the PRN order. There was no documentation to show the Zinc Oxide was applied twice daily as ordered.

* An order for Amlodipine 5 mg, give daily for high blood pressure. No parameters for holding the medication were ordered.

The April MAR showed the medication was held on 04/02/23, 04/28/23 and 04/29/23 for blood pressures or pulse outside of parameters. There was no additional documentation regarding why the medication was held or orders for when to hold the medication.

The need to ensure the facility administered all medications as ordered by the physician was discussed with Staff 1 (Campus Administrator), Staff 26 (Memory Care Administrator), Staff 27 (Wellness Director/LPN), Staff 28 (Assistant Wellness Director/LPN) and Staff 30 (RN) on 05/25/23. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in residents' facility records for all medications and treatments the facility was responsible to administer and to carry out medication and treatment orders as prescribed for 3 of 4 sampled residents (#s 2, 6 and 8) whose medications and treatments were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 12/2020 with diagnoses including Alzheimer's disease.

The resident's 04/01/23 through 05/23/23 MARs and physician orders were reviewed, and staff were interviewed. There were no physician orders in the resident's chart for the following medications:

* Acetaminophen 325 mg PRN (for pain);

* Nystatin 100,000u powder (for rashes);

* Lorazepam 1 mg tab PRN (for anxiety);

* Senna-S 8.6/50 mg PRN (for constipation);

* Bisacodyl 10 mg PRN (for constipation); and

* Secura protective 10% cream (for skin breakdown).

The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record was discussed with Staff 1 (Campus Administrator) and Staff 26 (Memory Care Administrator) on 05/25/23. They acknowledged the findings.

1) Resident 2, 6, and 8: Wellness Director or MCC will review Physician's Orders and confirm the appropriate prescriptions. MAR will be updated to reflect current Physician's Oders. Physician's Orders will be stored in residents' facility records for all medications and treatments. Med Tech will ensure proper documentation for medications and treatments given as ordered by the physician.

2) A Triple-Check Process will be used to ensure accuracy of MAR and Physician's Orders,  - Med Tech, MCC, Wellness Director. All medications and treatments must be documented given or not given prior to shift end. When a medication or treatment is refused or not given, proper documentation will show why medication or treatment is refused or not given.

3) This process will be evaluated for every Medication addition/change/discontinuation for every resident - Triple Check. Residents' facility records will be evaluated quartarly.

4) Responsible Party: Wellness Director and Administrator

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident-specific instructions related to the adverse effects of medications as applicable, and parameters for the administration and effectiveness of PRN medications for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to:

Review of the 08/01/22 through 08/29/22 MAR for Residents 1, 2, 3, and 4 revealed there were no resident-specific instructions related to adverse side-effects of the medications listed.

The need to ensure MARs were accurate and included resident-specific instructions related to the adverse effects of medications was discussed with Staff 3 (Memory Care Administrator) on 09/01/22. She acknowledged the findings.

1) Residents 1, 2, 3, 4: Resident specific instructions, parameters, and adverse reactions will be added to the MAR for each resident.

2) MCC will go through all Resident MARs. Specific Instructions, Adverse Effects and Parameters for PRN Medications will be added to the MAR for all residents. Non-Medicinal Interventions will be documented. Reason for giving PRN will be documented as well as effects of PRN medications. Triple Check Process will be used to ensure accuracy - Med Tech, MCC, Wellness Director.

3) This process will be continually evaluated as medications are added to the MAR for each Resident. Triple Check Process - Med Tech, MCC, Wellness Director.

4) Responsible Party: Wellness Director and Administrator

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions were attempted unsuccessfully prior to the administration of PRN psychotropic medications and failed to document how the resident expressed anxiety/agitation/aggression for 2 of 3 sampled residents (#s 1 and 3). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 07/2022 with diagnoses including vascular dementia.

The resident's current physician orders included alprazolam .25 mg PRN for anxiety, agitation, and aggression. Alprazolam was administered seven times between 08/01/22 and 08/30/22. There was no description of how the resident expressed anxiety/agitation/aggression, and no documentation non-pharmacological interventions were identified or attempted prior to administration of the medication.

The need to communicate how the resident expressed anxiety/agitation to staff and implement and document non-drug interventions prior to administering psychotropic medications was discussed with Staff 2 (Wellness Director/RN) on 08/30/22. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia.

A review of the resident's 07/01/22 through 08/31/22 MARs and physician orders revealed the following:

* The resident had a physician order for lorazepam (a psychotropic medication) 1 mg tab, 0.5 - 1 tablet by mouth or sublingually every four hours as needed for anxiety/agitation/nausea; and

* Between 07/01/22 and 08/31/22 lorazepam was administered to the resident a total of 75 times. There were no resident-specific parameters instructing staff when to administer 0.5 mg versus 1 mg or describing how the resident exhibited anxiety and agitation.

The need to include resident-specific parameters on the MAR for PRN psychotropic medication was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

1) Residents 1 and 3: Med Techs will be trained on proper procedures, non-drug interventions and how to use them. A description of how the resident is expressing potential need for PRN will be documented. Non-drug interventions used will also be documented. These steps will take place before the use of psychotropic medications. Parameters will be added to the MAR.

2) For each resident prescribed PRN psychotropics, Med Techs will be trained on proper procedures, non-drug interventions and how to use them. A description of how the resident is expressing the potential need for the prescribed medication will be documented. Non-drug interventions used will also be documented. These steps will take place before the use of psychotropic medications. Parameters will be added to the MAR.

3) This process will be evaluated during the initial order of PRN psychotropics and quarterly for each resident who is prescribed PRN psychotropics.

4) Responsible Party: Wellness Director and Administrator

Based on interview and record review, it was determined the facility failed to ensure a device with potentially restraining qualities had been assessed by an RN, PT, or OT for 1 of 1 sampled resident (#1) who had side rails. Findings include, but are not limited to:

Resident 1 was identified during the acuity interview on 08/30/22 to have side rails on his/her bed. The resident's clinical record was reviewed, and staff were interviewed.

There was no documented evidence an assessment had been completed by an RN, PT, or OT to determine if the side rails were a restraining device for the resident.

In interviews with Staff 2 (Wellness Director/RN) and Staff 3 (Memory Care Administrator/RN) on 08/31/22, both confirmed an assessment of the side rails had not been completed.

The need for an RN, PT, or OT to assess all devices with potentially restraining qualities was discussed with Staff 1 (Campus Administrator), Staff 2, and Staff 3 on 09/01/22. They acknowledged the findings.

1) Resident 1: A bed rail assessment will be completed immediately by the Wellness Director and will be added to the Resident's Care Plan.

2) Upon receiving an order for use of supportive devices with restraining qualities from either PCP, Hospice, or Home Health, the Wellness Director will perform an assessment pertaining to the use of the device per the individual needs. The assessment will be documented and the Resident's Care Plan will be adjusted accordingly.

3) This process will be evaluated for each instance and quarterly to make sure compliance is maintained.

4) Responsible Party: Wellness Director

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 14 and 18) completed First Aid and abdominal thrust training within the first 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/29/22.

There was no documented evidence Staff 14 (CG) and Staff 18 (CG) completed First Aid and abdominal thrust training within the first 30 days of hire.

The need to complete all training within the specified time frames was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (MCC Administrator/RN) on 09/01/22. They acknowledged the findings.

1) Staff 14 and 18: First Aid and Abdominal Thrust training will be given and documented immediately.

2) Competency/Skills Checks will be completed and signed during Floor Training/Orientation. The Trainer and New Hire will both sign off on all skills, including all state requirements. This includes First Aid and Abdominal Thrust Training.The New Hire will not be allowed to work the floor alone until all skills have been signed off.

3) This process will be evaluated for each New Hire and quarterly to ensure compliance.

4) Responsible Party: Administrator

Based on interview and record review, it was determined the facility failed to conduct fire drills and to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 08/30/22 with Staff 7 (Maintenance Director) and Staff 8 (Assistant Maintenance Director) identified the following:

* There was no documented evidence fire drills were conducted every other month, as required; and

* There was no documented evidence fire and life safety instruction was provided to staff on alternating months.

On 09/01/22 the need to conduct regular fire drills and to provide fire and life safety instruction to staff in accordance with the OFC, was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN) and Staff 3 (Memory Care Administrator/RN). They acknowledged the findings.

1. Fire Drills and Fire Training have been scheduled for the months of September and October. They will be performed on alternating months thereafter. Documentation will be kept in the appropriate places.

2. Fire Drills and Fire Training will be scheduled to alternate every other month. Fire Drills will be documented using forms provided by the Oregon Fire Marshall. Fire/Life Safety Trainings will be chosen from a list provided by the Oregon Fire Marshall that is specific to Assisted Living. Trainings will be documented using forms provided by the Oregon Fire Marshall. Administrator and Maintenance Director will coordinate drills to be performed on different work shifts using different routes and scenarios. Documentation for Drills and Training will be kept in the Fire/Life Safety Log, Employee Files, and Admin Master Binder.

3. This process will be evaluated quarterly to ensure compliance.

4. Responsible Party: Maintenance Director and Administrator

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

Fire drill records from 02/2022 through 08/2022 were reviewed on 08/30/22 with Staff 7 (Maintenance Director) and Staff 8 (Assistance Maintenance Director). The facility lacked documentation of the following required elements:

* Evidence residents were being instructed on fire and life safety procedures, including designated meeting places inside or outside of the building in the event of an actual fire, within 24 hours of admission and re-instructed at least annually.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN) and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

1. Fire/Life Safety Training for Current Residents will be held on an individual basis to catch up on compliance. For Residents who do not have the capacity to understand, POAs will be given the Fire Training curriculum. Documentation of the training will be kept in Resident Files, Fire/Life Safety Binder, and Admin Master Binder.

2. Fire/Life Safety Training will take place during Contract Signing or on the date of Move-In. Community is developing a video that will walk Residents through procedures, routes, and scenarios. Residents and/or Representatives will then be able to ask questions. Annual Training will take place on an individual basis on or before Resident's Anniversary date. Resident and Trainer will document the Training, which will be kept in Resident Files, Fire/Life Safety Binder, and Admin Binder.

3. This process will be evaluated during every training and once a semester to ensure compliance.

4. Responsible Party: Maintenance Director and Administrator

Based on 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 C270 and C280.

Refer to C270 and C280.

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

During a tour of the environment on 08/31/22, multiple drop-offs of up to three inches from the concrete to the planting surface were observed along the courtyard pathway edges.

The need to ensure facility pathways did not have drop-offs which posed a potential safety risk for residents was discussed with Staff 3 (Memory Care Administrator/RN) on 08/31/22. She acknowledged the findings.

1. To date, an estimate has been received by Landscapers to bring the Bark Mulch level with Walking Paths. A date will be scheduled for this maintenance ASAP, but at a minimum before compliance deadline.

2. Paths will be inspected by Maintenance Director and Administrator regularly during "rainy season" and at a minimum of quarterly to ensure compliance. Maintenance Director will perform necessary maintenance to ensure compliance. If more bark mulch needs to be added, landscapers will be notified and necessary work will be completed.

3. This process will be evaluated regularly during "rainy season" and at a minimum of quarterly to ensure compliance.

4. Responsible Party: Maintenance Director and Administrator

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

Refer to C 160, C 242, C 372, C 420, C 422, and C 510.

1) A licensed Administrator will be specifically assigned to Memory Care to regularly evaluate processes to ensure compliance.

2) A licensed Administrator will be specifically assigned to Memory Care to regularly evaluate processes to ensure compliance. Required documentation has been submitted to approve MC Administrator as of 09/23/2022.

3) Different areas will be evaluated according to a schedule. Different areas will be evaluated: ongoing, monthly, quarterly, by semester; depending upon area of concern.

4) Responsible Party: Administrator

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

Refer to C160 and C242.

1) Licensed Administrator will regularly evaluate processes to ensure compliance. A Memory Care Life Enrichment Director will be hired and assigned to ensure a daily activity program

2) Licensed Administrator will regularly evaluate processes to ensure compliance.

3) Different areas will be evaluated according to a schedule. Different areas will be evaluated: ongoing, monthly, quarterly, by semester; depending upon area of concern.

4) Responsible Party: Administrator

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 11, 14, 16, and 18) completed all pre-service orientation topics, 2 of 4 newly hired staff (#s 11 and 18) completed pre-service dementia training, 2 of 4 newly hired staff (#s 16 and 18) demonstrated competency in all assigned job duties within 30 days of hire, and 2 of 2 long-term staff completed a total of 16 hours of annual training. Findings include, but are not limited to:

Staff training records were reviewed on 08/29/22. The following was identified:

1. There was no documented evidence Staff 11 (CG), Staff 14 (CG), Staff 16 (CG), or Staff 18 (CG), hired 07/05/22, 07/25/22, 07/01/22, and 05/31/22, respectively, completed one or more of the following pre-service orientation topics:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures; and

* Signed job description.

2. There was no documented evidence Staff 11 or Staff 18 completed all required pre-service dementia training.

3. There was no documented evidence Staff 16 or Staff 18 demonstrated competency within 30 days of hire in one or more of the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

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

* General food safety, serving, and sanitation.

4. There was no documented evidence Staff 13 (MT/CG) or Staff 15 (MT/CG), both hired 07/27/20, completed the required 16 hours of annual in-service training, to include at least six hours of dementia care training.

The need for new and long-term staff to complete all required training in the specified time frames was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (MCC Administrator) on 09/01/22. They acknowledged the findings.

1) Staff 11,14,16,18: All have completed Pre Service Orientation and it is documented.

Staff 11 and 18: Both have completed Pre Service Dementia Training and it is documented.

Staff 16 and 18: Both have completed Competency/Skills Checks.

Staff 13 and 15: Both are working on completing the required training using Oregon Care Partners.

2) We are developing a better Master List that will track training. All training Certificates will be kept in triplicate - Employee Files, Training Binder, and Admin Master Binder. The Master List includes employee hire date to ensure compliance with yearly CEUs.

3) This process will be evaluated quarterly to ensure compliance.

4) Responsible Party: Administrator

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

Refer to C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 303, C 310, C 330, and C 340.

1) A licensed Administrator will be specifically assigned to Memory Care to regularly evaluate processes to ensure compliance.

2) A licensed Administrator will be specifically assigned to Memory Care to regularly evaluate processes to ensure compliance.

3) Different areas will be evaluated according to a schedule: ongoing, monthly, quarterly, by semester; depending upon area of concern.

4) Responsible Party: Administrator

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

Refer to C252, C260, C270, C280, C282, C290 and C303.

1) Licensed Administrator will regularly evaluate processes to ensure compliance.

2) Licensed Administrator will regularly evaluate processes to ensure compliance.

3) Different areas will be evaluated according to a schedule: ongoing, monthly, quarterly, by semester; depending upon area of concern.

4) Responsible Party: Administrator

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 C270 and C280.

Refer to C270 and C280

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

Resident 1, 2, and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN) on 09/01/22. They acknowledged the findings.

1) Residents 1,2,3: Care Plans will include individualized information on nutrition and hydration needs.

2) Care Plans are being updated to include individuaized information on nutrition and hydration needs. Nutrition and hydration times will be scheduled alongside of regular dining times to ensure proper nutrition and hydration are maintained.

3) This process will be evaluated quarterly to ensure compliance.

4) Responsible Party: Administrator

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

Residents 1, 2, 3, and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and individualized activity plans developed including:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate in activities; and

* Identified activities for behavior interventions.

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

On 09/01/22, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (Campus Administrator), Staff 2 (Wellness Director/RN), and Staff 3 (Memory Care Administrator/RN). The staff acknowledged the findings.

1) Residents 1,2,3,4: Residents will be evaluated using the MC Activities Evaluation Form to evaluate abilities, emotional/social needs, limitations, participation, and interventions for behaviors. This will be documented and added to the Care Plan accordingly.

2) We have hired a new MC Life Enrichment Director. She will be documenting the interests and participation of our MC Residents for activities. She will be using an Activities Evaluation Form to evaluate each resident's needs, personal interests, and abilities to plan her monthly Activities Calendar.

3) This area will be evaluated quarterly to make sure Evaluations are being performed and Residents are actively participating.

4) Responsible Party: MC Life Enrichment Director and Administrator  

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

Resident 3 was admitted to the facility in 07/2022 with diagnoses including vascular dementia.

Review of the 07/23/22 service plan, 07/23/22 through 08/30/22 progress notes, and interviews with staff revealed Resident 3 exhibited behaviors on multiple occasions which included yelling, cursing, hitting objects in the environment with a cane, and resisting care with ADLs. There was no documented evidence a plan to address the resident's behavior was included in the service plan.

Staff 10 (CG) reported Resident 3 got very upset when s/he thought other residents needed help.   

Staff 15 (MT/CG) stated Resident 3 recently got very upset and started yelling during a meal time when the resident seated next to him/her put a piece of a grilled cheese sandwich in their soup. Resident 3 started yelling for staff to come assist the resident. Staff checked on the other resident, who indicated they did not need assistance.

Resident 3's lack of behavioral service plan interventions and behaviors were discussed with Staff 3 (Memory Care Administrator/RN) on 09/01/22. She acknowledged the findings.

1) Resident 3: A behavior plan is being developed and a outside consultation will be coordinated if applicable. Wellness Director and MC Administrator will evaluate and add behavioral interventions to the Care Plan.

2) Behavioral evaluations and Service Plans will be completed for all residents exhibiting disruptive or harmful behaviors. Outside consultation will be coordinated if applicable. Wellness Director, Administator, and MCC will add behavioral interventions to the Care Plan for those Residents for whom it is required.

3) This process will be evaluated quarterly to ensure compliance.

4) Responsible Party: Wellness Director and Administrator

Based on observation and interview, it was determined the facility failed to ensure residents had access to a secure outdoor area which allowed them to enter and return without staff assistance. Findings include, but are not limited to:

During a tour of the environment on 08/31/22, the three doors that led to the secure outdoor courtyard were locked.

In an interview with Staff 15 (MT/CG), conducted the same day, she reported the courtyard doors were always locked unless a resident asked to go outside. Staff 3 (Memory Care Administrator/RN) confirmed Staff 15's comments to the Surveyor.

The need to ensure residents had access to the secure outdoor space without staff assistance was discussed with Staff 3 on 08/31/22. She acknowledged the findings.

1) Doors to the Courtyard will be unlocked during waking hours. The only times they will be locked are during sleeping hours and times of extreme weather that pose a safety risk to Residents.

2) The automated system that controls the locking mechanism for the doors to the courtyard will be be configured to allow Resident Access during waking hours.

3) This process will be evaluated quarterly and during times of extreme weather.

4) Responsible Party: Administrator