Monterey Court Memory Care

Based on interview and record review, conducted during a site visit on 05/06/24, it was confirmed the facility failed to ensure the preparation, completeness, accuracy of resident records for 1 of 1 sampled resident (#1). Findings include, but are not limited to:A review of Resident 1'sTemporary Service Plans (TSP) dated 07/26/23 through 10/25/23 revealed one TSP dated 08/02/23, which had the last name of the Resident 1 listed incorrectly.During an interview on 05/06/24, Staff 2 (Administrator) and Staff 3 (Operations Specialist) confirmed staff had written the wrong last name and there was no record of a different resident with the last name on the TSP.The findings were reviewed with and acknowledged by Staff 2 and Staff 3 on 05/06/24. The facility failed to ensure the preparation, completeness, accuracy of resident records.Verbal plan of Correction: In-service to be conducted at next MT meeting on Thursday 05/09/24 about record accuracy.

Based on interview and record review, conducted during a site visit on 05/06/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#6). Findings include, but are not limited to: A review of Resident 6's signed physician orders dated 10/25/23 indicated Resident 6 had an order for:*Carbidopa/Levo 25-100 mg tablet (A prescription for Parkinson's disease) 1 Tab by mouth three times daily at 9 am 12 pm and 5 pm.A review of Resident 6's MAR dated 10/1/23-10/31/23 revealed on 10/27/23, the medication could not be located and the 9 am dose was not given. The findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 3 (Operations Specialist) on 05/06/24 who agreed the medication was not given as prescribed.The facility failed to carry out medication orders as prescribed.Verbal plan of correction: Administrator and facility RN to review medication pass exceptions daily. Facility is now requiring MTs to print dashboard, address any missed medications, sign and date and give to nurse daily.

Based on observation, interview and record review, conducted during a site visit on 05/06/24, it was confirmed the facility failed to have accounting records for handling residents' personal incidental funds for 3 of 3 sampled residents (#s 4, 6 and 7). Findings include, but are not limited to:During an observation and interview on 05/06/24, Staff 3 (Operations Specialist) stated the s/he had found a binder of Personal Incidental Funds (PIF) locked in the old Executive Director's office and was not sure who was managing them previously. Staff 3 brought three envelopes with Resident #s 4, 6, and 7 names on them, which contained cash and were observed, but not handled by the Compliance Specialists. The envelope with Resident 6's name on it contained a receipt. Staff 3 stated there were no accounting records or sign in/sign out forms for any cash received.There was no documented evidence of any accounting for personal incidental funds.The findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 3 on 05/06/24.The facility failed to have accounting records for handling residents' personal incidental funds.Verbal plan of correction: Administrator and Operations Specialist will meet with new business office manager to count each person's remaining PIF. They will request permission and guidance from Frontier on how to handle cash by end of day 05/10/24.

The findings of the re-licensure survey, conducted 07/17/23 through 07/20/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home & Community-Based Services rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a daySituations were identified where there was a failure of the facility to comply with the Department's rules which were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas: OAR 411-054-0025(4) Reasonable Precautions; andOAR 411-057-0160(e) Behaviors. The facility put immediate plans of correction in place during the survey and the situations were abated.
The findings of the first re-visit to the re-licensure survey of 07/20/23, conducted 01/02/24 through 01/05/24, 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 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second re-visit to the re-licensure survey of 07/20/23, conducted 05/07/24 through 05/08/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:A tour of the facility conducted on 07/17/23 identified a copy of the most recent re-licensure survey, including all re-visits and plans of correction as applicable was not accessible to residents and visitors at all times.The need to ensure all required postings were in an accessible and conspicuous place was discussed with Staff 1 (Executive Director) on 07/18/23. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. That placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:Resident 3 moved into the facility in 03/2023 with diagnoses including major cognitive impairment and a history of alcohol abuse.During the acuity interview on 07/03/21, Resident 3 was identified as having exit-seeking behaviors.Resident 3's service plan, dated 06/12/23, was reviewed and identified the resident as a high elopement risk due to a "history of elopement from the hospital" prior to admission. The service plan indicated the resident had "recently" followed an outside provider through the secured doors of the MCC into the main lobby. In addition, the service plan indicated s/he enjoyed being outside and would need to be accompanied by a staff member when in the main lobby.Observation, interview, and record review identified the following elopement attempts:* A progress note from 07/04/23 revealed staff were unable to locate Resident 3 for approximately 45 minutes, after having left the resident unsupervised while s/he was sitting on a bench outside the main lobby entrance. In interviews, 07/17/23 through 07/18/23, Staff 9 (MT) and Staff 12 (CG/MT) confirmed they were completing a medication count in the med room while the resident was left on a bench in front of the building. After completing the medication count, they returned to the bench in front of the building and were unable to locate Resident 3. Staff 12 reported the resident was missing for approximately 45 minutes when Staff 1 (Executive Director) was notified. Staff 1 reviewed camera footage remotely and identified Resident 3 had walked towards the local shopping center. Staff 1 called the resident on his/her phone, who reported s/he was at the nearby store. Staff 9 walked to the local shopping center and brought Resident 3 back to the community. The resident was placed on alert monitoring with instructions to "Please keep an eye on [him/her]."* A progress note from 07/15/23 indicated the resident followed his/her family member into the main lobby and outside the front door. Resident 3 refused to go back inside the building. Staff 1 was called and was able to speak to Resident 3 via phone and convince him/her to go back inside.* During an observation on 07/17/23 at approximately 12:30 pm, Resident 3 was seen in the lobby talking with Staff 5 (Business Office Manager), who was seated behind her desk. At 12:35 pm Resident 3 stated s/he was going outside and "I'm going out front, what are you going to do, shoot me?" Resident 3 proceeded to walk out the front door unaccompanied by staff, and sat down on a bench in the front of the building. Staff 1 reported Resident 3 was to always be accompanied by the staff member who let Resident 3 into the main lobby outside the secured MCC. At the request of the surveyor, Staff 1 implemented an immediate plan of correction and interim service plan which indicated Resident 3 would "not be allowed to come to the front under no circumstances" and "is not to come to the front or be left in courtyards unsupervised. Resident 3 will be placed on safety checks for staff to check-in on him every 1-2 hours."* On 07/18/23, Resident 3 was again observed in the lobby. During an interview, Staff 9 stated she noticed room 203's door was shut, which was unusual for the resident that occupied the room. When Staff 9 attempted to open the door of room 203, it was found to be locked. Staff 9 unlocked the door and observed Resident 3 climbing out the bedroom window. The resident had opened the window and removed the window screen, allowing him/her to climb through the bedroom window. The window exited into the parking lot of the facility. Staff proceeded to walk through the front lobby and brought the resident back in from the parking lot.The failure of the facility to maintain supervision of Resident 3 and develop effective interventions resulted in further acts of elopement. That placed Resident 3 at risk and constituted an immediate threat to residents' health and safety.On 07/18/23, survey requested an immediate plan to address Resident 3's elopement behaviors and lack of supervision. Survey received the plan from the facility at 3:26 pm, and the situation was abated.On 07/18/23, the need to ensure behavior interventions were identified, implemented, and effective to protect residents was discussed with Staff 1. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct investigations for injuries of unknown cause to rule out abuse, or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office for 3 of 4 sampled residents (#s 1, 2, and 3) whose record was reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 03/2023 with diagnoses including major cognitive impairment.Record review revealed on 07/04/23 the resident had eloped from the facility. There was no documented evidence the facility had conducted an immediate investigation to rule out possible abuse or neglect.In an interview with Staff 1 (Executive Director) on 07/19/23, it was reported there had not been an investigation of the elopement and it had not been reported to the local SPD office.On 07/19/23, the need to conduct investigations to rule out possible abuse or neglect was discussed with Staff 1. She acknowledged the findings. Staff 1 reported the incident to the local SPD office per surveyor request and provided the surveyor with confirmation the incident had been reported.
3. Resident 2 was admitted to the facility in 04/2021 with diagnoses including dementia without behavioral disturbance, diastolic heart failure, and osteoarthritis in both knees.The resident's 04/18/23 through 07/14/23 charting notes and interim service plans (ISPs) were reviewed, and staff were interviewed. The following was identified:* On 04/18/23 staff discovered a bruise the size of a "golf ball" on the top of the resident's left hand. The resident was unable to state how s/he received the bruise. An ISP was implemented the same day.In an interview with Staff 2 (Health Service Director/RN), she stated she had not investigated the injury of unknown cause because no one told her about it.The facility provided a copy of an Incident Report & Investigation Worksheet indicating the facility nurse was notified of the incident on 07/17/23 and an investigation signed by Staff 2 dated 04/19/23. The investigation stated abuse and/or neglect was ruled out because the "resident stated no and was very clear that another person did not cause this even though [s/he] cannot remember how [s/he] got it. Do not feel that a staff member or other resident cause the bruise, it actually looks like [the resident] hit it against the side-rail [sic] and [s/he] agrees with this."The facility was instructed to report the incident to the local SPD office on 07/19/23. On 07/20/23 the facility provided confirmation the incident had been reported.The need to ensure injuries of unknown cause were investigated within 24 hours to reasonably rule out abuse and/or neglect, and to report them to the local SPD office when abuse and/or neglect could not be ruled out, was discussed with Staff 1 (Executive Director) on 07/20/23. She acknowledged the findings.
2. Resident 1 was admitted to the facility in 02/2021 with diagnoses including vascular dementia and type 2 diabetes.The resident's 04/18/23 through 07/14/23 charting notes, MAR 06/01/23 through 07/16/23, and interim service plans (ISPs) were reviewed. The following was identified:Resident 1 had a physician's order to administer Lantus 100-U/ml pen 3 ML to inject 10 units of insulin every morning and evening. The following medication error was noted:On 07/15/23 at 9:30 am, Staff 2 (Health Services Director/RN) was informed Resident 1 had not received insulin by Staff 23 (CG). Staff 18 (CG/MT) reported she observed Staff 23 in the process of giving the Lantus. However, Staff 23 denied that she administered the Lantus to Resident 1.On 07/15/23 at 11 am, Staff 2 administered the Lantus as prescribed. However, when she went to record it in the MAR, the medication had been signed off by Staff 23, who was not delegated to administer Lantus. Staff 2 spoke with Staff 18 and Staff 23, and she received conflicting reports on what had occurred. Staff 2 then notified the physician on call of the medication error.An interview with Staff 2 on 07/19/23 at 1:20 pm confirmed the facility was aware of the medication error prior to the re-licensure survey and had begun an investigation. She was not aware that an SPD report was required.There was no documented evidence the facility had immediately reported the medication error to SPD.The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 07/19/23 at 2:53 pm.The need to promptly investigate and report medication errors that could have a negative effect on the resident, was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) on 07/20/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide services to assist the residents in activities of daily living in the areas of bathing, dressing, and grooming for 1 of 4 sampled residents (#1) and multiple unsampled residents who required oversight, cueing, supervision and assistance with ADL's. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including vascular dementia and memory deficit. Resident 1 was dependent on staff for most ADL care, including bathing, personal hygiene, dressing, and grooming.The resident's 07/12/23 service plan indicated s/he required assistance with bathing twice weekly.Caregiver ADL task sheet binders for day and swing shifts in Oceanside and Mountainside communities, reviewed from 05/03/23 through 07/20/23, revealed the following:* Only three ADL task sheets were completed on 07/10/23, 07/11/23, and 07/19/23, respectively for the residents residing in Mountainside.* There was no documented evidence that bathing assistance was provided to Resident 1 since 05/03/23.Resident 1 was observed during the survey to be wearing the same clothes on 07/18/23 and 07/19/23.In an interview on 07/20/23 at 11:40 am, Resident 1 confirmed s/he had not had a shower "this week."2. Multiple unsampled residents were observed during the survey wearing the same clothes for two or more days in a row and needing grooming assistance.On 07/20/23, the lack of documented evidence of assisting residents with activities of daily living as outlined in their service plan was reviewed with Staff 1 (Executive Director) and Staff 3 (RCC) who acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components and to ensure smoking evaluations were reflective of the resident status for 1 of 2 sampled residents (#3). Findings include, but are not limited to:Resident 3 was admitted to the facility in 03/2023 with diagnoses including major neurocognitive disorder.Resident 3's move-in evaluation failed to address the following required components:* Customary routines, such as those related to sleeping, eating, and bathing;* Interests, hobbies, and social and leisure activities;* History of treatment related to mental health;* Effective non-drug interventions related to mental health;* Personality including how the person copes with change and challenging situations;* Nutrition habits and fluid preferences;* Emergency evacuation ability;* Recent losses; and* Environmental factors that impact the residents' behaviors including but not limited to noise, lighting, and room temperatureAdditionally, Resident 3's progress notes indicated s/he was a smoker. There was no documented evidence the facility had completed a smoking evaluation for Resident 3's ability to smoke safely.On 07/20/23, the need to ensure new move-in evaluations included all required components and smoking evaluations when needed was discussed with Staff 1 (Executive Director). 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' needs and provided a written description of who shall provide the services and what, when, how, and how often the services shall be provided for 2 of 4 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to facility in 02/2021 with diagnoses including vascular dementia.The current service plan dated 07/12/23 and Interim Service Plans (ISP's) from 05/03/23 to 07/13/23 were reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:* Ability to use the call system;* Ability to go outside to smoke as a behavioral intervention;* Psychotropic medications for behaviors;* Bathing; and* Presence of side rails, including correct use of and precautions.The need to ensure service plans were completed quarterly, were reflective of residents' current needs, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) on 07/20/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 04/2021 with diagnoses including dementia without behavioral disturbance, diastolic heart failure, and osteoarthritis in both knees.The resident's most recent service plan, dated 07/08/23, was reviewed, and interviews with staff and the resident were conducted. The service plan was not reflective in the following area:* Instructions to staff regarding the correct use of and precautions related to the use of side rails.The need to ensure staff were instructed on the proper use and the precautions related to the use of any supportive device with restraining qualities was discussed with Staff 1 (Executive Director) on 07/19/23 and 07/20/23. She acknowledged the findings.

2. Resident 5 was admitted to the facility in 07/2022 with diagnoses including dementia.The resident's most recent service plan, updated 11/20/23, was reviewed, and staff were interviewed. The service plan was not reflective of the resident's current care needs in the following areas:* Transfer assistance needed;* Behaviors;* Meal assistance required;* Nutrition and hydration needs; and* Psychotropic medications prescribed.The need for service plans to accurately reflect the current status and care needs of residents was discussed with Staff 25 (Executive Director) and Staff 26 (RN/Health Services Director) on 01/05/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences and included a written description of who should provide the services and what, when, how, and how often the services should be provided for 2 of 3 residents (#s 5 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 02/2023 with diagnoses including dementia, Parkinson's Disease, and repeated falls.The resident's service plan available to staff, dated 10/09/23, and interim service plans dated 09/18/23 to 01/02/24 were reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's current needs and preferences and failed to provide a written description of who provided the services and what, when, how, and how often the services were provided in the following areas:* Behaviors;* Ambulation status;* Transfer status;* Side rail instructions;* Feeding ability;* Ability to use call light;* Communication abilities;* Roommate status;* Nutrition and hydration plan; and* Fall history and interventions.The need to ensure service plans were reflective and included a written description of services provided was discussed with Staff 1 (Executive Director) on 01/05/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were identified, resident-specific interventions were developed and evaluated for effectiveness, and changes were monitored, at least weekly, to resolution for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 12/2013 with diagnoses including dementia, diabetes, and hypertension.Review of the resident's service plan, dated 06/21/23, progress notes dated 04/17/23 through 07/17/23, temporary service plans, and incident reports indicated the resident experienced eight falls between 04/20/23 and 07/11/23.There were some fall interventions documented, but the records lacked resident-specific interventions, including clear directions to staff regarding fall prevention. In addition, the existing interventions were not evaluated for effectiveness during the series of repeated falls.On 07/20/23 the need to ensure short-term changes of condition were evaluated and resident-specific interventions were implemented and evaluated for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (Health Service Director/RN). They acknowledged the findings.
3. Resident 1 was admitted to the facility in 02/2021 with diagnoses including vascular dementia and type 2 diabetes.Review of the resident's service plan, dated 07/12/23, progress notes, dated 04/18/23 through 07/16/23, and interim service plans were reviewed, and the following changes of condition were identified:* 05/07/23: Discontinuation of trazadone (for depression), nicotine patch, risperidone (for schizophrenia), morphine (for pain), ativan (for anxiety), and haldol (for hallucinations);* 05/07/23: New medications, including divalproex (for dementia) and olanzapine (for schizophrenia);* 05/07/23: Episode of low blood sugar;* 05/09/23: Changes in insulin sliding scale;* 05/30/23: Discontinuation of Chantix (for smoking cessation); and* 06/20/23: Increase in melatonin (for sleep).There was no documented evidence those changes of condition had been monitored through resolution, and documented weekly through resolution. There was no documentation of weekly monitoring regarding the increase in melatonin on 06/20/23.The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution was discussed with was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) on 07/20/23. They acknowledged the findings, and no additional documents were provided.
2. Resident 3 was admitted to the facility in 03/2023 with diagnoses including major neurocognitive disorder.Resident 3's clinical record were reviewed for changes of condition and revealed the following changes of condition:* On 04/29/23, the resident and an un-sampled resident were involved in a resident-to-resident altercation. There was no documented evidence the facility determined and documented what resident-specific actions or interventions were needed to minimize further occurrences.* On 07/04/23, the resident had eloped from the facility and was found at the nearby shopping center. There was no documented evidence the facility determined and documented what resident-specific actions or interventions were needed to minimize further elopement issues.On 07/20/23, the need to determine and document what actions and resident-specific interventions were needed when a resident experienced a short-term change of condition was discussed with Staff 1 (Executive Director). She acknowledged the findings.
4. Resident 2 was admitted to the facility in 04/2021 with diagnoses including dementia without behavioral disturbance, diastolic heart failure, and osteoarthritis in both knees. The resident's clinical record was reviewed and staff were interviewed. The following was identified:* On 04/18/23 a bruise the size of a "golf ball" was discovered on the top of the resident's left hand; and* An interim service plan dated 04/18/23 instructed staff to notify the MT or RN "for pain/swelling."There was no documented evidence the injury was monitored through resolution.The need for all changes of condition to be monitored through resolution, with at least weekly progress documented, was discussed with Staff 1 (Executive Director) on 07/19/23. She acknowledged the findings.



2. Resident 5 was admitted to the facility in 07/2022 with diagnoses including dementia.The resident's current service plan, dated 11/20/23, progress notes from 09/21/23 through 12/31/23, temporary service plans, incident reports, and the 12/2023 MAR were reviewed, and staff were interviewed. The following was identified.The resident experienced multiple changes of condition between 09/21/23 and 12/31/23, including medication changes, behaviors, falls, and admission to hospice. The following changes were either not monitored or not monitored through resolution:* 11/24/23 - Behavior including entering other residents' apartments;* 11/27/23 - Aggressive behavior toward staff;* 11/30/23 - Aggressive behavior toward staff;* 12/02/23 - Unwitnessed fall resulting in abrasions on both elbows;* 12/19/23 - Return from hospital; and* 12/24/23 - Unwitnessed non-injury fall.In addition, the 12/24/23 fall was not investigated, previous interventions were not evaluated for effectiveness, and new interventions were not determined, communicated with staff, or implemented.The need to monitor interventions for effectiveness, develop new interventions when needed, and monitor all changes through resolution was discussed with Staff 25 (Executive Director) and Staff 26 (RN/Health Services Director) on 01/05/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition had resident-specific actions or interventions determined and documented, and residents' changes of condition were monitored consistent with evaluated needs with progress noted at least weekly to resolution for 2 of 3 sampled residents (#s 5 and 7) who experienced short term changes of condition. Resident 7 continued to lose weight and sustain injuries from repeat falls. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 02/2023 with diagnoses including dementia, Parkinson's Disease, and repeated falls. Resident 7 was identified during the acuity interview as experiencing a significant weight loss, and s/he was on hospice. The resident's service plan available to staff, dated 10/09/23, interim service plans dated 09/18/23 to 01/02/24, 12/01/23 through 01/02/24 MARs, progress notes dated 09/18/23 to 01/02/24, and weight records dated 07/05/23 to 01/01/24 were reviewed, observations were made, and interviews with staff and the resident were conducted.a. Review of Resident 7's weight records revealed the following:* 10/05/23 - 102.4 pounds;* 11/05/23 - 104.2 pounds;* 12/05/23 - 95.8 pounds; and* 01/01/24 - 88.8 pounds.Between 11/05/23 and 12/05/23 Resident 7 lost 8.4 pounds, or 8% of his/her total body weight, which is considered severe.There was no documented evidence actions or interventions for the weight loss were developed, implemented, communicated to staff, and monitored for effectiveness.Between 12/05/23 and 01/01/24 Resident 7 lost an additional 7 pounds, or 7.3% of his/her body weight, constituting another severe loss.Resident 7 was interviewed on 01/04/24 during lunch. S/he reported the food served was "not bad." S/he did not respond when asked about favorite foods or preferred meal times. However Staff 32 (CG) and Staff 35 (CG) reported during interviews on 01/03/24 and 01/04/24 that his/her favorite foods included ice cream, salmon, Thai food, and snacks the resident's family provided, available in his/her room. Staff further reported the resident often slept in past breakfast and did not consume that meal. The resident was offered nutritional shakes if s/he consumed less than 50% of meals.Observations made during breakfast and lunch on 01/03/24 and 01/04/24 revealed the resident demonstrated distracted behaviors during both meals. S/he wheeled away from the table several times during breakfast. Staff redirected him/her back to the meal. Staff offered bites of food from a fork which the resident refused. S/he often used his/her fingers to pick up food items but was able to use a fork when cued. During lunch on 01/04/24, taken in his/her room, s/he fell asleep intermittently. Staff checked on him/her intermittently during the meal, encouraging him/her to finish the meal. Resident 7 consumed 10-20% of both meals observed.During an interview at 10:05 am on 01/04/24, Staff 36 (RN Consultant) stated the facility had implemented weekly weight monitoring for all residents and added it to the MAR. MTs were instructed to notify the RN and hospice if residents experience a five pound weight loss or gain. MAR documentation indicated the facility RN was notified of the significant weight loss from 11/05/23 to 12/05/23.The lack of interventions and monitoring resulted in ongoing severe weight loss. This constituted a risk to the health, safety, and welfare of the resident.b. Resident 7 experienced seven falls between 10/14/23 and 11/26/23, as follows:* 10/14/23 - unwitnessed fall in the resident's bedroom by the door resulting in a head injury;* 10/17/23 - unwitnessed non-injury fall in the resident's bedroom by the door;* 10/18/23 - unwitnessed non-injury fall in the resident's bedroom, exact location unknown/not documented;* 10/24/23 - unwitnessed fall in front of resident's room with "rebounding pain to the left elbow";* 11/19/23 - unwitnessed fall outside the resident's room resulting in an abrasion on the right cheek;* 11/23/23 - unwitnessed non-injury fall in the resident's room near the sink; and * 11/26/23 - unwitnessed fall in the resident's room near the bed resulting in a skin tear on the left eyebrow and pain in the left arm/shoulder.The facility documented interventions in progress notes and ISPs as follows:* 10/14/23 - "increase rounding," documented on an ISP;* 10/17/23 - "encourage activity during the day to promote sleep at night" and "reinforce the use of [the resident's] walker when ambulating," documented in the progress notes; and* 11/23/23 - "ensure resident is using FWW [front wheel walker] at all times," documented in the progress notes.During an interview on 01/05/24 at 11:00 am, Staff 26 (RN/Health Services Director) stated the resident's ambulation status was variable. Some days s/he could use his/her walker, and some days s/he needed a wheelchair for ambulation.There was no documented evidence interventions were implemented and communicated with staff on all shifts for the following falls:* 10/17/23, 10/18/23, 10/24/23, 11/19/23, and 11/23/23.There was no documentation any actions/interventions were monitored for effectiveness. The resident continued to fall and sustained multiple injuries, causing a serious risk to the health, safety, and welfare of the resident.c. The following short-term changes of condition, documented in the progress notes, lacked actions or interventions, and/or were not monitored at least weekly to resolution:* 09/30/23 - Resident 7 had "been anxious in the evening [sic] calling the family member and saying [sic] lady is harassing [him/her]";* 10/03/23 - Red spot on right leg from a resident-to-resident altercation;* 10/05/23 - Skin tear on left forearm and bruise above left eye from a resident-to-resident altercation;* 10/13/23 - Burning/discomfort in peri area;* 10/14/23 - Head laceration with staples from an unwitnessed fall;* 10/14/23 - Injury of unknown cause-bump on left elbow;* 10/28/23 - Resident-to-resident altercation;* 11/11/23 - Urinary tract infection;* 11/25/23 - Agitation toward staff;* 11/26/23 - Laceration on left eyebrow from an unwitnessed fall; and * 12/01/23 - "[R]ed color on [his/her] cheeks and in [his/her] mouth."The need to ensure all changes of condition had actions or interventions developed, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was discussed with Staff 25 (Executive Director) and Staff 26 on 01/05/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to failed to ensure an RN conducted a significant change of condition assessment including findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (# 4) who experienced a significant change of condition. Findings include, but are not limited to:Resident 4 was admitted to the memory care community in 12/2013 with diagnoses including dementia, diabetes, and hypertension.Review of progress notes, dated 04/17/23 through 07/17/23, and interviews with staff indicated Resident 4 returned from the hospital on 07/01/23. At that time the resident exhibited a significant change in mobility. Resident 4 had been ambulatory prior to the hospitalization, but was unable to stand or walk after returning to the facility.In an interview on 07/18/23, Staff 2 (Health Service Director/RN) agreed Resident 4 had experienced a significant change of condition related to loss of functional mobility.There was no documented evidence an RN assessment for the resident's significant change of condition had been completed.On 07/20/23, the need to ensure all significant changes of condition were assessed by the facility RN, including findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status, and interventions, for 1 of 3 sampled residents (#7) who experienced significant changes of condition. The resident experienced ongoing, severe weight loss. 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 dementia, Parkinson's Disease, and repeated falls. Resident 7 was identified during the acuity interview as experiencing a significant weight loss and was receiving hospice services. The resident's service plan available to staff, dated 10/09/23, interim service plans dated 09/18/23 to 01/02/24, 12/01/23 through 01/02/24 MARs, progress notes dated 09/18/23 to 01/02/24, and weight records dated 07/05/23 to 01/01/24 were reviewed and interviews were conducted.a. Review of Resident 7's weight records revealed the following:* 10/05/23 - 102.4 pounds;* 11/05/23 - 104.2 pounds;* 12/05/23 - 95.8 pounds; and* 01/01/24 - 88.8 pounds.Between 11/05/23 and 12/05/23 Resident 7 lost 8.4 pounds, or 8% of his/her total body weight, which was considered severe and constituted a significant change of condition, requiring an RN assessment. Resident 7 continued to lose weight and experienced an additional 7 pound weight loss between 12/05/23 and 01/01/24 or 7.3% of his/her body weight, constituting another severe loss.There was no documented evidence an RN completed an assessment of the severe weight loss. The severe, ongoing weight loss represented a serious risk to the health, safety, and welfare of the resident.The need to ensure all significant changes of condition were assessed by an RN, with documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 25 (Executive Director) and Staff 26 (RN/Health Services Director) on 01/05/24. They acknowledged the findings.Refer to C270, example 1a.

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 2 of 2 sampled residents (#s 1 and 4) who received insulin injections by non-licensed facility staff. Findings include, but are not limited to:During the acuity interview on 07/17/23, Residents 1 and 4 were identified to be administered insulin injections by non-licensed staff. This prompted the survey team to request the facility's delegation records.Review of the facility's delegation records indicated the facility failed to document the following:* Skills and abilities of non-licensed staff, through individual observation/return demonstration of competence in performing the designated task;* Rationale for how frequently the client should be reassessed by the RN; and* Rationale for how frequently the unlicensed person(s) should be supervised and reevaluated based on the competency of the MT.The need to ensure all staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Executive Director) and Staff 2 (Health Service Director/RN). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols and to provide a safe, sanitary, and comfortable environment for 1 of 4 sampled residents (#1). Findings include, but are not limited to:Observations made during the survey, 07/17/23 through 07/20/23, determined the facility failed to adhere to universal precautions for infection control in the following areas:1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including vascular dementia and dysphagia. Observations and interviews with staff during the survey identified s/he relied on staff for incontinence care and meal assistance needs. * On 07/17/23 at 8:47 am, Staff 24 (CG) was observed providing ADL incontinence care for Resident 1. During the observation, Staff 24 donned gloves without performing hand hygiene. Staff 24 proceeded to remove the soiled incontinence brief and perform perineal care with wipes while wearing soiled gloves. Staff 24 failed to doff soiled gloves, perform hand hygiene, and don clean gloves before touching the resident's body, placing clean incontinence products, and providing dressing assistance. The soiled brief was placed on Resident 1's bed. Staff 24 then assisted Resident 1 with dressing. Staff 24 then deposited the soiled brief in a trash receptacle. While still wearing the soiled gloves, Staff 24 transferred Resident 1 from the bed to the wheelchair, brushed his/her hair, and assisted with washing his/her face with a washcloth. Staff 24 proceeded to take Resident 1 to the dining room in his/her wheelchair, and then doffed gloves and washed her hands.* On 07/18/23 at 8:51 am, Staff 14 (CG) was observed providing ADL incontinence care for Resident 1. During the observation, Staff 14 removed the soiled incontinence brief and performed perineal care with spray and wipes while wearing soiled gloves. Staff 14 removed the soiled incontinence brief and placed it in the trash can. Staff 14 failed to doff soiled gloves, perform hand hygiene, and don clean gloves before touching the resident's body, placing clean incontinence products, and assisting Resident 1 with dressing, grooming, washing his/her face, and transferring to a wheelchair. Staff 14 proceeded to take Resident 1 to the dining room in his/her wheelchair, and then removed the soiled gloves and started pushing the kitchen cart with dirty dishes without performing hand hygiene.* On 07/18/23 at 09:06 am, Staff 22 (CG) was observed providing meal assistance for Resident 1. During the observation, Staff 22 had her right hand gloved to assist in feeding Resident 1, and her left hand was not gloved. Staff 22 was observed to take a piece of bacon from a separate plate with her left hand and eat it while providing meal assistance to Resident 1.2. During lunch and breakfast observations throughout the survey, care staff serving food were not wearing aprons in both Mountainside and Oceanside communities.During an interview on 07/19/23 at 11:45 am, Staff 14 confirmed that aprons were available to care staff to wear while serving food, and clean cloth aprons were observed in kitchenette.The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) on 07/20/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols. This is a repeat citation. Findings include, but are not limited to:Observations completed 01/02/24 through 01/05/24, noted the following:a. During lunch service, in both the Oceanside and Mountainside dining rooms, observations revealed multiple staff who did not complete one or more of the following:* Proper hand sanitization prior to and/or in-between assisting residents with dining; and* The use of a protective barrier when assisting with meals.b. During an observation on 01/03/24 at 2:20 pm, an unsampled Resident exited room 207, undid his/her pants, and proceeded to urinate in the hallway directly on the floor. When the Resident was finished, s/he adjusted his/her pants and ambulated to the opposite end of the hall close to room 208. By 2:25 pm, this surveyor had notified Staff 10 (MT) and Staff 35 (Housekeeper) of the soiled area covering an approximate 12" x 14" area. At 2:45 pm, there had been no observations of the soiled area being disinfected or cleaned. When the area was observed the following day, it was clean. The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 25 (Executive Director) on 01/05/24. She 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 and documented by the same person who administered the medications for 4 of 4 sampled residents (#s 1, 2, 3, and 4). Findings include, but are not limited to:In an interview with Staff 18 (CG/MT) on 07/18/23, she stated when she returned to work from her vacation she was unable to log-in to the facility's medication administration record system. She indicated she told Staff 1 (Executive Director) about the issue on 07/17/23. She said she had been initialing for medication administration under another staff's log-in, then noting in the exception, "Administered by [Staff 18]."Review of Charting Notes dated 04/18/23 through 07/17/23 and MARS dated 06/01/23 through 07/17/23 for Residents 1, 2, 3, and 4 revealed Staff 18 had made a note about initialing for administration using another MTs log-in in each of the resident charts on 07/14/23 or 07/16/23.The need for all medications to be administered and documented by the same person was discussed with Staff 1 (Executive Director) on 07/20/23. She 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 written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 1, 2, and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 02/2021 with diagnoses including vascular dementia and type 2 diabetes.Resident 1's MARs/TARs, dated 06/01/23 through 07/17/23, corresponding progress notes, and prescriber orders were reviewed and revealed the following:Resident 1 was receiving the following medications for diabetes:a. Basaglar 100-U/ml pen 3 ML: inject 20 units subcutaneously every morning.The Basaglar was "held per MD orders" seven times in June and four times in July when CBGs were documented to be below 70, despite no documented evidence the physician had instructed the facility to hold the medication.b. Insulin Aspart 100-U/ML pen to be administered four times per day before meals and at bedtime. The amount of insulin administered was based on the resident's CBG level according to the following sliding scale:* Less than 200: 0 units;* 200 - 250: 2 units;* 251 - 300: 3 units;* 301 - 350: 4 units;* 351 - 400: 5 units; and* Above 400, call provider.The sliding scale insulin was not administered as prescribed on 11 occasions in June and three occasions in July.c. Glutose 15 40% Gel: Take 15 grams by mouth as needed for low blood sugar, CBG less than 70.On 20 occasions throughout June and July, Resident 1's CBGs were less than 70, and there was no documented evidence the facility had administered the Glutose Gel.During an interview on 07/18/23 at 1:20 pm, Staff 2 (Health Services Director/RN) acknowledged the insulin had not been administered per sliding scale on 14 occasions and that there was no documented evidence that Glutose Gel had been administered as prescribed in June or July.The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) on 07/20/23. They acknowledged the findings, and no additional information was provided.
3. Resident 3 moved into the facility in 03/2023 with diagnoses including major cognitive impairment and a history of alcohol abuse.Resident 3's signed physician orders and 06/01/23 through 07/17/21 MARs were reviewed. The following deficiencies were identified: *Resident 3's MAR indicated s/he was receiving Losartan 25 mg once daily (for hypertension). There were no signed physician orders for these medications found in the resident record.On 07/20/23, the need to ensure signed provider orders were documented in the resident's record for all medications the facility was responsible for administering was discussed with Staff 1 (Executive Director). She acknowledged the findings.
2. Resident 2 was admitted to the facility in 04/2021 with diagnoses including dementia without behavioral disturbance, diastolic heart failure, and osteoarthritis in both knees.A review of the resident's 06/01/23 through 07/17/23 MARs and physician orders revealed the following medications were discontinued on 06/07/23:* Haloperidol (for agitation);* Hyoscyamine (for secretions); and* Lorazepam (for anxiety).There was no documented evidence the facility had signed physician orders to discontinue these medications.The need to have signed physician orders in the resident's chart for all discontinued medications was discussed with Staff 1 (Executive Director) on 07/20/23. She acknowledged the findings.
2. Resident 6 was admitted to the MCC in 07/2021, with diagnoses including hypertension, Diabetes, and dementia. Review of the resident's MAR, dated 12/01/23 through 12/31/23, and current physician orders revealed the following medications or procedures were not carried out as ordered: * Resident 6 had an order regarding the administration of PRN haloperidol, which directed "give acetaminophen first to rule out pain as a source of agitation." On 12/05/23, haloperidol was administered to the resident without giving acetaminophen first, as ordered; and* Resident 6 had an order to "get resident weight monthly. Notify RN, RCC, ED if weight gain or loss of 3 lbs or more." There was no weight recorded for the resident in December.On 01/05/24, the need to ensure all medication and treatment orders were carried out as prescribed was discussed with Staff 25 (Executive Director) and Staff 26 (RN/ Health Services Director). They acknowledged the findings.


3. Resident 5 was admitted to the facility in 07/2022 with diagnoses including dementia.Review of the resident's 12/01/23 through 01/04/24 MAR and current physician orders revealed the following:* The resident was prescribed hydromorphone (a narcotic pain reliever), 2 mg, 0.5 tablet (1 mg) by mouth every four hours scheduled. MAR documentation indicated the resident was receiving the hydromorphone four times a day, or every six hours, from 12/23/23 through 01/04/24. The MARs also indicated the medication had been discontinued on 12/27/23, and the facility was unable to provide a discontinuation order from a physician.* Hydromorphone 2 mg, 0.5 tablet (1 mg) by mouth was also prescribed every hour as needed for pain. The MAR indicated this medication had also been discontinued on 12/27/23, and there was no signed physician order to stop the medication.* The resident was prescribed Senna 8.6 mg one tab every day as needed to prevent constipation and Bisacodyl 10 mg suppository one per day every day as needed for constipation, to be started on day three of no bowel movement. Documentation on the 12/2023 MAR indicated the resident did not have a bowel movement on 12/27/23 through 12/31/23 until after 8:00 pm. There was no documentation the resident was administered either PRN bowel care medication.* Morphine sulfate 20 mg/5 ml solution (for pain) was on the 12/2023 MAR with instructions to offer Tylenol before administering the narcotic. Morphine was administered 11 times between 12/19/23 and 12/22/23, with no documentation Tylenol had been administered first.The need to have physician orders in the resident's chart and to carry out all physician orders as prescribed was discussed with Staff 25 (Executive Director) and Staff 26 (RN/Health Services Director) on 01/05/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 3 of 3 sampled residents (#s 5, 6, and 7) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 02/2023 with diagnoses including dementia. Review of the resident's 09/18/23 through 01/02/24 progress notes, 12/01/23 through 01/04/24 MAR, and current physician orders revealed the following:a. The resident was prescribed the following medications:* Acetaminophen (for pain), 325 mg, two tablets (650 mg) by mouth every six hours as needed; and * Morphine sulfate (for pain), 20 mg, 0.25 ml (5 mg) by mouth every four hours as needed, with instructions to "give Tylenol first. If resident still showing signs of pain after an hour you may give morphine."Staff administered the morphine without first administering acetaminophen on the following dates:* Two times on 12/6/23;* One time on 12/7/23;* Two times on 12/13/23;* Three times on 12/14/23;* One time on 12/18/23;* One time on 12/20/23;* One time on 12/25/23;* Two times on 12/27/23;* One time on 12/28/23; and * Two times on 12/29/23.b. The resident was prescribed lorazepam 0.5 mg, one tablet by mouth every four hours as needed for anxiety or dyspnea. Staff documented in an 11/25/23 progress note the lorazepam was administered for "agitation."The need to ensure medication orders were carried out as prescribed was discussed with Staff 25 (Executive Director) and Staff 26 (RN/Health Services Director) on 01/05/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions for multiple PRN pain medications were on the MAR for 1 of 1 sampled resident (#2). Findings include, but are not limited to:Resident 2 was admitted to the facility in 04/2021 with diagnoses including dementia without behavioral disturbance, diastolic heart failure, and osteoarthritis in both knees.Review of the resident's 06/01/23 through 07/17/23 MARs and physician orders revealed the resident was prescribed the following PRN pain medications:* Acetaminophen 325 mg tab; and* Tramadol 50 mg tab, to be given only if acetaminophen was "ineffective."The resident also had an order for scheduled acetaminophen, to be administered at 9:00 am and 5:00 pm each day.There were no documented parameters instructing staff in which order and at what intervals to administer the PRN pain medications.The need to ensure all PRN medications had resident-specific parameters and instructions was discussed with Staff 1 (Executive Director) on 07/19/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychotropic medication, for 2 of 2 sampled residents (#s 1 and 4) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to:1. Resident 4 was admitted to the memory care community in 12/2013 with diagnoses including dementia, diabetes, and hypertension.Review of the resident's 06/01/23 through 07/17/23 MARs revealed he/she was prescribed Haloperidol 2 mg/ml and lorazepam 2 mg/ml (psychotropic medications) as needed for anxiety. Each of these medications was administered once in July.The facility failed to ensure the MAR included specific parameters regarding the sequential order of use for these PRN medications, and there was no documented evidence non-pharmacological interventions were attempted without success prior to administration of these medications.On 07/20/23 the need to ensure the MAR included specific parameters regarding the sequential order of use for PRN psychotropics and documentation that non-drug interventions were tried unsuccessfully prior to administration of a PRN psychotropic was discussed with Staff 1 (Executive Director) and Staff 2 (Health Service Director/RN). They acknowledged the findings.
2. Resident 1 was admitted to the facility in 02/2021 with diagnoses including vascular dementia and depressive disorder.The resident was prescribed Olanzapine 2.5 mg twice daily as needed for schizophrenia.The resident's 06/01/23 through 07/17/23 MARs were reviewed and revealed staff administered PRN Olanzapine on nine different occasions.There were no resident-specific parameters on the MAR to indicate behaviors for when the medication would be administered or non-pharmacological interventions to try prior to administration.In an interview on 07/19/23 at 12:55 pm, Staff 3 (RCC) confirmed there were no resident-specific parameters or non-pharmacological interventions to attempt prior to administration of a PRN psychotropic on the electronic version of the MAR.The need to have resident-specific parameters and to document non-pharmacological interventions attempted with ineffective results prior to administering a PRN psychotropic medication was discussed with Staff 1 (Executive Director) and Staff 3 on 07/20/23. They acknowledged the findings.
2. Resident 6 was admitted to the MCC in 07/2021, with diagnoses including hypertension, diabetes, and dementia. Review of Resident 6's MAR, dated 12/01/23 through 12/31/23, indicated the resident was prescribed the PRN psychotropic haloperidol 0.5 mg, to be given "1 tablet by mouth daily as needed for agitation." This medication was administered on 12/05/23.There was no documented evidence non-pharmacological interventions were tried and documented as unsuccessful, prior to administration of the haloperidol.In an interview on 01/04/24, Staff 25 (Executive Director) and Staff 26 (RN/ Health Services Director) both acknowledged the failure to attempt and document non-drug interventions prior to the PRN psychotropic administration.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented as unsuccessful prior to PRN psychotropic medication being administered for 2 of 3 sampled residents (#s 5 and 6) who were prescribed as needed psychotropic medications. This is a repeat citation. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 07/2022 with diagnoses including dementia.Review of the resident's 12/01/23 through 01/04/24 MARs and physician orders revealed the following psychotropic prescriptions:* Haloperidol (a psychotropic medication) 2 mg/ml concentrate, 1 ml every two hours "as needed for agitation, restlessness, increased confusion, combativeness, and/or nausea, vomiting" started 12/19/23;* Lorazepam 0.5 mg tabs, every four hours as needed for "anxiety or insomnia" started 12/19/23;* Quetiapine fumarate 25 mg tabs, one tab two times a day "as needed for agitation." This medication was discontinued on 12/19/23; and*Quetiapine fumarate 25 mg tabs, every four hours as needed "for nausea, vomiting, or agitation," also discontinued on 12/19/23.The following were identified:* Non-pharmacological interventions for the resident's PRN psychotropic medications were consistently documented as ineffective prior to administration of the psychotropic; and* On 12/19/23 both quetiapine and lorazepam were administered at the same time (7:41 pm).The findings were discussed with Staff 25 (Executive Director) and Staff 26 (RN/Health Services Director) on 01/05/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:The facility's ABST was reviewed on 07/18/23 and discussed with Staff 1 (Executive Director) on 07/18/23, 07/19/23, and 07/20/23. She reported the ABST was populated by the service plan for each resident.ABST data was reviewed for Residents 1, 2, 3, and 4. All sampled residents had 10, 20, or 30 minutes listed for "wound treatment," but there was no documented evidence any of these residents had wounds.In addition, the facility provided three different printouts of their ABST:* The first report was incomplete, showing only 15 of the 22 required ADLs. The printout had cut off the remainder of the ADLs.* The second report listed 15 ADLs, and they did not match the ADLs listed in the rule.* The third report listed all required ADLs.Staff 1 was unsure why the second report showed different ADLs.The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 on 07/19/23 and 07/20/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 8, 14, and 16) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 07/18/23 and identified the following:Staff 8 (MT), hired 03/11/23, Staff 14 (CG), hired 04/03/23, and Staff 16 (CG), hired 04/14/23, lacked documentation of demonstrated competency in first aid/abdominal thrust.During an interview at 11:45 am on 07/18/23, Staff 1 (Executive Director) confirmed the lack of documented evidence the above sampled staff completed first aid and abdominal thrust training. A plan of correction to ensure staff were trained in first aid and abdominal thrust was requested and received on 07/18/23.The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 on 07/18/23. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired direct care staff (#31) demonstrated competency of skills in all assigned job duties, including first aide and abdominal thrust, within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Training records reviewed on 01/04/24 identified the following:There was no documented evidence Staff 31 (MT), hired 10/02/23, demonstrated competency in first aid/abdominal thrust within 30 days of hire.The need to ensure all direct care staff demonstrated competency in all assigned job duties within 30 days of hire including first aide and abdominal thrust, was discussed with Staff 25 (Executive Director) on 01/05/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:On 07/17/23, fire drill and fire and life safety training records for the previous six months were reviewed, Staff 1 (Executive Director) was interviewed and the following was revealed:* Fire drill records lacked the following components: - Escape route used; - Evidence fire drills were conducted at different times of the day including evening and night shifts; - Problems encountered, comments relating to residents who resisted or failed to participate in the drills; - Staff members on duty and participating; - Number of occupants evacuated; and - Evidence alternate routes were used during fire drills.* There was no documented evidence fire and life safety instruction was provided to staff on alternate months.The requirements regarding fire drill documentation and fire and life safety instruction for staff were reviewed with Staff 1 and Staff 6 (Environmental Services Director) on 07/18/23. They acknowledged the findings.

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 C260, C270, C280, C295, C303, C330, C372, C513, Z155, and Z165.

Based on observation and interview, it was determined the facility failed to ensure outside surfaces were maintained in good repair. Findings include, but are not limited to:Observations of the interior courtyards on 07/17/23 revealed multiple drop-offs along the pathways, from two to four inches, which presented a fall hazard.The need to ensure outside surfaces were maintained in good repair was discussed with Staff 1 (Executive Director) and Staff 6 (Environmental Services Director) on 07/18/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure interior and exterior materials and surfaces were kept clean and in good repair and free from unpleasant odors. Findings include, but are not limited to:The interior of the building was toured on 07/17/23 at 9:30 am and the following was identified:* There was a urine odor at the entrance and throughout the south Mountainside unit that did not dissipate during the survey;* Walls throughout the facility had food splashes, drips, gouges, and chipped paint;* Orange couches and striped chairs in the common areas had stains on the arms, seat cushions, and frames;* One ceiling light in the Mountainside dining area was missing a cover;* Baseboard was missing on the wall to the right of the stove in the south Oceanside kitchenette and to the right of the low cabinets in the north Oceanside kitchenette; and* The floor in the spa room was chipped and peeling.The need to ensure the environment was kept clean and in good repair and free of odors was discussed with Staff 1 (Executive Director) and Staff 6 (Environmental Services Director) on 7/18/23. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the indoor environment was kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:During observations conducted 01/02/24 through 01/05/24, the following were found to be in need of cleaning and/or repair:* Baseboards throughout facility had spills/splatters, chips/cracks/gouges, warped material where baseboard was detaching from wall, and/or missing sections;* The walls throughout facility had spills/splatters, drips, gouges, and chipped paint;* The ceiling in the Oceanside kitchenette had a dark splatter;* Living room sofas and cloth armchairs throughout the facility had dark stains on arm rests and seat cushions and chipped/cracked wooden legs and/or frames;* Dining room chairs had broken/heavily worn material on seat cushions and chipped/cracked wooden chair frames;* The carpet at the entry of the Mountainside pod had an 11" x 3" tear where the carpet was missing;* The carpet at the entry of the Oceanside pod had a 6" x 1" tear where the carpet was missing;* The carpet throughout the facility had multiple 1" x 1" areas of discoloration;* The carpet throughout the facility had multiple seams where the carpet had separated, creating a trip hazard;* There were multiple transitions throughout the facility that had gaps of missing material and/or were loose, creating trip hazards;* The flooring in the Oceanside kitchenette had multiple gaps between floor planks, creating a trip hazard and an uncleanable surface;* The Mountainside kitchenette cabinet on left, had a cabinet door that had a half inch hole and was too small to cover the cabinet opening; * The Mountainside kitchenette counter tops had sections of missing laminate ranging from one inch to seven inches in length; * One ceiling light in the Mountainside dining area was missing a cover;* The spa room floor had a 12" x 12" area that was chipped and peeling;* Wooden handrails throughout the facility had scratches and gouges exposing material and creating an uncleanable surface; * The screen on the window located in room 205 side "B", had an 11" tear; and * Bookshelf located near both Mountainside living rooms had broken shelves.On 01/05/24 at 9:10 am, the areas in need of cleaning and/or repair were reviewed with Staff 25 (Executive Director) and Staff 6 (Environmental Services Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by people. Findings include, but are not limited to:The facility was toured on 07/17/23 and the following was identified:* A wall heater was installed in the spa room which, when turned on, reached a temperature of 157 degrees Fahrenheit.The need to ensure wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by people was discussed with Staff 1 (Executive Director) and Staff 6 (Environmental Services Director) on 07/18/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure a call system connected resident units to the care staff center or staff pagers. Findings include, but are not limited to:The facility was toured on 07/18/23 and the following was revealed:The pull cord in Room 112 A was pulled at 12:00 pm on 07/18/23. No one responded to the call from 12:00 pm to 12:30 pm. Staff 9 (MT) was asked to demonstrate how the facility's call system worked. She stated when a resident pulls a cord for assistance, the notification goes to the MT's computers, and the MTs inform the caregivers of the call. When a demonstration was requested, Staff 9 was unable to get the system loaded on her computer.During an interview with Staff 1 (Executive Director) on 07/18/23, she stated calls were also received in the staff office via a device that showed which room number had called. When a demonstration was requested, she was unable to login to show how the call system worked.The need to ensure a call system that connects resident units to the care staff center or staff pagers was discussed with Staff 1 on 07/18/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure only the resident and appropriate staff had a key access to the resident's unit. Findings include, but are not limited to:Observations were made of the memory care units and interviews with staff were completed.On 07/17/23, Staff 4 (Lifestyle Director) stated one key opened all the doors in the facility. Staff 6 (Environmental Services Director) demonstrated opening a locked door by inserting his fingernail in the slot on the lock and turning it.Observations of resident rooms throughout the survey revealed they had lockable doors.Any resident who had a key to their room would be able to open any other resident unit door at any time.The need for only the resident and appropriate staff to have key access to a resident's room was discussed with Staff 1 (Executive Director) on 07/20/23. She 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 C 152, C 160, C231, C 295, C 361, C 372, C 420, C 510, C 513, C 540, C 555, and 1518.
Based on observation, interview, and record review, it was determined the facility failed to provide non-health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C295, C372, and C513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly hired staff (#s 8, 14, and 16) completed all required pre-service orientation training prior to performing any job duties and demonstrated satisfactory performance in any task assigned in the provision of individualized resident services before independently providing personal care or other services to residents. Findings include, but are not limited to:Staff training records were reviewed on 07/18/23 and the following was identified:1. There was no documented evidence Staff 8 (MT), Staff 14 (CG), and Staff 16 (CG), hired 03/11/23, 04/03/23, and 04/14/23, respectively, completed one or more of the following pre-service orientation training topics prior to performing any job duties:* Abuse reporting requirements;* Infectious disease prevention;* Fire safety and emergency procedures;* Written job description; and* Pre-service dementia care training.2. There was no documented evidence Staff 8 (MT), Staff 14 (CG), and Staff 16 (CG), hired 03/11/23, 04/03/23, and 04/14/23, respectively, demonstrated competency within 30 days of hire or prior to working independently with residents 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 that require assessment, treatment, observation and reporting; and* General food safety, serving, and sanitation; and* Medication administration.During an interview on 07/18/23 at 11:45 am, Staff 1 (Executive Director) verified there was no documented evidence of medication administration competencies for the sampled staff. The survey team requested a plan of correction to ensure MTs were trained in medication administration prior to working on the floor. A plan was received and accepted on 07/18/23 at 3:15 pm.The need to ensure staff completed all required pre-service orientation training prior to performing any job duties and demonstrated satisfactory performance in all assigned job duties within 30 days of hire was reviewed with Staff 1 on 07/18/23 at 12:00 pm. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly hired staff (#s 31 and 34) completed all required pre-service orientation training prior to performing any job duties and demonstrated satisfactory performance in any task assigned in the provision of individualized resident services before independently providing personal care or other services to residents. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 01/04/24 and the following was identified:1. There was no documented evidence Staff 34 (MT), hired on 10/02/23, completed one or more of the following pre-service orientation topics prior to performing any job duties:* Abuse reporting requirements; and* Infectious disease prevention.2. There was no documented evidence Staff 31 (MT) and Staff 34 (MT), both hired 10/02/23, completed one or more of the following pre-service dementia care training or additional dementia care training topics prior to performing any job duties:* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;* Environmental factors that are important to a resident's well-being;* Family support and the role the family may have in the care of the resident;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia; including an orientation to the resident service plan; and* Use of supportive devices with restraining qualities in memory care communities.3. There was no documented evidence Staff 31 (MT) and Staff 34 (MT), both hired 10/02/23, demonstrated competency within 30-days of hire or prior to working independently with residents 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 that require assessment, treatment, observation and reporting;* General food safety, serving, and sanitation; and* Medication administration.During an interview on 01/04/24, Staff 25 (Executive Director) verified there was no documented evidence of medication administration competencies for the sampled staff. Staff 25 was informed that staff who had not demonstrated competencies were to be removed from administering medications until required competencies were complete. The need to ensure staff completed all required pre-service orientation training prior to performing any job duties and demonstrated satisfactory performance in all assigned job duties within 30 days of hire was reviewed with Staff 25 on 01/05/24. She 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 C 243, C 252, C 260, C 270, C 280, C 282, C 301, C 303. C 310, and C 330.
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 C260, C270, C280, C303, and C330.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 3 of 3 sampled residents (#s 5, 6, and 7) whose service plans were reviewed. Findings include, but are not limited to:Residents 5, 6, and 7's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. On 01/05/24, the need to develop individualized service plans which addressed residents' nutrition and hydration needs was discussed with Staff 25 (Executive Director) and Staff 26 (RN/Health Services Director). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 02/2021 with diagnoses including vascular dementia and Wernicke-Korsakoff syndrome.Resident 1's record documented behavior to include yelling and cursing at staff or other residents and socially inappropriate comments or actions.The resident's service plan, dated 07/12/23, lacked specific instruction to staff to assist staff in minimizing the negative impact of his/her behaviors.During survey, the resident was observed on multiple occasions yelling and cursing at staff while in his/her room and in common areas.There was no documented evidence the facility had evaluated the residents behaviors or updated the service plan as a result of the evaluation. In an interview on 07/19/23 at 11:45 am, Staff 14 (CG) stated that taking the resident outside and giving him/her compliments were effective in redirecting behaviors. This information was not provided in the residents current service plan. The need to ensure resident behaviors which negatively impacted the resident and others in the community were evaluated and the service updated as a result of the evaluation, was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) on 07/20/23. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the memory care community, update the resident's service plan, and initiate outside consultation or acute care when indicated, for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Resident 3 displayed repetitive exit-seeking behaviors and aggression towards other residents, which placed the resident and others at risk of harm or injury. Findings include, but are not limited to:1. Resident 3 moved into the facility in 03/17/23 with diagnoses including major cognitive impairment and a history of alcohol abuse.During the acuity interview on 07/03/21, Resident 3 was identified as having exit-seeking behaviors, having been involved in resident-to-resident altercations, and being a smoker.Review of Resident 3's progress notes indicated s/he had been involved in the following:* 04/29/23 - hit another resident on the right side of his/her head;* 05/04/23 - took another resident's phone, called him/her a "stupid [b****]," and told the med tech to "[f***] off";* 05/06/23 - verbally aggressive toward an unsampled resident;* 05/08/23 - yelled at another resident after breakfast and told him/her to go to their room; * 05/10/23 - pulled a chair away from an unsampled resident after s/he said s/he wanted to sit in the chair. Resident 3 pulled the chair toward himself/herself, then pushed it back to the other resident, hitting his/heir right knee;* 05/10/23 - tried to stab another resident with a fork;* 05/11/23 - yelled at other residents and staff, and tried to throw something at an unsampled resident who was approaching his/her door;* 06/17/23 - was verbally abuse to another resident;* 07/02/23 - tried to trip another resident;* 07/03/23 - smoked in his/her room;* 07/04/23 - eloped after being left sitting outside the front door of the facility and staff were unable to locate him/her; and * 07/15/23 - followed his/her family member out the front door and refused to go back inside the building.Resident 3's service plan and quarterly evaluation, dated 06/12/23, instructed staff to redirect him/her when s/he was having behaviors by playing music in common areas and/or play podcasts on his/her phone. In an interview on 07/18/23, Staff 1 (Executive Director) confirmed the facility had not evaluated Resident 3's behaviors. There was no documented evidence the facility had evaluated the residents behavior, or updated the residents service plan based on the evaluation. Resident 3 continued to exhibit negative behaviors toward him/herself and other residents. The facility's failure to evaluate the residents behaviors put Resident 3 and other residents at risk of harm or serious injury. On 07/18/23, survey requested an immediate plan to address Resident 3's elopements and behaviors. The plan was provided and approved by the survey team at approximately 3:25 pm, and the situation was abated.On 07/18/23, the need for evaluation and service planning for behavioral symptoms which negatively impacted the resident and others was discussed with Staff 1. She acknowledged the findings.


Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 1 of 3 sampled residents (#7) whose records were reviewed. 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 dementia. The resident's current service plan available to staff dated 10/09/23, interim service plans dated 09/18/23 to 01/02/24, and progress notes dated 09/18/23 to 01/02/24 were reviewed. Interviews were conducted and observations were made. The following was identified:* Observations made on 01/03/24 and 01/04/24 revealed distracted behaviors during ADL tasks; for example, wheeling away from the table during meals. When care staff offered him/her bites of food, s/he moved her head backwards and said "no." S/he also was observed to refuse care staff offered, to assist with putting a sweater on.* Interviews with care staff on 01/03/24 and 01/04/24 revealed the resident often refused care, including offers for assistance with feeding, toileting, dressing, and transferring.* The resident's service plan dated 10/09/23 indicated "no behaviors at this time."* Progress notes dated 09/30/23 and 11/25/23 indicated the resident experienced hallucinations and demonstrated aggressive behaviors toward staff.There was no documented evidence the behaviors had been evaluated and included on the service plan. The need to ensure behavioral symptoms which negatively impacted the resident were evaluated and included on the service or care plan was discussed with Staff 1 (Executive Director) on 01/05/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:Observations conducted 01/02/24 thru 01/05/24, revealed the doors to the exterior courtyard were locked and there was not an inclement weather policy posted. On 01/03/24 at 2:20 pm, a resident was observed attempting to open a door to an outdoor recreation area by room 207, when the resident was unable to open the door. S/he stood at the door for 20 minutes before observations ended.During an interview with Staff 25 (Executive Director) on 01/05/24, she stated she was unaware that staff had locked the doors to the outdoor recreation areas. The need to ensure residents had access to a secured outdoor space without staff assistance was reviewed with Staff 25 and Staff 6 (Environmental Services Director) on 01/05/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:On 01/02/24 through 01/05/24, observations of two exterior courtyards revealed multiple pieces of furniture made of lightweight material which were easily moveable and not of sufficient weight or design to prevent aiding a resident in elopement.The need to ensure the facility had furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement, was discussed with Staff 25 on 01/05/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of or inside their rooms at any time. Findings include but are not limited to: Observations made between 01/02/24 and 01/05/24 identified the following: * Multiple unsampled residents residing in the Mountainside pod, were locked out of rooms; * On 01/04/24 in the Mountainside pod, there were five identified resident rooms locked; and* On 01/05/24 in the Mountainside pod, there were four identified resident rooms locked (Room #s 103, 104, 110, and 111).On 01/05/24, during staff interviews, the following was identified:* At 11:15 am Staff 18 stated they locked some resident rooms in the Mountainside pod due to a resident who entered others' rooms without permission. They stated they used to do this in the Oceanside pod, when the same resident resided there; and* At 11:18 am Staff 20 stated they started locking resident rooms in the Mountainside pod when they [administration] transferred a resident from the Oceanside pod who was wandering and entering other resident apartments.The need to ensure residents were not locked out of or inside their rooms at any time was discussed with Staff 25 (Executive Director) on 01/05/24. She acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 01/24/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on observation and interview it was confirmed that the facility failed to have their staffing plan posted. Findings include but not limited to:During an unannounced site visit on 1/24/2023, Compliance Specialist (CS) was unable to locate the facility's posted staffing plan.During interview, Staff #3 (S3) stated that the posted staffing plan went missing and they currently don't have one.Plan of correction: Executive Director (ED) had their Business Office Manager (BOM) order a board and stand on 1/24/2023 to display their posted staffing plan and manager on duty information. Facilty to post a word document with this information by end of day 1/25/2023.

Based on interview and record review it was confirmed that the facility failed to promptly investigate all reports of abuse and suspected abuse. Findings include but not limited to:During an unannounced site visit on 1/24/2023, Compliance Specialist (CS) interviewed Staff #2 (S2) who reported an incident on 1/20/2023 when only one medication technician (MT) was working in the morning until a second MT arrived at 0845. S2 stated that R1 received their morning medications late because of this and that afternoon medications were held because the morning medications were late. S2 stated that no incident report was completed for this. During separate interviews Staff #6 and #7 stated: *R1 was moved from one side of building on 1/19/2023 but that all medications and treatments had not been moved to the appropriate cart. *The Electronic Medication Administration Report (EMAR) was not reflective of the move on the morning of 1/20/2023. *Only R1's morphine was moved to the other medication cart. *S6 was working as the only MT until S7 arrived at 0845. *S6 popped and prepared R1's medications. *At some point during the day R1 was removed from S6's EMAR. *S7 did not give the medications that S6 prepared for R1 until later in the morning, but was unsure of the time. *Afternoon medications were held because the morning medications were late.A review of Resident #1 (R1)'s Medication Administration Report (MAR) and progress notes for January 2023 revealed that R1 missed afternoon medications due to receiving morning medications late.These findings were reviewed with Staff #3 on 1/24/2023 who confirmed that there was no incident report or investigation and that this incident was not reported to Adult Protective Services.Plan of Correction: CS emailed DHS's Abuse Reporting and Investigation guide to Executive Director (ED). ED to in-service staff on facility' s incident report policy and abuse and neglect reporting policy beginning 1/24/2023. Incident reports and investigations to be reviewed in standup meeting daily with all pertinent staff.

Based on interview and record review it was confirmed that the facility failed to assist resident with toileting and bowel and bladder management. Findings include but not limited to:During an unannounced site visit on 1/25/2023, Compliance Specialist (CS) reviewed Resident #2 (R2)'s most recent service plan dated 11/17/2021 which revealed R2 needed full assistance with toileting needs and that staff were to toilet R2 up to four times per shift using a bedside commode and perform peri care after toileting. R2's progress notes for May 2022 revealed five occassions when resident was noted to have done their own peri care, was upset about not getting cleaned after a large bowel momement, was upset that staff did not respond to their call light, did not get them cleaned up, and were unable to help her fast enough. During interview Staff #3 stated that staff are to document completed tasks on task sheets but that facility had four different Resident Care Coordinators recently so task sheets were not available for that time. These findings were reviewed with S3 on 1/24/2023 who was in agreement.Plan of Correction: CS emailed Acuity-Based Staffing Tool (ABST) resources to Executive Director (ED). ED will have all residents entered into ABST by 2/3/23. Resident Care Coordinator and nurse to begin auditing all service plans tomorrow 1/25/23. Facility will have all service plans updated by 2/3/23. ED to verify task sheets are in place for staff and begin reviewing in standup meeting daily.

Based on record review and interview it was confirm that the facility failed to complete quarterly service plans. Findings include but not limited to:During an unannounced site visit on 1/24/2023, Compliance Specialist requested the most recent service plan for Resident #2 (R2) which was dated 11/17/2021. The most recent service plan for Resident #1 (R1), taken from the facility's service planning binder was dated 9/1/2022. A review of Resident #3 (R3's) latest service plan, recevied by email on 1/25/2023 was dated 3/6/2022.During interview, Staff #3 (S3) stated that R2 moved out of the facility in August 2022. S2 stated that they are not surprised that their service plans are out of date as the facility has had four to five Resident Care Coordinators (RCC) since they started and it is their responsibility to manage service planning meetings.Plan of Correction: RCC and nurse to begin auditing all service plans 1/25/23. Facility will have all service plans updated by 2/3/23. Based on observation, interview and record review it was confirmed that the facility failed to provide care as listed in the service plan. Findings include but not limited to:During an unannounced site visit on 1/24/2023, Compliance Specialist (CS) observed Staff # 4 and Staff #5 (S4-S5) enter Resident #1 (R1)'s room to provide incontinence care. During interview, S4 and S5 stated that resident is totally dependent, requiring two person extensive assistance for brief changes as R1 was actively passing.A review of R1's service plan dated 9/1/2022 indicated that staff are to assist R1 to the restroom 3-4 times per shift. No Interim Service Plans (ISP)s related to this need were available.These findings were reviewed with Staff #3 on 1/24/2023.Plan of correction: Resident Care Coordinator and nurse to begin auditing all service plans tomorrow 1/25/23.Facility will have all service plans updated by 2/3/2023. Executive Director to verify task sheets are in place for staff and begin reviewing in standup meeting daily.

During an unannounced site visit on 1/24/2023, Compliance Specialist (CS) interviewed Staff #2 (S2) who reported an incident on 1/20/2023 when only one medication technician (MT) was working in the morning until a second MT arrived at 0845. S2 stated that R1 received their morning medications late because of this and that afternoon medications were held because the morning medications were late.During separate interviews Staff #6 and #7 stated: *R1 was moved from one side of building on 1/19/2023 but that all medications and treatments had not been moved to the appropriate cart. *The Electronic Medication Administration Report (EMAR) was not reflective of the move on the morning of 1/20/2023. *Only R1's morphine was moved to the other medication cart. *S6 was working as the only MT until S7 arrived at 0845. *S6 popped and prepared R1's medications. *At some point during the day R1 was removed from S6's EMAR. *S7 did not give the medications that S6 prepared for R1 until later in the morning, but was unsure of the time. *Afternoon medications were held because the morning medications were late.A review of Resident #1 (R1)'s Medication Administration Report (MAR) and progress notes for January 2023 revealed that R1 missed afternoon medications due to receiving morning medications late. Similar instances also occurred on 1/2/2023 and 1/22/2023.These findings were reviewed with Staff #3 and Staff #8 on 1/25/2023 by phone.Plan of Correction: Medication Technician training will be occurring today to review medication rights and training for charting within their MAR system.

Based on interview and record review it was confirmed that the facility failed to keep an accurate MAR. Findings include but not limited to:During an unannounced site visit on 1/24/2023, Compliance Specialist (CS) interviewed Staff #2 (S2) who reported an incident on 1/20/2023 when only one medication technician (MT) was working in the morning until a second MT arrived at 0845. S2 stated that R1 received their morning medications late because of this and that afternoon medications were held because the morning medications were late.During separate interviews Staff #6 and #7 stated: *R1 was moved from one side of building on 1/19/2023 but that all medications and treatments had not been moved to the appropriate cart. *The Electronic Medication Administration Report (EMAR) was not reflective of the move on the morning of 1/20/2023. *Only R1's morphine was moved to the other medication cart. *S6 was working as the only MT until S7 arrived at 0845. *S6 popped and prepared R1's medications. *At some point during the day R1 was removed from S6's EMAR. *S7 did not give the medications that S6 prepared for R1 until later in the morning, but was unsure of the time. *Afternoon medications were held because the morning medications were late.A review of Resident #1 (R1)'s MAR for January 2023 stated "MEDS GIVEN ON TIME-LATE ENTRY' on 1/20/2023 while a progress note on that date revealed that afternoon meds were missed due to morning meds being late. These findings were reviewed with Staff #3 and Staff #8 by phone on 1/25/2023. Plan of Correction: Medication Technician training will be occurring today to review medication rights and training for charting within their MAR system.

Based on observation, interview and record review it was confirmed that the facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident. Findings include but not limited to:During an unannounced site visit on 1/24/2023 Compliance Specialist observed four caregivers (CG) and two medication technicians (MT) working on the floor.During separate interviews Staff #3 - Staff #4 (S3-S4), Staff #6-#7 (S6-S8) stated: *The facility needs five CGs and two MTs on day and swing shift and two CG and 1 MT on noc. *There is not enough staff on NOC shift. *When we come in in the morning residents have not been changed all night. *Sometimes I am the only one working. *The facility is not using an Acuity-Based Staffing Tool (ABST). *Staffing levels are determined by the task sheets and feedback from staff. *We have not used task sheets since October.A review of the facility's time cards for 1/2/2023, 1/20/2023 and 1/22/2023 revealed that the facility only had three people working on swing shift on 1/2/2023, five people working on day shift on 1/20/2023, one person working on noc shift on 1/20/2023, three people working on swing shift on 1/22/2023 and two people working on noc shift on 1/22/2023.A review of the Resident #1 (R1)'s Medication Administration Record (MAR) and progress notes for January 2023 revealed occasions on 1/2/2023, 1/20/2023 and 1/22/2023 when medications were late and medications were not given due to the previous dose being given late.A review Resident #2 (R2)'s most recent service plan dated 11/17/2021 revealed R2 needed full assistance with toileting needs and that staff were to toilet R2 up to four times per shift using a bedside commode and perform peri care after toileting. R2's progress notes for May 2022 revealed five occasions when resident was noted to have done their own peri care, was upset about not getting cleaned after a large bowel moment, was upset that staff did not respond to their call light, did not get them cleaned up, and were unable to help fast enough. The facility did not have their staffing plan posted. No ABST records were available for review.These findings were reviewed with S3 on 1/24/2023.Plan of Correction: Compliance Specialist emailed ABST resources to Executive Director (ED) at their request. ED will have all residents entered into ABST by 2/3/23. ED to verify task sheets are in place for staff and begin reviewing in standup meeting daily.

Based on observation, interview and record review it was confirmed that the facility failed to fully implement an Acuity Based Staffing Tool. Findings include but not limited to:During an unannounced site visit on 1/24/2023 Compliance Specialist (CS)observed four caregivers (CG) and two medication technicians (MT) working on the floor.During separate interviews Staff #3 - Staff #4 (S3-S4), Staff #6-#8 (S6-S8) stated: *The facility needs five CGs and two MTs on day and swing shift and two CG and 1 MT on noc. *There is not enough staff on NOC shift. *When we come in in the morning residents have not been changed all night. *Sometimes I am the only one working. *The facility is not using an Acuity-Based Staffing Tool (ABST). *Staffing levels are determined by the task sheets and feedback from staff. *We have not used task sheets since October.A review of the facility's time cards for 1/2/2023, 1/20/2023 and 1/22/2023 revealed that the facility only had three people working on swing shift on 1/2/2023, five people working on day shift on 1/20/2023, one person working on noc shift on 1/20/2023, three people working on swing shift on 1/22/2023 and two people working on noc shift on 1/22/2023.The facility did not have their staffing plan posted. No ABST records were available for review.These findings were reviewed with S3 and S8 by phone on 1/25/2023.Plan of Correction: Compliance Specialist emailed ABST resources to Executive Director (ED). ED will have all residents entered into ABST by 2/3/23.

Based on interview and record review, it was confirmed the facility failed to carry out medication and treatment orders as prescribed. Findings include, but not limited to; a. A review of facility's and Resident #1's records, indicated that he/she was ordered [medication x] for "1 tablet by mouth 5 times daily for 7 days....". Administration started 12/21/2020 through 12/28/2020 for a total of 36 administered doses. However, on 12/30/2020, it was noted that there were 4 tabs remaining after the order ended. R1's MAR indicated the remaining doses were administered one dose on 12/30 and four doses on 12/31/2020 for a total of 5 doses. In separate interviews, Staff #2 stated that upon discovery of the remaining doses, he/she contacted the prescriber's office and requested directions and were approved to administer the remaining doses. b. A review of facility's and Resident #2's records, indicated that he/she was prescribed "0.25ML [pain medication] by mouth 3 times daily at 8 a.m., 12 p.m., and 4 p.m...." On 01/09/2021, R2 was administered 4 total doses of this medication. c. A review of the facility's Self-Report Form, dated 12/17/2020, and Resident #3's (R3) Medication Administration Record (MAR), dated November and December 2020, and January 2021, and Progress Notes, indicated that on 11/11/2020, the prescriber ordered "check CBG daily in the AM before breakfast for two weeks". There was no end date entered into the electronic MAR resulting R3 receiving CBG checks for an additional 25 times, until it was identified and discontinued 12/20/2020.In separate interviews on 12/10/2020 and 01/21/2021, Staff #1-#3 stated that medications are to be re-ordered seven days before the medication runs out. New orders are received by the medication aide (MT), are entered into the MAR, faxed to the pharmacy; then the physical order is put into the box for the RCC for a double check for accuracy and the RN third check. Staff #1 stated there was no written policy and procedure for entering new orders and ensuring its accuracy. On 01/29/2021 in a telephone interview, these findings were reviewed with and acknowledged by Staff #2.