Print Inspection: ZNSJ

The findings of the re-licensure survey, conducted 03/18/24 through 03/26/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/26/24, conducted 07/08/24 through 07/11/24, are documented in this report. The survey was conducted to determine compliance with 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 the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:           Medication Aide

MAR:Medication Administration Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:          Resident Care Coordinator

RN:         Registered Nurse

TAR:         Treatment Administration Record

tid:          three times a day

The findings of the second revisit to the re-licensure survey of 03/26/24, conducted 11/13/24 through 11/14/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

During the re-licensure survey, conducted 03/18/24 through 03/26/24, administrative oversight to ensure adequate care and services rendered in the facility was found to be ineffective.

Refer to deficiencies in report.

2. On 03/20/24, the surveyor entered the dining room 8:50 am. There were seventeen residents in the room, with only one staff member present. The CG was assisting one resident with eating, while all others were left unattended. Several residents were observed in undignified positions, such as sitting with food on face or clothes, or slumped over the table, resting. Also observed, were repeated disruptive behaviors, such as striking silverware on a plate loudly, with no staff intervention.

On 03/26/24, the need to ensure residents were treated with dignity and respect while in the dining room, was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents were treated with dignity and respect and had a homelike environment for multiple unsampled residents. Findings include, but are not limited to:

1. On 3/20/24 and 3/25/24 during lunch service, an unsampled resident was observed walking up to multiple unsampled residents seated in the assisted dining room, and consuming their food and beverages.

In an interview on 3/20/24, Witness 1 (Family Member), reported s/he visits daily during mealtime and observed the behavior every day.

The need to ensure residents were treated with dignity and respect, including not having their food and beverages taken and eaten by other residents, was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to consistently provide a daily program of social and recreational activities based upon individual and group interests and physical, mental, and psychosocial needs. Findings include, but are not limited to:

During the survey, many residents in the community were observed in common areas, siting in chairs and wheel chairs, or wandering the halls. On 03/18/24 and 03/19/24 the survey team did not observe staff  initiating any organized activities for the residents.

On 03/19/24 at 10:10 am an unsampled resident sitting in a hallway in a wheelchair said to a surveyor, "I don't know where to go. I don't know what's going on." At 10:11 a CG approached nearby and the surveyor told the CG that the resident was looking for something to do. The CG kneeled in front of the resident, looked at his/her watch, and stated, "Well, we're going to be having lunch in an hour and a half and there's really not much going on. People are just wandering around right now. Would you like a cup of hot chocolate?"  

Review of the MCC activity calendar indicated the scheduled activities for 03/19/24 were:

* 10:00 am - Cocoa and Coffee bar;

* 11:00 am - The Matchgames;

* 1:00 pm - Bingo;

* 2:30 pm - Food from Denmark; and

* 3:30 pm - Scramble Games.

The survey team did not observe these activities occur as scheduled between 10:00 am and 3:30 pm.

In an interview on 03/20/24, Staff 7 (Life Enrichment Manager) stated there were at least two days per week when he was off work, and there was currently no assistant activity person to cover those days.

On 03/26/24, the need to ensure the facility provided a daily program of social and recreational activities for residents was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of current care needs and provided clear direction to staff for 3 of 6 sampled residents (#s 15, 17 and 18) who required 2-3 person transfers. Findings include, but are not limited to:

1. Resident 15 was admitted to the facility in 02/2024, with diagnoses including hypertension and dementia. The resident's service plan documented Resident 15 "transfers on [his/her] own and ambulates on [his/her] own".

2. Resident 17 was admitted to the facility in 05/2024, with diagnoses including dementia. The resident's service plan documented the resident "is a one person transfer assist to standing position on weak days".

3. Resident 18 was admitted to the facility in 11/2023, with diagnoses including atrial fibrillation and dementia. The resident's service plan identified him/her as "a one person assist to standing position".

In separate interviews on 07/11/24, Staff 20 (CG), Staff 22 (CG), and Staff 25 (CG) each identified Residents 15, 17, and 18 as requiring three person transfer assistance.

On 07/11/24, the need to ensure service plans were reflective of resident care needs and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), and Staff 31 (Operations). They acknowledged the service plans were not reflective of resident care needs, regarding transfers.

1. Resident 15, 17 and 18 all had service plan updates to reflect current transfer ability. 2. Audit of all Resident Service Plans will be completed to review accuracy. All updates will be made in an ISP for each individual resident and will be updated on service plan during next quarterly review. Willamette Springs has implemented a new form for care givers to fill out prior to quarterly updates addressing all ADL's and any updates necessary. Staff training will be provided and documented to all staff on reporting changes and inaccuracies of service plans to clinical team immediately. Shift Huddles will include caregivers sharing any accuracies or changed needed for care/instructions to evaluations and service plans. Elderwise is assisting in auditing service plans. 3. Daily, weekly, quarterly. 4.Executive Director, RN/LPN and Clinical Team

4. Resident 5 was admitted to the MCC in 04/2022, with diagnoses including dementia and altered mental status.

Review of Resident 5's service plan, dated 01/25/24, progress notes, dated 12/18/23 through 03/18/24, and incident reports indicated the resident was involved in nine physical resident-to-resident altercations between 12/18/23 and 03/18/23.

The service plan listed multiple interventions for managing difficult or aggressive behaviors, including, but not limited to:

* Re-direct resident away from other residents until s/he calmed down;

* Offer resident a snack;

* Offer to turn on a movie in his/her room;

* Offer to walk with resident;

* If the resident will not leave, staff should remove other residents;

* If the resident continued to escalate and be agitated, one staff member should stay with him/her while another staff member called 911 for a higher level of assistance; and

* Resident had an order for PRN quetiapine for behaviors.

There was no documented evidence the current interventions were monitored for effectiveness, and Resident 5 continued to display aggressive behaviors and initiate repeated altercations.

In an interview on 03/21/24, Staff 13 (CG) stated "We just do the best we can with [him/her], regarding conflicts with other residents. We direct [him/her] away from others when tensions arise, walk together, and offer coffee or a snack. It just depends on the day, whether these approaches work."

On 03/26/24, the need to monitor existing interventions for effectiveness and develop new interventions following additional altercations was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure interventions for changes of condition were monitored and evaluated for effectiveness for 4 of 7 sampled residents (#s 2, 4, 5, and 8) who experienced changes of condition. Resident 8 experienced severe on-going weight loss. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 02/2023 with diagnoses including dementia, depression, and anxiety. The resident moved out of the facility in 03/2024 and subsequently passed away.

The resident's clinical record, including weight records from 03/03/23 through 02/22/24, progress notes from 04/05/23 through 03/01/24, and interim service plans, was reviewed. Staff interviews were conducted. The following was identified:

* 03/03/23 - Resident weighed 190 pounds; and

* 04/04/23 - Resident weighed 176.2 pounds.

The resident lost 13.8 pounds in one month, or 7.26% of his/her total body weight. This constituted a severe weight loss. On 04/04/23 the Staff 23 (Former RN) sent a fax to the resident's primary care physician (PCP) asking if it was "okay for order for health shakes daily?" On 04/05/23 Staff 23 completed an "Evaluation for Weight Change," a significant change of condition assessment, and an interim service plan (ISP).

Staff 23's assessment indicated there were concerns about the resident's intake prior to 04/04/23 and the following interventions had been documented on the assessment as having been implemented prior to 04/05/23:

* Direct the resident to meals;

* Cut up food; and

* Place food and drink in his/her direct line of vision.

On 04/05/23 Staff 23 created an ISP which directed staff to:

* Walk the resident to the table;

* Place food and drink in direct line of vision;

* Cue the resident to eat;

* Continue cutting up food;

* Attempt to give the resident bites if s/he was not eating;

* Encourage the resident to return to the table if s/he walked away; and

* If the resident "still does not eat meal, give peanut butter and jelly sandwich, place in [his/her] hand and cue [him/her]." The ISP noted the resident liked bananas for a snack.

The assessment also noted the resident had been "somewhat sedentary" prior to moving into the facility, but since being admitted, had been spending "hours per day" walking around the facility. Staff 23 wrote the resident's spouse agreed the resident's "activity level has increased significantly over the past month." The nurse implemented weekly weights on 04/05/23.

There was no documented evidence the facility followed-up with the resident's PCP regarding an order for health shakes until 05/05/23, or evidence the additional weight loss interventions had been monitored or evaluated for effectiveness.

Between 04/12/23 and 04/27/23 the following weights were documented:

* 04/12/23 - 172.2 pounds;

* 04/21/23 - 167 pounds; and

* 04/27/23 - 165.7 pounds.

An ISP dated 04/28/23 instructed staff to encourage the resident to sit with specific residents when they were in the dining room, as s/he "tends to stay at the table and eat" when sitting with them.

There was no documented evidence staff implemented or monitored this intervention, nor was there documented evidence the intervention was evaluated for effectiveness. The resident's weight loss continued:

* 05/02/23 - 164.2 pounds; and

* 05/05/23 - 161 pounds.

On 05/05/23, a month after the first severe weight loss was noted and after a total loss of 29 pounds, Staff 23 documented the PCP was faxed a request for "approval for pro-cal TID."

There was no documented evidence the facility followed-up with the resident's PCP regarding the pro-cal health shake until 05/19/23.

Between 05/12/23 and 06/07/23 the resident continued to lose weight:

* 05/12/23 - 158.8 pounds;

* 05/19/23 - 154.8 pounds;

* 05/24/23 - 151.8 pounds;

* 06/07/23 - 144.8 pounds.

On 05/12/23 Staff 23 noted, "Food intake varies at meals. [Resident] observed being fed at some meals this week and also observed feeding self. Intake fluctuates from poor to good." Staff 23 documented, "Resident spouse reports weight loss is to be expected since resident was sedentary when living at home and is now physically active most of the day."  There was no documented evidence the resident's meal intake had been monitored.

A 05/19/23 progress note by Staff 23 indicated the resident "was observed frequently crying and reported lower back pain several times this week. PCP faxed regarding concerns."

On 05/24/23 Staff 23 documented in a progress note the resident's ". . . intake fluctuates from poor to fair. [Resident] continues to walk around facility a lot of the day." There was no documented evidence the resident's meal intake had been monitored, and no evidence previous weight loss interventions had been monitored or evaluated for effectiveness.

As of 06/07/23, the resident had lost a total of 45.2 pounds, or 23.78% of his/her total body weight.

There was no documented evidence the facility had followed up on the request from 05/05/23 for a daily health shake.

On 06/06/23 a daily health shake was prescribed by the resident's PCP, two months after the initial request from Staff 23. There was no documented evidence the facility provided high calorie meals or snacks for the resident while waiting for an order for a nutritional supplement from the PCP.

On 06/07/23 Staff 23 documented the resident had seen his/her PCP that day "for further assessment for continued weight loss, moods and follow up after UTI." Staff 23 noted she had "sent coordination note to summarize weight loss concerns, resident moods, lower back pain." Staff 23 also documented the resident's spouse reported the "PCP stated weight loss and moods were disease progression and no labs or further studies were ordered." Staff 23 documented the PCP had sent orders for "patch for lower back pain, Mirtazapine, and health shake daily."

Between 06/14/23 and 07/03/23 the resident continued to lose weight:

* 06/14/23 - 143.8 pounds;

* 06/23/23 - 141.6 pounds; and

* 07/03/23 - 140.2 pounds.

A progress note dated 06/14/23 states, "PO [oral] intake continues to vary. [Resident] has been drinking health shakes daily. Resident continues walking throughout facility most of the day and into the night."

Between 03/03/23 and 07/03/23 the resident lost a total of 49.8 pounds, or 26.21% of his/her total body weight. There was no documented evidence interventions implemented between the initial weight loss on 04/04/23 and 07/03/23 were monitored or evaluated for effectiveness.

An ISP dated 07/03/23, written by Staff 1 (Executive Director), included an existing intervention ("Staff to assist feeding [Resident] at each meal.") and directed staff to "make sure they are offering [Resident] a straw with all drinks."

On 07/06/23 the resident's PCP sent an order stating, "When patient is given [his/her] daily Ensure meal supplement, please have staff observe [him/her] and confirm that [s/he] has finished the meal." Staff 23 documented the resident's PCP had ". . . sent order to make sure resident completes Ensure daily." There was no documented evidence the facility monitored the resident's daily intake of the meal supplement, as ordered by the physician.

In an interview on 03/26/24, Staff 1 (Executive Director) and Staff 4 (LPN) both stated it was against corporate policy to monitor meal intake. A copy of the policy was requested and received on 03/26/24. The policy stated: ". . . the LN [licensed nurse] may initiate temporary meal monitoring to evaluate nutritional intake."

On 07/07/23 Staff 23 wrote an ISP directing staff to "squat down in below [him/her] (where person feeding [him/her] is about level with [his/her] chest) to feed [him/her]" when resident was sitting down for meals. There was no documented evidence this intervention was implemented, monitored, or evaluated for effectiveness.

Between 07/14/23 and 08/23/23 the resident continued to lose weight:

* 07/14/23 - 133 pounds;

* 07/21/23 - 132.4 pounds;

* 07/26/23 - 131.2 pounds;

* 08/02/23 - 130.8 pounds;

* 08/07/23 - 127.6 pounds;

* 08/15/23 - 127 pounds; and

* 08/23/23 - 124.5 pounds.

On 08/23/23, after the resident had lost a total of 65.5 pounds since 03/03/23, or 34.47% of his/her total body weight, Staff 5 (Regional RN) noted: "[Resident] requires feeding assistance and would not do well with on the go snacks" and states the PCP was faxed "to inform of further weight loss as well as request increase Ensure to BID."

Staff 5 created an ISP on 08/23/23 which included the existing intervention of re-directing the resident back to the table if s/he got up and walked away during a meal, and communicated a new intervention directing staff to provide extra butter and gravy to meals, offer peanut butter and jelly sandwich as a snack between meals each day, offer ice cream for a snack in the evening, and offer him/her a bowl of cereal with whole milk if s/he does not eat offered breakfast. Staff 5 noted she provided a copy of the ISP to the kitchen.

There was no documented evidence these interventions were implemented, monitored, or evaluated for effectiveness.

The resident lost another 0.9 pounds between 08/23/23 and 08/30/23, then had a 0.2 pound gain between 08/30/23 (123.6 pounds) and 09/07/23 (123.8 pounds).

An interim service plan dated 09/08/23 indicated the resident had a "new order for ensure [sic] supplement drink." There was no indication what the change was. Staff were directed to ". . . observe for the following and report any concern to the Med Tech or LN: (shortness of breath, nausea, constipation)."

From 09/07/23 to 09/13/23 the resident remained at 123.8 pounds, following which additional weight loss continued:

* 09/21/23 - 123 pounds;

* 09/26/23 - 123.2 pounds (a gain of 0.2 pounds);

* 10/05/23 - 117.7 pounds;

* 10/10/23 - 117.2 pounds;

* 10/19/23 - 116.1 pounds;

* 10/26/23 - 115.2 pounds;

* 11/02/23 - 113.6 pounds;

* 11/09/23 - 113.2 pounds;

* 11/15/23 - 113.2 pounds;

* 11/17/23 - 113 pounds; and

* 11/22/23 - 112.2 pounds.

On 11/27/23 the resident was admitted to hospice, and his/her weight continued to trend down:

* 12/05/23 - 111.1 pounds;

* 12/14/23 - 109.9 pounds;

* 12/21/23 - 110.2 pounds (a gain of 0.3 pounds);

* 12/27/23 - 110 pounds;

* 01/04/24 - 110.2 pounds (a gain of 0.2 pounds);

* 01/10/24 - 109.6 pounds;

* 01/26/24 - 109 pounds;

* 02/01/24 - 105.6 pounds; and

* 02/15/24 - 103.2 pounds.

From 08/23/23, when high calorie food interventions were implemented, to 02/15/24, the resident lost a total of 21.3 pounds, or 17.11% of his/her total body weight. There was no documented evidence these weight loss interventions were monitored or evaluated for effectiveness.

An ISP dated 02/16/24 written by Staff 3 (RN), then recently hired, directed staff "to provide high protein/high caloric snacks twice daily between meals and before bedtime. Offer foods such as: PB&J sandwich, ice cream, pudding, bananas, yogurt. Staff are to assist resident with eating, which may include walking with [him/her] to promote intake."

There was no documented evidence the resident was being offered additional high protein/high caloric snacks or that the intervention was being monitored or evaluated for effectiveness.

On 02/22/24 the resident's weight was documented as 105.8 pounds, a gain of 2.6 pounds, and on 03/01/24 his/her weight was recorded as 103.6 pounds.

Staff 14 (CG) was interviewed on 03/18/24 at 10:58 am. She reported the resident had to be fed because "[s/he] wouldn't feed [himself/herself]." She stated she "never had any concerns" about the resident.

In an interview on 03/26/24 at 11:15 am, Staff 19 (CG) reported she knew the resident "had lost weight, and it was being tracked." She indicated the resident was weighed weekly, was receiving health shakes, ". . . and we gave her extra snacks." When asked how the resident's consumption of meals and health shakes was recorded, she stated, "We don't normally record meal percentages, but [s/he] regularly got [his/her] shakes." Staff 19 said the resident "had difficult behaviors, and often walked until [s/he] was exhausted. Often, we couldn't get [him/her] to stay seated in the dining room to eat."

Between 03/05/24 and 03/08/24, some progress notes stated the resident was out of the facility and some progress notes indicated staff continued to monitor several changes of condition on alert charting. The resident's 03/01/24 through 03/19/24 MAR indicated s/he was administered medication "for transport" on 03/04/24.

On 03/18/24 at 12:20 pm, Staff 1 (Executive Director) and Staff 2 (Resident Services Manager) reported the resident's family moved him/her out of the facility into a "hospice house" on 03/05/24 at 8:00 pm, and s/he passed away "last week."

On 03/22/24 at 10:40 am, Staff 2 (Resident Services Manager) reported the resident's family switched the resident to a different hospice service on 03/04/24 and moved him/her to a "hospice house" at 8:00 pm.

Resident 8 experienced on-going severe weight loss for one year, losing a total of 86.4 pounds, or 45.47% of his/her total body weight. There was no documented evidence interventions to prevent ongoing weight loss were consistently implemented in a timely manner, monitored, or evaluated for effectiveness, nor was there documented evidence staff were monitoring the resident's daily intake of Ensure as ordered by the resident's PCP.

The facility's failure to monitor and evaluate weight loss interventions for effectiveness and implement new interventions when previous ones were ineffective placed the resident at risk for continued weight loss.

The facility's failure to implement weight loss interventions in a timely manner, monitor the resident consistent with his or her evaluated needs and service plan, with progress documented at least weekly, and to monitor evaluations for effectiveness was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease.

The resident's clinical record, including progress notes dated 12/18/23 through 03/17/24, interim service plans, and incident reports, was reviewed, and staff interviews were conducted.

The resident experienced the following falls:

* 02/07/24 - Non-injury fall;

* 03/11/24 - Non-injury fall; and

* 03/14/24 - Two non-injury falls.

Interim service plans which included interventions were created after each fall. There was no documented evidence the 02/07/24 fall monitoring was resolved.

A different intervention was identified on the interim service plan for each fall. However, there was no documented evidence the facility was reviewing previous interventions for effectiveness after each successive fall.

The need to determine if previously implemented interventions were effective in keeping resident's safe was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 11/2016 with diagnoses including bipolar disorder, traumatic brain injury with psychosis, and dementia.

The resident's clinical record, including progress notes dated 12/18/23 through 03/18/24, interim service plans, and incident reports, was reviewed, and staff interviews were conducted.

a. Between 01/28/24 and 03/05/24 Resident 4 was found on the floor seven times in which s/he reported intentionally climbing out of bed or wheelchair onto the floor. These were non-injury events.

Between 12/20/23 and 03/18/24 Resident 4 was found on the floor an additional 20 times, including multiple times in which the resident reported attempting to self-transfer and two times in which the resident reported "slipping" or "falling" out of his/her wheelchair. Three of the falls resulted in injury, including a red mark on resident's forehead and back and complaint of shoulder pain.

Interventions were determined and added to the resident service plan which included but were not limited to:

* "Staff to leave [Resident 4]'s door as [s/he] allows to help provide additional oversight."  

* "WS [Willamette Springs MC] to request family to order a non slip mat for [Resident 4]."

* "Staff to make sure if they see [Resident 4] going to [his/her] room after breakfast they go with [him/her] and offer to transfer [him/her] into bed."

* "Staff are to offer to help [Resident 4] into [his/her] wheelchair during checks."

* "Staff to remind [Resident 4] to use [his/her] pendant for help during checks."

* "Staff to ensure they leave [Resident 4]'s door open as [s/he] allows, so when we pass [his/her] room we can see inside if [s/he] is trying to transfer."

During the survey Resident 4's door was observed to be closed all the time when s/he was in the room.

A different intervention was identified on the interim service plan for each fall. However, there was no documented evidence the facility was reviewing previous interventions for effectiveness after each successive fall.

b. Between 12/20/23 and 03/19/23 Resident 4 experienced 18 resident-to-resident altercations with nine other residents. Eleven of the altercations were initiated by other residents. Seven of the altercations were initiated by Resident 4. None of the altercations resulted in injury to either resident.

Interventions were determined and added to the resident service plan which included but were not limited to:

* "If staff see that [Resident 4] is becoming agitated they are to ask if [s/he] would like to watch a movie in [his/her] room."

* "If staff see [Resident 4] close to other residents in the hallway, they are to redirect [her/him] to another area."

* "If staff see [Resident 4] and [unsampled resident] in the same dining room they are to offer to take [unsampled resident] or [Resident 4] to a separate one and offer a snack."

* "When staff observe residents approaching [Resident 4] closely they are to try and redirect them immediately."

* "If staff see [Resident 4] wheeling into the dining room while other residents are trying to go through at the same time they are to assist [him/her] to a table."

There was no documented evidence the facility was monitoring the resident-to-resident altercation interventions to determine if they were in place and/or continued to be effective.

On 3/19/23 at 10:16, two caregivers were observed exiting Resident 4's room with Resident 4, while two unsampled residents were sitting in their wheelchairs directly outside Resident 4's room. The two caregivers walked away and did not attempt to redirect Resident 4.

Throughout the survey multiple unsampled residents were observed approaching Resident 4 closely, and nearby staff did not redirect them immediately.

Staff 5 (Regional RN) and Staff 3 (RN) reported in an interview on 03/25/24 changes of condition were monitored weekly by the facility RN in the "Significant change of condition/Follow up on COC [change of condition] notes" in resident progress notes. They acknowledged the weekly monitoring notes for falls and resident-to-resident altercations were recaps of the events and did not contain monitoring of weekly progress.

The need for the facility to weekly monitor progress of changes of condition, including the effectiveness of interventions for falls and resident-to-resident altercations, was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3, and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment which documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#8) who experienced significant changes of condition. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 02/2023 with diagnoses including dementia, depression, and anxiety. The resident moved out of the facility in 03/2024 and subsequently passed away.

Review of the resident's clinical record, including hospice admit orders, progress notes from 04/04/23 through 03/01/24, service plan dated 11/30/23, and interim service plans (ISPs) was completed, and staff were interviewed. The following was identified:

* Resident 8 was admitted to hospice on 11/27/23.

* An ISP was created on 11/27/23 by Staff 23 (Former RN) communicating the resident had been admitted to hospice and would receive nursing and medical social worker services, as well as shower assistance. The ISP informed staff the resident had medication that could be used "for anxiety or agitation," and if they observed the resident "making laps at a rapid pace, [stating] 'I'm scared' or similar," pushing, hitting, or "aggressively" denying care, they should attempt interventions, including offering a snack, turning on music from the 1960s and 1970s and encouraging the resident to sit and listen, and trying to provide conversation while walking with the resident. If the non-pharmacological interventions were not effective, staff were directed to report to the MT so PRN psychotropic medication could be administered.

* On 11/28/23 Staff 23 documented a note labeled "Significant change of condition/Follow up on COC [change of condition] notes," which indicated the resident was admitted to hospice services. Staff 23 wrote she met with the admitting RN and the resident's spouse for an admission assessment, and she reviewed the resident's history focusing "on weight loss despite interventions and at times of fair intake [sic]." The 11/28/23 "Significant change of condition/Follow up on COC notes" documentation did not constitute an assessment which documented findings, resident status, or interventions made as a result of the assessment.

On 03/25/24 at 10:24 am, Staff 5 (Regional RN) reported the 11/28/23 RN note was a "continuation" of the ongoing weight loss significant change of condition documentation, which began on 04/04/23. She stated Staff 23 should "probably" have written she was "initiating a significant change of condition" related to going on hospice.

* The resident's service plan was updated 11/30/23. The service plan indicated the resident had been admitted to hospice. There was no information about PRN psychotropic medication being available for any resident behaviors, nor were the non-pharmacological interventions listed on the 11/27/23 ISP included. In addition, the service plan did not include that bathing would be provided by hospice.

The need for an RN to complete an assessment which documented findings, resident status, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24 at 11:00 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medications administered by the facility were set-up or poured and documented by the same person who administered the medications for 1 of 8 sampled residents (#8). Findings include, but are not limited to:

Resident 8 was admitted to the facility in 02/2023 with diagnoses including dementia, depression, and anxiety. The resident moved out of the facility in 03/2024 and subsequently passed away.

The resident's 01/01/24 through 03/19/24 MARs were reviewed, and the following was identified:

* The resident had an order for acetaminophen (for pain) 500 mg, two tablets three times per day at 8:00 am, 2:00 pm, and 8:00 pm. On 01/24/24, a MT initialed the MAR for acetaminophen being administered at 2:00 pm, with a note stating, "Given by [staff name]"; and

* The resident had an order for Phenobarbital (for agitation and aggression) 64.8 mg, one tablet three times a day at 12:00 am, 12:00 pm, and 6:00 pm. On 02/29/24 a MT initialed the MAR for Phenobarbital being administered at 12:00 am, with a note stating, "Refused-[staff name] said she refused [sic].-Administered as prescribed."

The need to ensure the same person who administered the medication to the resident documented the administration of the medication on the MAR was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to carry out physician or other legally recognized practitioner orders as prescribed for all medications and treatments the facility was responsible to administer for 2 of 7 sampled residents (#s 3 and 8) whose physician orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 12/2023 with diagnoses including diabetes.

During the acuity interview on 03/18/24, Resident 3 was identified as having insulin administered multiple times daily by unlicensed facility staff.

The resident's 02/01/24 through 03/18/24 MARs and signed physician orders were reviewed.

Resident 3 had an Insulin Aspart 100 unit/ml pen order to be administered based on their blood glucose level (CBG) at 08:00 am, 12:00 pm, and 05:00 pm daily. Sliding scale parameters were listed on the MAR as follows:

* One unit for CBG 151-201;
* Two units for CBG 202-252;
* Three units for CBG 253-303;
* Four units for CBG 304-354;
* Five units for CBG 355-400; and
* Six units for CBG above 400.

There were 28 occasions between 02/01/24 and 03/18/24 where insulin units administered were outside of CBG parameters.

On 03/19/24, in an interview with Staff 1 (Executive Director) and Staff 2 (Resident Services Manager), it was reported the facility at the time was unable to determine if Resident 3 received the correct insulin dose or if the facility had failed to follow sliding scale parameters.  A "1" is how CBG's checks were documented on the MAR as being completed. It was reported the Medication Technician had likely mistakenly placed a "1" under the insulin units, meaning the insulin was administered, but the units of insulin were not documented.

On 03/26/24, the need to ensure all medications were administered as ordered was discussed with Staff 1, Staff 2, Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

2. Resident 8 was admitted to the facility in 02/2023 with diagnoses including dementia, depression, and anxiety. The resident moved out of the facility in 03/2024 and subsequently passed away.

A review of Resident 8's 01/01/24 through 03/19/24 MARs and physician orders identified the following:

* The resident had an order dated 07/06/23 stating staff should observe the resident consuming her daily Ensure meal supplement and confirm s/he had finished the meal.

There was no documented evidence staff monitored and documented how much of each Ensure the resident consumed each day.

* There was an order for Paxlovid (to treat COVID) dated 02/18/24. The order the physician signed did not match the order transcribed onto the MAR.

There was no documented evidence the facility attempted to clarify the order with the physician.

* There was an order for a one-time dose of phenobarbital (for agitation/aggression) 32.4 mg tablet dated 02/28/24. The MAR indicates the medication was administered on 02/28/24 "per RN instruction," and was administered a second time on 02/29/24 due to "agitation."

There was no documented evidence of another PRN phenobarbital in effect on 02/29/24.

In an interview on 03/26/24 at 11:00 am, Staff 1 (Executive Director) reported the hospice RN attempted to give her a verbal phone order to administer a PRN phenobarbital on 02/29/24, but Staff 1 requested hospice speak to Staff 3 (RN). Staff 1 stated Staff 3 wrote a progress note about the phone order to administer a PRN phenobarbital on 02/29/24.

There was no documented evidence of a hospice order for a PRN phenobarbital administration on 02/29/24.

* There was an order for hydromorphone (for pain) 1 mg tab, one tab four times per day at 12:00 am, 6:00 am, 12:00 pm, and 6:00 pm. An order dated 03/04/24 states "ok to give patient's 6 PM hydromorphone." The 03/2023 MAR indicated the medication was not administered to the resident at 6:00 pm. A note on the MAR indicated: Med on hold-per provider orders."

The need to carry out physician orders as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings. No additional information was provided.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents, and failed to indicate on the Acuity Based Staffing Tool (ABST) sufficient staff time needed to provide care. Findings include, but are not limited to:

During the entrance conference on 03/18/24 the following was identified:

* The memory care community was home to 67 residents at the time of the re-licensure survey. The facility was constructed as one large loop consisting of two long corridors and two short connecting corridors.

* Eight residents needed two-person assistance with transfers for all or part of their care.

* Three additional residents were identified as heavy care, needing assistance with all or most of their care.

* The facility had 11 residents who had been involved in resident-to-resident altercations in the last three months.

1. On 03/19/24 observations in the unassisted dining room during lunch service identified the following:

* An unsampled resident was observed using a straw to attempt to scoop food off of his/her plate. The resident then poured his/her chocolate milk over the plate of food, and began to stir the food/milk mixture with the straw. A family member arrived, removed the plate of food, and requested a new plate of food from the kitchen staff. After the second lunch arrived, the resident ate the majority of his/her lunch, with one-to-one assistance from the family member.

* Another unsampled resident was observed slouched down in his/her chair with a cup of coffee and goblet of water placed in front of him/her, and his/her plate of uneaten food placed behind the cups, out of reach on the back edge of the placemat. The resident had gotten up and started to walk away when a kitchen staff member placed a dessert on the place mat. The resident took one bite of the cake before exiting the dining room.

There were no caregiving staff in the dining room during the meal.

Staff 14 reported on 03/20/24 that the residents in the unassisted dining room are those who don't need assistance with meals.

2. On 3/20/24 at 11:02 am Resident 4 asked a caregiver to change his/her pants because they had yogurt on them. The caregiver radioed for assistance and a second caregiver arrived at 11:17 am. Two caregivers were unable to complete the task and a third caregiver arrived to assist at 11:25 am. The three caregivers exited the room with the resident at 11:30 am.

Throughout the re-licensure survey, interview and observation noted Resident 4 consistently required three staff to assist with multiple continence care and clothing changes per shift. Staff 18 stated in an interview on 03/19/24 that in one recent day shift Resident 4 had required brief and/or clothing changes 10 times.

During these periods of care for Resident 4, multiple residents were observed wandering the halls, walking into other residents' rooms, and asking this surveyor where they should go, with no caregivers to assist.

3. On 03/20/24 observations in the assisted dining room during lunch service identified the following:

* After eating 100% of his/her lunch, an unsampled resident was observed to begin to eat the lunch of a second unsampled resident seated next to him/her. The second resident verbally protested multiple times, and the first resident continued to eat the food.

* Another unsampled resident was observed attempting to scoop a 3"x3" ravioli with a utensil. When it fell on her his/her lap, s/he ate it off his/her lap, then ate a few more bites from his/her plate with his/her fingers. No functional utensil use was observed.

* At 12:35 pm there were observed to be 10 residents sitting in the dining room, after their table service had been cleared. At 1:03 four residents remained, slumped down in their chairs, with no caregiver interaction since their plates had been cleared. At 1:19 pm one of the residents told this surveyor s/he wanted to go back to their room.

The caregiving staff interacting with residents during the meal were two staff who were providing one-to-one feeding assistance with two residents. They did not interact with other residents in the dining room during the meal.

Staff 24 (Cook) was observed interacting frequently with residents toward the end of the meal service time, cueing for continuation of intake and suggesting other items. Staff 24 reported s/he knows the residents well and that "only the resident's at the back 2 tables need help eating."

4. Multiple sampled residents (#s 1, 3, 4, 5, 6, and 8) had insufficient staff time needed for provision of their care on the facility ABST in areas including but not limited to:

* Dressing and undressing;

* Bowel and bladder management;

* Bathing;

* Repositioning;

* Escorting to and from meals or activities;

* Supervising or supporting while eating;

* Ensuring non-drug interventions for behaviors; and

* Monitoring behavioral conditions or symptoms.

The need to ensure the facility provided a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of residents was discussed

with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

Refer to C 361.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents. This is a repeat citation. Findings include, but are not limited to:

The memory care community was home to 68 residents at the time of the re-visit survey. The facility was constructed as one large loop consisting of two long corridors and two short connecting corridors.

Multiple interviews with staff conducted on 07/09/24 through 07/11/24 revealed the following:  

* Staff identified six residents who required three-person assistance for transfers and/or ADL care;

* Staff identified 10 residents who required two-person assistance for transfers and/or ADL care;

* The facility had 12 residents who had been involved in resident-to-resident altercations since 05/25/24; and

* Staff identified six residents who required 1:1 feeding assistance.

1. On 07/08/24 and 07/09/24, multiple incidents occurred in the general activity/entry area where a resident was observed yelling profane statements at one or more other residents. During these incidents, no staff members were present, and no staff members arrived to intervene or monitor the residents.

2. On 07/09/24 at 11:36 am, an unsampled resident was observed entering Resident 11's room. No staff members were present in the hallway to observe this occurring. No staff members were available along the long hallway or in the activity area which could be visualized when standing outside of Resident 11's room for six minutes. After speaking with the surveyor about the unsampled resident in Resident 11's room, the staff member asked the unsampled resident to leave the room in order to go to lunch, and the unsampled resident refused. The staff member stated she needed to keep taking other residents to lunch, and left the unsampled resident in Resident 11's room. No other staff members returned to the room to assist in removing the unsampled resident. The unsampled resident left independently three minutes later.

3. On 07/09/24 at 9:39 am, an unsampled resident entered Resident 12's room, where Resident 12 and his/her visiting spouse were talking, with the apartment door ajar. The spouse asked the unsampled resident to leave, saying, "This isn't your room." Resident 12 yelled loudly "Move!" and the spouse said to the unsampled resident, "[S/he] doesn't want you in here. Please leave." At 9:40 am the spouse came out of the room and walked to the end of the short hallway where Resident 12's room was and looked down the long hallway at the back of the facility. The spouse then walked back, passing Resident 12's room and walked to the other end of the short hallway, turning the corner down the long hallway at the front of the facility. At 9:42 am the spouse came back to Resident 12's room, where the unsampled resident had remained. Resident 12 was heard by this surveyor to say something inaudible to which the spouse responded, yelling, "I couldn't find anybody to take [him/her] out." At 9:45 this surveyor requested that the spouse press Resident 12's call light. The unsampled resident, who had been out of sight of this surveyor, was observed to be in Resident 12's bathroom. At 9:47 am, Staff 6 (Maintenance Director) arrived and said "I heard your air conditioning isn't working," and then stated, "I'm going to get someone to help [unsampled resident] to [his/her] room."  At 9:50 am, a caregiver arrived and redirected the unsampled resident to leave the room, taking three minutes due to the unsampled resident's resistance.

4. Throughout the survey, unsampled residents requested assistance from survey team members, who were unable to find staff members to assist.

5. The facility's posted staffing plan designated one MT and two CGs for the NOC shift. Considering the number of residents requiring two-person and three-person transfers, as listed above, this was not an adequate number of floor staff in case of an actual emergency evacuation.

The need to ensure the facility provided a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 4 (LPN) and Staff 31 (Operations) at 4:00 pm on 07/11/24. They acknowledged the findings.

1. Willamette Springs has updated all ABST for residents for staffing requirements including care staff documenting minutes it takes to assist residents with ADL's. 3 of the 6 residents identified by staff that neeeded a 3 person transfer have since moved out or have passed away. Staff have also received training on how to properly transfer residents to help them become an easier transfer. The facility has done additional training with staff on how to redirect to prevent altercations and the altercations have decreased significantly. The facility now only has 4 residents that require feeding assistance (cueing or full assist). The facility has increased staffing and is actively hiring ito support the needs of residents that need feeding assistanceWilliamette Springs is hiring an additional activities person with longer hours to help provide oversight for residents in the common area and redirect if they start yelling. Willamette Springs Staffing for Noc shift has been increased. 2. WIllamette Springs has implemented a new form that staff fill out quarterly prior to service plan updates that includes time for ADL care. Shift huddles are being done daily with staff which includes reviewing any changes to residents ADL's. Staffing will be updated as required as ABST minutes are updated. Staff have been retrained on communication over walkies expectations.

3. Daily, Weekly, Monthly 4. Executive Director and clinical Team

Based on observation, interview, and record review, it was determined the facility failed to ensure Acuity Based Staffing Tool (ABST) entries were reflective of the resident's current care needs for 6 of 7 sampled residents reviewed (#s 1, 3, 4, 5, 6, and 8). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 12/2023 with diagnoses including diabetes.

Observations of the resident, interviews with staff, and review of the resident records revealed Resident 3's ABST minutes and/or frequencies were not reflective in the following area:

* Medication administration, passing out medications.

On 03/26/24, the need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

5. Resident 8 was admitted to the facility in 02/2023 with diagnoses including dementia, depression, and anxiety. The resident moved out of the facility in 03/2024 and subsequently passed away.

Review of the resident's record and interviews with staff revealed the ABST data was not accurate in the following areas:

* Supervising, cueing, or supporting while eating;

* Cueing or redirecting due to cognitive impairment or dementia;

* Ensuring non-drug interventions for behaviors;

* Monitoring behavioral conditions or symptoms; and

* Safety checks, fall prevention.

The need to ensure ABST data accurately represented the time staff needed to provide care to a resident was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2024 with diagnoses including senile dementia and stroke.

Observations of the resident, interviews with staff, and review of the resident records indicated Resident 1's ABST minutes and/or frequencies were not reflective in the following areas:

* Bowel and bladder management;

* Repositioning;

* Activities; and

* Eating.

3. Resident 4 was admitted to the facility in 11/2016 with diagnoses including bipolar disorder, traumatic brain injury with psychosis, and dementia.

Observations of the resident, interviews with staff, and review of the resident records indicated Resident 4's ABST minutes and/or frequencies were not reflective in the following areas:

* Dressing and undressing;

* Bowel and bladder management;

* Non-drug intervention for behaviors; and

* Activities.

On 03/26/24, the need to ensure ABST entries were reflective of resident care needs, including minutes reflective of multiple caregivers required for completion of task, was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

4. Resident 5 was admitted to the facility in 04/2022 with diagnoses including dementia and altered mental status.

Observations of the resident, interviews with staff, and review of the resident records indicated Resident 5's ABST minutes and/or frequencies were not reflective in the following area:

* Monitoring behavioral conditions or symptoms.

5. Resident 6 was admitted to the facility in 01/2022 with diagnoses including cardiovascular disease, depression, and dementia.

Observations of the resident, interviews with staff, and review of the resident records indicated Resident 6's ABST minutes and/or frequencies were not reflective in the following areas:

* Repositioning in bed or chair;

* Supervising, cueing, or supporting while eating;

* Cueing or redirecting due to cognitive impairment or dementia; and

* Monitoring behavioral conditions or symptoms.

On 03/26/24, the need to ensure ABST entries were reflective of  resident care needs was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure Acuity Based Staffing Tool (ABST) entries were reflective of the resident's current care needs for 1 of 4 sampled residents (#4). This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 11/2016 with diagnoses including bipolar disorder, traumatic brain injury with psychosis, and dementia.

Observations of the resident, interviews with staff, and review of the resident records indicated Resident 4's ABST minutes and/or frequencies were not reflective in the following areas:

* Dressing and undressing;

* Bowel and bladder management;

* Bathing;

* Transferring in or out of bed or a chair; and

* Non-drug interventions for behaviors.    

The need to ensure ABST entries were reflective of resident care needs was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 4 (LPN) and Staff 31 (Operations) on 07/11/24. They acknowledged the findings.

1. Willamette Springs has implented the state staffing requirements. Resident 4's ABST was updated with frequencies and minutes for the following areas: Dressing and undressing, Bowel and Bladder management, bathing, transferring in or our of bed or a chair, and non-drug interventions for behaviors. 2. WIllamette Springs has implented a new form that staff fill out quarterly prior to service plan updates that includes time for ADL care. Shift huddles are being done daily with staff which includes reviewing any changes to residents ADL's. ABST will continue to be updated upon admission, 30-day review, quarterly and with significant change of condition. 3. Daily, Weekly, Monthly 4. Executive Director and clinical Team

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

Refer to C360, C361, Z142 and Z162.

1. Refer to C360, C361, Z142 and Z162

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

Observations of the MCC, conducted 03/18/24 through 03/26/24, showed the following:

* Deep scratches on outside lower surface of wood front desk;

* Gouges and damage on wood base boards near rooms 101, 116, 119, 121, and 122;

* Scrapes and gouges on doors and door jambs of rooms 119, 206, 207, 209, and 214;

* Scratches on wood chair legs of hallway furniture;

* Chipped paint and plaster damage on walls near sink in dining room;

* Room 126 had dark stains on carpet;

* Room 124 had a strong odor of urine; and

* The Residential section of the building, as a whole, had an odor of urine which failed to dissipate throughout the survey.

The need to maintain the interior of the facility and all equipment and surfaces free from unpleasant odors, clean, and in good repair was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

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

Refer to C150, C200, C242, C360, and C361.

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 C360 and C361.

1. Refer to C360 and C361

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 13, 16, and 19) completed all pre-service dementia training before independently providing personal care to residents. Findings include, but are not limited to:

Staff training records were reviewed on 03/25/24. The following was identified:

There was no documented evidence Staff 13 (CG), hired 12/26/23, Staff 16 (CG), hired 01/29/24, and Staff 19 (CG), hired 01/01/24, had completed approved pre-service dementia training in the following topics:

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

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

On 03/26/24, the need to ensure staff completed all required training prior to independently providing personal care to residents was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

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 C270, C280, C301, and C303.

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

Refer to C260.

1. Refer to C260

2. Resident 8 was admitted to the facility in 02/2023 with diagnoses including dementia, depression, and anxiety. The resident moved out of the facility in 03/2024 and subsequently passed away.

Review of the resident's record, including weight records, RN assessments, interim service plans (ISPs), and the service plan, dated 02/29/24, and staff interviews revealed the following:

* The resident began losing weight soon after she was admitted to the facility;

* S/he experienced on-going severe weight loss between 03/03/23 and 03/01/24, losing a total of 86.4 pounds, or 45.47% of his/her total body weight, in one year;

* Multiple ISPs were created with weight loss prevention interventions, including high calorie/high protein foods, health shakes daily, and adding extra butter and/or gravy to meals; and

* The 02/29/24 service plan did not include the most recent weight loss interventions or how much weight the resident had lost.

The need to have individualized nutrition and hydration plans included in resident service plans was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN) on 03/26/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 7 sampled memory care residents (#s 1 and 8) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2012 with diagnoses including senile dementia and stroke.

During the acuity interview on 03/18/24, Resident 1 was identified as being bedbound and fully dependent on staff for all ADLs, including one-to-one feeding. Observations during the survey revealed the resident was also fully dependent on staff for hydration.

Review of Resident 1's service plan identified there was no information regarding the who, what, when, how, and how often hydration would be provided.

On 03/26/24, the need to ensure nutrition and hydration plans were developed and included in the service plan was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the residents and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6, and 8) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, 4, 5, 6, and 8's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents' individual activity needs in one or more of the following areas:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and/or

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

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

Observations between 03/18/24 and 03/26/24 showed minimal to no group activities being led by staff. Residents were observed wandering the halls, sleeping in chairs, or seated in common areas with the television playing or with music playing.

On 03/9/24 at 10:10 am an unsampled resident sitting in a hallway in a wheelchair said to a surveyor, "I don't know where to go. I don't know what's going on." At 10:11 a CG approached nearby and the surveyor told the CG that the resident was looking for something to do. The CG kneeled in front of the resident, looked at his/her watch, and stated, "Well, we're going to be having lunch in an hour and a half and there's really not much going on. People are just wandering around right now. Would you like a cup of hot chocolate?"    

On 03/26/24, the need to ensure all residents had individualized activity plans developed and consistently implemented to engage them in meaningful activities was discussed with Staff 1 (Executive Director), Staff 2 (Resident Services Manager), Staff 3 (RN), and Staff 4 (LPN). They acknowledged the findings.