Emerald Gardens

Based on observation and interview, it was determined the facility failed to maintain the kitchen in a sanitary manner and ensure food was prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to:

On 08/13/25, from 10:40 am to 2:02 pm, interviews with staff and observations of the facility kitchen, memory care kitchenette, food storage areas, food preparation, and food service were conducted. The following was identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following:

* Walls throughout the facility kitchen;
* Flooring under, around, in-between, and behind large equipment, ice machine, sinks, food and non-food preparation areas, and ware wash area;
* Industrial can opener blade and casing;
* Food traps and/or water drains located under the ware wash machine and under the memory care steam table; and
* The interior of the cabinet drawer located under the microwave memory care kitchenette.

b. The following areas were noted in need of repair:

* The walls and base board located under and around the ware wash area and ice machine had cracked, broken, and/or missing material and was not maintained in a way to ensure proper sanitization and infection control practices;
* The ware wash area had different sized metal sheets attached to the wall and beside the ware wash machine and observed to have holes, missing and loose screws, and was not tightly sealed to the wall or maintained in a way to ensure proper sanitization and infection control practices;
* The walls around kitchen entrances had cracked, broken, and/or missing material;
* There was a wooden pallet under the ware wash area with broken and exposed material;
* The exterior of the kitchenette cabinet drawer located under the microwave in the memory care, had a piece of material missing on the left side; and
* The interior of the kitchenette cabinet located under the steam table in the memory care, had a large square section of material, around the steam table drain, was unfinished and had exposed material.

On 08/13/25 at 1:35 pm, Staff 2 (Dining Service Director) and Staff 3 (Cook) toured the kitchen with the surveyor and reviewed the areas identified above.

The need to ensure the kitchen was maintained in a sanitary manner and food was prepared and served in accordance with Food Sanitation Rules was reviewed with Staff 1 (Executive Director) on 08/13/25 at 1:49 pm. She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:

Based on observation and interview, 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 C240.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure infection prevention and control protocols were maintained for 1 of 2 sampled residents (#7) and multiple unsampled residents who were dependent on staff for meal escorts. Findings include, but are not limited to:

Resident 7 moved into the facility in 08/2019 with diagnoses including dementia and stroke and was identified in the acuity interview as having a urinary catheter and was dependent on staff for transfers and escorts.

Observations of staff transferring the resident were conducted on 02/10/25 and 02/11/25 and revealed the following:

a. At 11:18 am on 02/10/25, Staff 14 (CG) and Staff 15 (CG) entered Resident 7’s room to assist him/her with transferring to a wheelchair. Resident 7 was sitting in a recliner with the catheter bag laying on the floor, exposing it to potential contamination. Staff 14 picked up the catheter bag without single-use gloves, and the bag spilled urine onto the floor. She confirmed the catheter bag had a leak. Staff 14 then placed the leaking bag onto Resident 7’s lap. She exited the resident’s room without first performing hand hygiene, grabbed and donned a pair of single-use gloves, and reentered the resident’s room. Staff 14 used paper towels to wipe the spilled urine from the floor. She disposed of the gloves and paper towel and left the room again without performing hand hygiene. Staff 14 then proceeded to physically assist five unsampled residents to the dining room, touching their person and/or their personal mobility devices.

b. At 11:35 am on 02/11/25, Staff 15 (CG) and Staff 17 (MT) entered Resident 7’s room to assist him/her with transferring to his/her wheelchair. The resident’s catheter bag was again laying on the floor, exposing it to potential contamination. Staff 17 picked up the catheter bag and placed it on the resident’s lap during the transfer. They assisted the resident to the dining room, then proceeded to assist three unsampled residents to the dining room without first performing hand hygiene, touching their person and/or their personal mobility devices.

At 9:38 am on 02/12/25, the observation was shared with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 6 (Operations Specialist). They acknowledged infection prevention and control protocols had not been practiced.

OAR 411-054-0050(1-5) Infection Prevention & Control

(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

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 1 of 1 sampled resident (# 6) who was prescribed and received as needed psychotropic medications. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 04/2024 with diagnoses including Alzheimer’s disease.

The resident's 01/01/25 through 02/09/25 MARs, physician’s orders and progress notes were reviewed. Staff were interviewed and the following was identified:

Resident 6 had physician’s orders and instructions for the following PRN psychotropic medications for behaviors:

*Haloperidol 5 mg every four hours as needed for agitation and hallucinations.

*Lorazepam 0.5 mg every two hours as needed for anxiety, insomnia, or restlessness.

* Parameters for administration of the medications included the haloperidol was to be administered first, prior to the lorazepam.

Although there was non-drug interventions listed on the MAR for staff to try prior to administrating the PRN behavior medications, there was no documented evidence staff attempted non-drug interventions prior to the administration of the medications.

Additionally, on 01/02/25, 02/02/25, and 02/11/25 staff did not follow the parameters and administered PRN haloperidol and PRN lorazepam to Resident 6 at the same time.

The need to ensure non-pharmacological interventions were documented as attempted and failed prior to the administration of PRN psychotropics and parameters for administration were followed was discussed with Staff 1 (ED), Staff 2 (Wellness Director), Staff 3 (Wellness Nurse/RN) and Staff 6 (Operations Specialist) on 02/11/25. The staff acknowledged the findings.





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OAR 411-054-0055 (6) Systems: Psychotropic Medication

(6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

This Rule is not met as evidenced by:

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?Based on interview and record review, it was determined the facility failed to ensure direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, enough direct care staff to meet fire safety and evacuation standards based on resident acuity and facility structural design on night shift, and a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs for multiple sampled and unsampled residents. Findings include, but are not limited to:

The facility was licensed as a RCF with two floors and a separate, distinct, locked MCC unit. During the acuity interview at 9:11 am on 02/10/25, the RCF consensus was confirmed at 34 residents, and the MCC census was confirmed at 20 residents. Twelve residents were identified as needing two-person assistance for transfers and/or ADL cares, nine on the RCF unit and three on the MCC unit.

During a group resident interview at 3:00 pm on 02/10/25, two unsampled residents reported excessive call light response times.

The facility’s posted staffing plan, staffing schedule from 02/01/25 to 02/08/25, and call light response times for two unsampled residents from the group interview were reviewed with Staff 1 (ED) and Staff 2 (Wellness Director) at 9:00 am on 02/12/25. The following was identified:

The posted staffing plan for the facility RCF was as follows:

* Day shift: 3 CG, 1 MT;

* Evening shift: 2.5 CG, 1 MT; and

* Night shift: 1 CG, 0.5 MT.

The posted staffing plan for the facility MCC was as follows:

* Day shift: 2.5 CG, 1 MT;

* Evening shift: 2 CG, 1 MT; and

* Night shift: 1 CG, 0.5 MT.

The two unsampled residents called for assistance a total of 32 times from 02/01/25 to 02/08/25. Nine calls were in excess of 20 minutes, ranging from 22 minutes to 61 minutes, or a total of 28% of calls.

During the interview at 9:00 am on 02/12/25, Staff 1 stated on night shift, staff offered toileting for residents who needed two-person assistance on a schedule, to accommodate staff lunches. She acknowledged the CG assigned to the MCC unit would not be able to leave the locked unit to assist with unscheduled needs in RCF while one staff was on lunch. She further acknowledged, given the high number of residents requiring two-person staff assistance and the facility design of two RCF floors plus a locked MCC unit, the number of staff scheduled on night shift was insufficient to meet fire safety and evacuation standards.

The need to ensure adequate staffing to meet residents’ scheduled and unscheduled needs and fire safety and evacuation standards was discussed with Staff 1, Staff 2 (Wellness Director), and Staff 6 (Operations Specialist) on 02/12/25. They acknowledged the findings.

Refer to C363.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

(Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

This Rule is not met as evidenced by:

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Based on interview and record review, it was determined the facility failed to ensure their Acuity-Based Staffing Tool (ABST) accurately captured care time and care elements that staff were providing for 2 of 4 sampled Residents (#s 1 and 6). Findings include but are not limited to:

A review of the facility’s ABST revealed the care times and care elements documented for cares provided by staff were not accurate for Residents 1 and 6.

On 02/12/25 the need to ensure the ABST accurately captured care time and care elements was discussed with Staff 1 (ED). She acknowledged the findings.





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OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time

(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING
(b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average.
(c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents.
(d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1).
(e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule.
(f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.
(g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) evaluation was updated and reviewed before a resident moved in, no less than quarterly at the same time of service plan update, and/or with a significant change of condition for 2 of 4 sampled Residents (#s 1 and 3) and multiple unsampled residents, and failed to ensure documentation of consistently staffing to meet or exceed the posted staffing plan. Findings include, but are not limited to:

The facility was licensed as a RCF with a separate, distinct MCC unit.

1. During the acuity interview, four residents were identified as having recently moved into the facility, two residents were identified as having experienced a recent significant change of condition, and the facility census was confirmed as 54 residents. The facility’s ABST was reviewed with Staff 1 (ED) at 9:00 am on 02/12/25. The following was identified:

a. The four residents who recently moved into the facility had no ABST evaluations.

b. Resident 1, who experienced a significant change of condition, requiring meal escorts and full physical feeding assistance, did not have evidence the ABST was updated with the significant change of condition.

c. Thirty-three out of 54 residents’ ABST evaluations did not have evidence they were updated no less than quarterly, at the time of the service plan update.

During an interview at 9:00 am on 02/12/25, Staff 1 stated the facility was updating and reviewing residents’ ABSTs “at the beginning of the month and at admission.”

2. The facility’s posted staffing plan and staffing schedule from 02/01/25 to 02/08/25 were reviewed with Staff 1 and Staff 2 (Wellness Director) at 9:00 am on 02/12/25. The following was identified:

The posted staffing plan for the facility RCF was as follows:

* Day shift: 3 CG, 1 MT;

* Evening shift: 2.5 CG, 1 MT; and

* Night shift: 1 CG, 0.5 MT.

The posted staffing plan for the facility MCC was as follows:

* Day shift: 2.5 CG, 1 MT;

* Evening shift: 2 CG, 1 MT; and

* Night shift: 1 CG, 0.5 MT.

Review of the facility schedule from 02/01/25 to 02/08/25 revealed the facility failed to staff per the posted staffing plan on three shifts in RCF and ten shifts in MCC, or 27% of total shifts. During the interview, Staff 2 provided evidence that one of the shifts had been covered by the facility’s Wellness Directors. No documentation of coverage was provided for the remaining shifts.

The need to ensure residents’ ABST evaluations were updated before move-in, with significant changes of condition, and no less than quarterly, and the need to ensure consistent staffing to meet or exceed the posted staffing plan was discussed with Staff 1, Staff 2, and Staff 6 (Operations Specialist) on 02/12/25. They acknowledged the findings.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan

(4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule.
(a) Before a resident moves in.
(b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b).
(c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034.

(5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST:
(a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule.
(b) Staffing plan must account for unscheduled care needs.
(c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week.
(d) The staffing requirements outlined in OAR 411-054-0070(1).
(e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.)
(f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift.
(g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area.
(h) The staffing needs required under the Specific Needs Contracts, if applicable.

(6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract:
(A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents.
(B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST.
(b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST.
(c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

This Rule is not met as evidenced by:

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 C 330.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity

(1) Residential and non-residential HCB settings must have all of the following qualities:
(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

This Rule is not met as evidenced by:

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 295, C 360, C 362, C 363 and H 1510.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:

?Based on interview and record review, it was determined the facility failed to ensure documentation all preservice orientation training requirements had been completed by 4 of 4 staff (#s 10, 12, 13, and 16) prior to beginning their job duties and LGBTQIA2S+ training had been completed by 1 of 3 long-term non-direct care staff (#11). Findings include, but are not limited to:

Staff training records were reviewed with Staff 6 (Operations Specialist) and Staff 9 (Business Office Director) on 02/12/25. The following was identified:

a. There was no documented evidence Staff 10 (Cook), hired 10/16/24, completed the following required preservice orientation training:

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and

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

b. There was no documented evidence Staff 12 (MT), hired 01/07/25, completed the following required preservice orientation training:

* Approved LGBTQIA2S+ course.

c. There was no documented evidence Staff 13 (CG), hired 09/05/24, completed the following required preservice orientation training:

* Infectious disease prevention training; and

* Preservice dementia training.

d. There was no documented evidence Staff 16 (CG), hired 11/20/24, completed the following required preservice orientation training:

* Approved Home and Community-Based Services course.

e. There was no documented evidence Staff 11 (Cook), hired 09/13/23 completed the required biennial LGBTQIA2S+ course.

The need to ensure all preservice orientation training was completed by staff prior to beginning job duties and to ensure LGBTQIA2S+ training was completed biennially was discussed with Staff 1 (ED), Staff 6, and Staff 9. They acknowledged the findings.





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OAR 411-057-0155(1-6) Staff Training Requirements

(1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

This Rule is not met as evidenced by:

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 C 330.

OAR 411-057-0160(2b) Compliance with Rules Health Care

(b) Health care services provided in accordance with the licensing rules of the facility.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 05/09/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, Oregon Health Service Food Sanitation Rules OARs 333-150-0000, and OARs 411 Division 57 for Memory Care Communities.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.
The findings of the first re-visit to the kitchen inspection of 05/09/24, conducted on 07/18/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:On 05/09/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas:* Wall and floor behind and underneath the stove/grill - drips, spills, debris;* Vent above the dishwasher - significant build-up of dust;* Ceiling and sprinkler head near dishwasher - dust build-up;* Floor and drain under dishwashing area - significant debris build-up;* Commercial can opener - black matter and food debris on the blade; and* Spice shelf next to the stove/grill - food debris.Two sinks next to the ice machine were used for both handwashing and prepping/cleaning food items, creating potential for cross contamination. Staff 1 (Kitchen Manager) indicated a single sink on the opposite side of the kitchen was for handwashing only.The areas of concern were observed and discussed with Staff 1 and discussed with Staff 2 (Executive Director) on 05/09/24. The findings were acknowledged.

Based on observation and interview, 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 C240.

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 02/02/2023. 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 interview, observation, and record review it was confirmed the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include:During separate interviews on 02/02/2023, Resident #2 (R2) and Witness #1 (W1) stated that R2 was without a working call pendant from 09/30/2022-10/27/2022. W1 stated that R2 is a fall risk and is unable to leave their bed without assistance. W1 stated the facility ' s " fix " to the problem was to tie a string to the call light in the bedroom area, where R2 is unable to pull. R2 stated they are not able to use the bedroom and bathroom pull cords for their call lights, the pendent is the only one they are able to use. Staff #1 (S1) stated that they were aware that R2 was without a call pendent, however they did not have any extra pendants in the facility and had to order them. S1 stated that the company they order them from takes 3-5 weeks to ship. During an unannounced site visit on 02/02/2023, Compliance Specialist (CS) observed the string tied to the bedroom pull cord. CS observed that R2 is unable to grab the string. A review of email correspondence with S1 and the call pendent company shows the facility does not have effective methods to resolving to R2 ' s needs.On 02/02/2023, these findings were reviewed and acknowledged by S1.Plan of Correction: S1 has provided R2 with a working call pendant.

The findings of the kitchen inspection, conducted 08/11/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 08/11/22, conducted 11/14/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the kitchen inspection, conducted 07/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first re-visit to the kitchen inspection of 07/06/23, conducted 08/24/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 08/11/22 at 11:25 am, the facility kitchen was observed to need cleaning and repair in the following areas:a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:* Pipes and wall underneath the hand wash sink;* Rungs of storage racks;* Pipes under the three-compartment sink;* Ceiling vents;* Floor perimeter and tile grout lines;* Floor drain in dish machine area; and* Interior of MCC kitchenette microwave.b. The following areas needed repair:* The wall underneath the hand wash sink had an approximately six inch by a half inch crack. Black matter was visible inside the crack; and* The low temperature chemical dish machine was observed to operate multiple times and inconsistently registered the required temperatures for sanitation. The repair company was immediately contacted.Additionally, a dietary staff person was observed to not sanitize his hands upon entering the kitchen and handling clean dishes.The areas which required cleaning and repair were observed and discussed with Staff 1 (Administrator), Staff 2 (Dining Services Director) and Staff 3 (Maintenance Director) on 08/11/22. The findings were acknowledged.

Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation, and food service on 07/06/23 revealed:* Splatters, spills, drips, dust and debris noted on:- Walls in the food preparation and cooking areas;- Upper shelving throughout kitchen;- Top of the mixer machine;- Top of the range hood;- On both sides of kitchen entrance and exit doors; - Front of the freezer and fridge/freezers in the storage room; - Fire extinguishers; and- Floor under the hand washing sink.* Paint was observed to be chipped, worn or scraped off on: - Kitchen entrance and exit doors and door frames; - Walls in food preparation and cooking areas; and- Paint had bubbled up on the ceiling in front of steam table area approximately four by six inches in size, with a small area of paint peeled open.* A gallon of milk in the fridge expired on 06/30/23.* Staff were not using alcohol swabs to clean thermometer probe after use. * There was no policy available for when kitchen staff were sick.* Plastic pieces were broken off from the inside of the white storage room freezer.* There was no documented evidence that all employees involved in food preparation and serving had a current food handlers card.The areas in need of cleaning and repair, the need to use alcohol swabs to clean the thermometer probe after use, the need for a policy and procedure for sick staff, and all employees involved in food preparation and service needed to have a food handlers card was discussed with Staff 1 (ED) on 07/06/23. She acknowledged the findings.

Based on observation and interview, 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 C240.
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 240.

The findings of the re-licensure survey, conducted 10/18/21 to 10/21/21 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 and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily 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 first re-visit to the re-licensure survey of 10/21/21, conducted 01/19/22 through 01/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 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 10/21/21, conducted 04/19/22 through 04/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. The facility was found to be in substantial compliance with the regulations.

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, and failed to implement effective methods of infection control for 1 of 1 sampled resident (#9). Findings include, but are not limited to:Resident 9 was admitted to the facility in 2016. Observations, interviews with the resident and staff, and review of the clinical record revealed s/he was dependent on staff for ADL care including incontinence care needs, had bilateral ½ siderails, and staff washed his/her bed linens and personal laundry.a. On 01/19/22 at 11:30 am, the surveyor obtained permission and observed two CGs provide incontinent care to Resident 9. During the observation, the CGs removed the soiled brief (saturated with urine and feces) and wiped the resident's perineum with wet wipes. The soiled brief and wipes were not immediately placed into a trash bag/receptacle but placed on the floor next to the bed. Neither staff changed gloves after handling the soiled incontinence products or wiping urine/feces from Resident 9's perineum. Wearing the same soiled gloves, both staff touched the resident's clothing, clean incontinent brief, bed linens, Hoyer lift and wheelchair handles. After care was completed, the CGs removed their gloves and left the room. No hand hygiene was observed. As they walked down the hall, one of the CGs removed their face shield and adjusted their face mask. Review of staff training documentation on 01/20/22 revealed only one of the two CGs had received infection control training. The above observation was discussed with Staff 1 (Executive Director) on 01/20/22 at 1:10 pm. She acknowledged appropriate infection control practices were not implemented. She stated the CGs would receive infection control training. No further information was provided.b. Observations on 01/19/22 at 11:25 am revealed a strong urine odor permeated Resident 9's room. Bed linens were on the floor at the foot of the bed. Soiled personal laundry was observed on the floor of the room and closet. In an interview with the resident on 01/19/22, s/he stated "staff always place my wet laundry [wet with urine] on the floor. I should have a laundry basket. They need to put it in the basket and wash it right away." The above information was discussed with Staff 1 on 01/20/22 at 1:10 pm. The room was immediately toured. Staff 1 acknowledged the strong urine odor and stated linens should never be placed onto the floor. c. Resident 9's bed was observed on 01/19/22 with raised ½ siderails on both sides of the bed. When touched, the rails were loose and not secured to the bed frame. Additionally, there were gaps between the mattress and rails. The current service plan instructed staff to notify the Maintenance Director, Wellness Director or Executive Director if the rails were loose or broken. The surveyor and Staff 1 observed the rails on 01/20/22 at 1:10 pm. She said staff had not informed her that the rails were loose. She acknowledged the rails were not secured to the bed frame and stated she would have maintenance staff tighten them immediately.

Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local SPD office or conduct an immediate investigation which reasonably concluded and documented the physical injuries were not the result of abuse, for 2 of 2 sampled residents with injuries of unknown cause (#s 5 and 6.) Findings include, but are not limited to:
1. Resident 5 was admitted to the memory care unit with diagnoses including dementia and had multiple falls.During an interview with Staff 9 (Wellness Director) s/he stated Resident 5 was dependent on staff for most ADL care.A review of Resident 5's progress notes dated 07/28/21 through 10/18/21 revealed s/he had six unwitnessed falls from 7/29/21 through 10/18/21, resulting in multiple skin tears, lumps, and bruising. Additionally, progress notes on 7/31/21, 8/20/21, 9/10/21 and 9/29/21 documented four injuries of unknown cause. There was no documented evidence the injuries of unknown cause had been investigated to reasonably rule out abuse nor had the injuries been reported to the local SPD.During an interview with Staff 1 (Executive Director) on 10/20/21, the process for reporting and investigating incidents was discussed. Staff 1 verified the facility had not conducted an investigation within 24 hours of some of the falls and the four injuries of unknown cause.The surveyor asked Staff 1 to report the incidents to the local SPD office. Confirmation of the self report to the local SPD office was received on 10/20/21.The need to ensure resident incidents were investigated immediately to rule out abuse or reported to the local SPD office when abuse could not be ruled out was discussed with Staff 1 and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.
2. Resident 6 was admitted to the memory care unit in 3/2020 with diagnosis including dementia with behavioral disturbance.Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents:* Progress note dated, 9/9/21, indicated Resident 1 had a wound on the left calf. Progress note dated, 9/21/21, indicated the wound on left calf was related to a fall.* Progress note dated, 9/22/21, indicated Resident had an unwitnessed fall with bruising on the right knee. An incident report was completed at the time the incident was discovered; however, the incident was not reviewed by the administrator until 10/18/21. These represented unwitnessed falls and injuries of unknown cause. There was no documented evidence the facility either conducted an immediate investigation of the unwitnessed falls and injuries which reasonably concluded and documented that the falls or injuries were not the result of abuse or neglect. There was no documented evidence the facility reported the injuries to the local SPD office as suspected abuse or neglect. The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. Staff 1 did not provide any documentation the injuries were investigated, and abuse was ruled out. The facility was asked to report the incident to local SPD office. Verification of self- report was received before surveyors exited the facility.

Based on interview and record review, it was determined the facility failed to report injuries of unknown cause to the local SPD office or conduct an immediate investigation which reasonably concluded and documented the physical injuries were not the result of abuse, for 1 of 1 sampled resident (#10) with an injury of unknown cause. This is a repeat citation. Findings include, but are not limited to:Resident 10 was residing on the memory care unit with diagnoses including dementia.During an interview on 01/20/22, Staff 3 (RN) stated Resident 10 had a skin wound that was being monitored.A review of Resident 10's progress notes, dated 01/02/22, revealed staff noticed a skin tear on the resident's bottom during a shower. An incident report, dated 01/18/22, was reviewed and identified the skin wound as an injury of unknown cause. Staff were unable to determine how the resident sustained the injury. There was no documented evidence the injury of unknown cause had been investigated to reasonably rule out abuse nor had the injury been reported to the local SPD office.During an interview with Staff 1 (Executive Director) on 01/20/22, the process for reporting and investigating incidents was discussed. Staff 1 verified the facility had not conducted an immediate investigation of the injury and it had not been reported as it was initially believed to be a pressure wound.The need to ensure resident incidents were investigated immediately to rule out abuse or neglect and reported to the local SPD office when abuse could not be ruled out was discussed with Staff 1 on 01/20/22. She acknowledged the findings. The surveyor asked Staff 1 to report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 01/20/22.
1. The Executive Director reported the incident for resident #9 on 1/20/22. 2.The Executive Director and Wellness Director(s), will receive additional training on the Incident/Accident Report Policy. 3. The Wellness Director and Executive Director will review and investigate Incident Reports daily following the Quality Assurance - Health Services Review Schedule. 4. The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interest. Findings include, but are not limited to:Observations made between 10/18/21 and 10/21/21 in the RCF unit of the facility revealed many of the activities on the calendar did not take place. During an interview on 10/21/21 at 10:00 am, Staff 6 (Life Enrichment Director) stated she was pulled from activity duties to complete other tasks such as taking residents to their appointments and working as a MT on the MCC unit. She further stated she was not able to follow all of the activity calendar as outlined. Additionally, everyday, Staff 6 spent half a day in the RCF unit and the other half of the day in MCC unit providing activities.
The following observations were made on the memory care unit between 10/18/21 and 10/20/21: * Bingo, scheduled at 10:00 am did not take place on 10/18/21;* Sit and Be Fit, scheduled at 10:45 am did not take place on 10/18/21 and (Conductorcise) 10/20/21;* Hand aromatherapy, scheduled at 11:30 am did not take place on 10/19/21 10/20/21 and 10/21/21; * Scenic drive, scheduled for 10:00 am on 10/21/21 did not occur;* There were no activities observed occurring after 2:30 pm on 10/18/21, 10/19/21 or 10/20/21; * Residents sat out in the common areas for long periods of time watching TV, people-watching or remained in their rooms; and* A resident was observed pacing the halls frequently without being approached to engage in any individual or group activity.Multiple facility staff, interviewed on 10/18/21 and 10/19/21, stated the direct care staff usually needed to conduct activities as time allowed between resident care because the activity staff were needed to drive residents to appointments, provide medication technician duties or conduct activities in other areas of the facility.On 10/21/21, Staff 6 revealed an evaluation of the residents' activity preferences and history was obtained when the resident first arrived at the facility, and quarterly thereafter, and stated many of the evaluations were behind schedule for updates. The need to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large was discussed with Staff 1 (Executive Director) on 10/21/21. No additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to:a. Observations made between 01/19/22 and 01/20/22 in the RCF unit of the facility revealed many of the activities on the calendar did not take place. The following observations were made on the RCF unit between 01/19/22 and 01/20/22: * There were no activities observed occurring before 1:30 pm on 01/19/22;* Scenic drive, scheduled for 10:00 am on 01/20/22, did not occur; and* Balance and Stretch, scheduled for 11:15 am on 01/20/22 did not occur.During an interview on 01/19/22 at 1:50 pm, Staff 17 (Wellness Director) stated there was "no activity staff this time". She further stated, the direct care staff or MT usually conducted activities as time allowed between resident care and MT duties.b. The following observations were made on the memory care unit between 01/19/22 and 01/20/22: The activity calendar posted on the unit and observations made revealed the following for 01/19/22:* 10:00 am Sit and Be Fit (did not occur);* 10:30 am Pretty Nails (did not occur. A balloon ball game was provided at 11:00 am);* 1:30 pm One on Ones (did not occur); * 3:00 pm Activity Boxes (did not occur); and * A staff was observed assisting one resident with painting nails at 2:00 pm.On 01/20/22:* 10:00 am Scenic Drive (did not occur);* 11:15 am Balance and Stretch (did not occur. A ceramic painting activity was held with four residents attending);* 1:30 pm Portrait painting (did not occur);* 3:00 Bingo (did not occur); and* 4:00 Tech Corner (a movie was playing on the television).On 01/20/22, residents were observed sitting in common areas for long periods of time watching television, people-watching or remained in their rooms. A resident was observed pacing the halls frequently without being approached or engaged in any individual or group activities.Interviews on 01/19/22 and 01/20/22 with multiple facility staff revealed there was no activity staff and that one housekeeping staff was assigned to conduct activities in both areas of the facility (RCF and MCC Units). Staff confirmed that many of the posted activities did not occur due to a lack of staff available.The need to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Services) on 01/20/22. They acknowledged the findings and stated the facility was working on hiring an activity staff person.

1. The new Life Enrichment Director will adjust the program schedule to meet resident preferences for individual and group interests, physical, mental, and psychosocial neededs. 2. The Life Enrichment Director will receive training on the Life Enrichment Program for Residents Policy and Procedure. 3. The Life Enrichment Director will review this area weekly per the Quality Assurance - Activities Review Schedule.4. The Executive Director will be responsible for ensuring corrections are completed and monitored.

3. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and Parkinson's Disease.During the survey, Resident 3 required assistance with toileting, grooming and bathing. S/he was unable to use utensils and required finger foods to eat independently. The service plan, dated 7/27/21, and ISP's were reviewed and were not reflective of the resident's needs in the following areas:* Receiving hospice services;* Weight loss; and* Use of a private caregiver.The service plan did not provide clear direction to staff regarding set up for independent eating and risk of weight loss.The need for service plans to be reflective of resident's needs and provide clear direction for staff to follow was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.
4. Resident 4 was admitted to the facility in 2015 with diagnoses including edema.Observations of Resident 4, interviews with staff, review of the service plan dated 07/15/21 and ISP's during the survey revealed the following were not reflective of the resident's needs:* Oral health status; and* Diet status.The service plan was not followed by staff in the following areas:* Providing oral care; and* Use of Ted/compression stocking.The need for service plans to be reflective of resident's needs and to follow was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.
2. Resident 5 was admitted to the memory care in 2020 with diagnoses including anxiety and dementia. During observations and interviews on 10/18/21, caregivers reported Resident 5 needed help with ADL care and recently needed help eating, s/he wore glasses but they were "unable to locate his/her glasses at this time", was incontinent of bladder frequently and needed assistance daily with incontinence care.The service plan, dated 8/3/21, and ISP's (Interim Service Plan) were reviewed and were not reflective of the resident's needs in the following areas:* Use of glasses;* Weight loss and meal assistance needed;* Receiving Hospice services;* Incontinence of bladder and need for assistance with toileting; and* Current skin injuries requiring treatment.The service plan did not provide clear direction to staff in the following areas:* Fall interventions;* How/when to use a thera-bear and weighted blanket provided by hospice; and* Interventions to follow to prevent falls.The need for service plans to be reflective of resident's needs and provide clear direction for staff to follow was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs, provided instructions for staff as to what, when, how and how often services would be provided and were followed for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:1. Observations of resident care on 10/19/21 through 10/21/21, interviews with staff, and review of the resident's current service plan and temporary service plans were conducted during the survey. Resident 6's current service plan, dated 7/13/21, was not reflective of the resident's current care needs and lacked clear instructions for staff in the following areas:* Incontinent of bowel and bladder and use of incontinent supplies; * Need for assistance with wheelchair mobility; and* Skin issues related to frequent bruising and skin tears to bilateral lower extremities.The need to ensure service plans were reflective of the resident's current care needs and provided clear instructions to staff was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings.
4. Resident 4 was admitted to the facility in 2015 with diagnoses including diabetes.Observations of Resident 4, interviews with staff, review of the service plan dated 12/15/21, and ISP's during the survey revealed the following was not reflective of the resident's needs or not followed by staff:* Oral health status; and* Transfer status, one-person assist versus two-person assist.The need for the service plan to be reflective of the resident's needs and followed by staff was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Services) on 01/20/22. They acknowledged the findings.
2. Resident 8 was admitted to the memory care unit in 01/2021 with diagnoses including hypertension and macular degeneration. During observations and interviews on 01/20/22, caregivers reported Resident 8 had been slowly declining over the past two months and needed help with ADL care including transfers, walking and dressing, was incontinent of bowel and bladder, and needed assistance daily with incontinence care.The service plan, dated 11/16/21, and ISP's (Interim Service Plans) were reviewed and were not reflective of the resident's needs in the following areas:* Exit seeking behaviors;* Mobility, escort needed (to meals and activities);* Toileting assistance needed; and* Current concerns and interventions regarding constipation.The need for the service plan to be reflective of the resident's needs was discussed with Staff 1 (Executive Director) on 01/20/22. She acknowledged the findings.

3. Resident 6 was admitted to the facility in March of 2020 with diagnoses including dementia and kidney disease.The quarterly service plan, provided by Staff 1 (Executive Director) to the surveyor during the revisit, was dated 07/13/21.During an interview on 01/19/22 at 2:30 pm, the surveyor asked Staff 1 (Executive Director) if the service plan had been reviewed and updated since 07/13/21. She reviewed the record and stated a quarterly review had not been completed since July 2021.The need to ensure service plans were reviewed quarterly was reviewed with Staff 1 on 01/20/22 at 2:30 pm. 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, provided clear direction regarding the delivery of services, were followed by staff, and reviewed quarterly for 4 of 4 sampled residents (#s 4, 6, 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 9 was admitted in 2016. The quarterly service plan, provided by Staff 1 (Executive Director) to the surveyor during the revisit, was dated 07/09/21.During an interview on 01/20/22 at 11:30 am, the surveyor asked Staff 18 (Director of Health Services) if the service plan had been reviewed and updated since 07/09/21. She reviewed the record and stated a quarterly review had not been completed.The need to ensure service plans were reviewed quarterly was reviewed with Staff 1 on 01/20/22 at 1:10 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 3, 4, 5 and 6). Findings include, but are not limited to:Resident 3, 4, 5 and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.On 10/20/21 and 10/21/21, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 4 sampled residents (#s 4, 6 and 9). This is a repeat citation. Findings include, but are not limited to:Resident 4, 6 and 9's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.On 01/20/22, Staff 1 (Executive Director) and Staff 18 (Director of Health Service) confirmed there was no documented evidence of a Service Planning Team for Residents 4, 6 and 9.

Based on observation, interview and record review, it was determined the facility failed to evaluate changes of condition, monitor according to evaluated needs, identify and implement interventions for 4 of 4 sampled residents (#s 3, 4, 5 and 6) reviewed for changes of condition. Residents 3 and 5 experienced ongoing significant weight loss and other changes of condition. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in June of 2019 with diagnoses including Parkinson's Disease and dysphagia (difficulty swallowing).During the survey, Resident 3 required assistance with toileting, grooming and bathing. S/he was unable to use utensils and required set up with finger foods to eat independently. A review of Resident 3's clinical records revealed the following:* 05/01/21 Weight recorded was 168 lbs;* 05/07/21 RN Quarterly Assessment documented "ability to eat: independent", "nutrition adequate", and "Weight 187 lbs.";* 06/01/21 Weight recorded was 156 lbs, (a loss of 12 lbs or 7% weight loss in 30 days);* 07/01/21 Weight recorded was 157 lbs;* 07/20/21 The "diet information sheet" updated to "please provide finger food";* 07/26/21 Weight recorded as 145 lbs (a loss of 12 lb or 7.5% weight loss in 30 days)* 07/27/21 Resident 3's quarterly service plan was developed with no mention of weight loss; and* 09/22/21 Hospice note documented the resident was served food they could not eat (mashed potatoes and soup).Resident 3 experienced a significant weight loss from 5/1/21 to 6/1/21, when s/he lost 7% of body weight. The resident continued to lose weight, an additional 7.5% of body weight from 7/1/21 to 7/26/21.There was no documented evidence Resident 3 had been evaluated, consistently monitored, interventions with resident-specific instructions communicated to staff, or the service plan updated with interventions related to declining meal intake, weight loss, and the need for finger foods at meals.In an interview on 10/20/21, Staff 1 (Executive Director) and Staff 2 (Operations Director) were asked to weigh Resident 3, and recorded the weight at 144 lbs. Observations of meals on 10/20/21 and 10/21/21 showed the resident was served finger foods per the service plan and was able to eat independently. On 10/21/21 Resident 3 was served oatmeal and a caregiver assisted with eating.Staff 1 and Staff 2 acknowledged the lack of monitoring of Resident 3's weight loss, and confirmed no weights were taken in August, September, or October despite a physician's order for monthly weights.b. Further review of Resident 3's clinical records revealed additional changes of condition that had not been monitored to resolution, or for which no actions or interventions were determined and communicated to staff:* A home health noted dated 10/8/21 documented Resident 3 was experiencing painful urination with a foul smell, and notified the physician. There was no documentation of an evaluation, response from the physician, or monitoring to rule out UTI or infection;* A note dated 10/10/21 documented "res was found on floor 4 abrasions, one on right side of head 3 on right arm"; and* A home health note dated 10/14/21 documented "concerned with heavy blood during bms [bowel movement], up to a cup of blood during a bm, rectal exam completed. Instructions for care team: MAR bms call with 24/7 if more bleeding noted."There was no documented evidence the painful urination, skin abrasions from a fall, or bleeding during bowel movements were evaluated or monitored.The need to ensure the facility developed actions or interventions, communicated actions and interventions to staff and monitored all changes of condition to resolution was discussed with Staff 1 and Staff 2 on 10/21/21. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 2015 with diagnoses including a diabetic ulcer.The resident's clinical records dated 07/23/21 through 10/18/21 indicated the following:* 7/28/21 staff documented on a facility progress note the resident was on alert for "Redness and rash persist to abdominal and groin skin folds with moderate foul odor and moisture ..."There was no documented evidence the resident's short-term change of condition related to skin was consistently monitored and progress documented weekly through resolution.The need to ensure the facility monitored the resident's changes of condition weekly through resolution was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.
2. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia. a. During the survey, s/he was identified to have recently been admitted to hospice and needed assistance to eat.A review of Resident 5's clinical records revealed the following:* 5/01/21 weight recorded was 139.2 lbs;* 6/01/21 weight recorded was 140.0 lbs;* 7/28/21 resident returned to the facility following an extended stay at a skilled care facility. The facility RN assessment stated the resident was eating poorly;* 8/20/21 the facility RN documented a current weight would be obtained and referral made to hospice services; * 8/24/21 weight recorded was 122.0 lbs (a 17.2 lb loss or 12.8%);* 8/31/21 hospice evaluation completed and documented "recent significant weight loss";* 9/23/21 weight recorded was 108.0 lbs (a 14 lb loss or 11.4% in one month); * 10/03/21 weight recorded was 106.8; and* 10/11/21 weight recorded was 106.0 lbs. Resident 5 had a severe weight loss in 3 months, from June to August, when s/he lost 12.8% of body weight. There was no RN assessment to address the weight loss. The resident continued to lose weight, 11.4% from August to September with no RN assessment or interventions for the weight loss.Resident 5's 08/03/21 evaluation and service plan for change of condition states the resident "does not have any current or known history of weight gain/loss". The service plan stated the resident did well with finger foods and instructed staff to "notify the Wellness team" s/he misses a meal or refuses to eat.During interviews on 10/19/21 and 10/20/21, Staff 9 (Wellness Director) stated the resident had been declining and recently needed assistance to eat. Staff 3 (Regional RN) stated an assessment for weight loss had not yet been completed.On 10/18/21, observations of the lunch meal showed Resident 5 sat in the dining room but needed cuing to stay awake and eat. Resident 5 was handed a bread stick and could eat several bites when it was in his/her hand. The resident was not able to feed him/herself. A caregiver assisted the resident to eat three bites of food, however, the resident was not able to remain awake to eat any more and was assisted back to bed. On 10/20/21, Resident 5 was asleep in his/her room until 11:35 am. Hospice staff and facility staff helped to get the resident up and walk part of the way into the common area. A Med Tech made a jelly sandwich and handed it to Resident 5 who ate the sandwich, feeding it to him/her self. Resident 5 required staff to assist with drinking water from a cup.There was no documented evidence Resident 5 had been evaluated, consistently monitored, interventions with resident-specific instructions communicated to staff, or the service plan updated with interventions related declining meal intake, weight loss, and the need for meal assistance. In an interview on 10/20/21, Staff 1 (Executive Director) and Staff 2 (Operations Director) stated the RN was working on the assessment and interventions were identified to address the weight loss.b. Further review of Resident 5's clinical records revealed additional changes of condition that had not been monitored to resolution, or for which no actions or interventions were determined or communicated to staff.Progress notes reviewed from 7/28/21 through 10/18/21 documented the resident had the following skin injuries:* 7/31/21 - lump on his/her head;* 8/20/21 - wound to left arm; * 9/10/21 - cut and bruising to left eye, skin tear to elbow and "severe bruising" to hip; and* 9/29/21 - cut above right eyebrow.There was no documented evidence the skin injuries had been treated and monitored at least weekly to resolution. c. Progress notes documented the resident experienced falls on 7/29/21, 8/15/21, 9/17/21, 9/29/21, and 10/18/21.There was no documented evidence the facility had identified interventions to address the pattern of falls and monitor the interventions for effectiveness.During interviews with Staff 1 and Staff 3 (Regional RN) on 10/18/21 and 10/19/21, staff were aware of the falls and skin injuries, but were unable to provide additional documentation of interventions or monitoring. The need to ensure the facility developed actions or interventions, communicated actions and interventions to staff and monitored all changes of condition to resolution was discussed with Staff 1 and Staff 2 on 10/21/21. They acknowledged the findings.
4. Resident 6 was admitted to the facility in 3/2020 with a diagnosis of dementia with behavioral disturbance. During the acuity interview on 10/18/21, Resident 6 was identified as a fall risk who had a history of falls.Progress notes, incident reports, service plans and temporary service plans were reviewed during the survey. The facility failed to adequately determine and document what actions or interventions were needed for the resident and communicate the interventions to staff in response to repeated falls and injuries of unknown cause and failed to monitor service-planned interventions for effectiveness as follows:* On 8/24/21 - skin tear on the left outer wrist; * On 9/9/21 - wound on left calf;* On 9/19/21 - staff documented alert monitoring for a fall; and* On 9/22/21 - staff documented "heard [Resident] screaming for help, when I entered [his/her] room [s/he] was on the bathroom floor and had a bruise on the right knee."There was no documented evidence the facility communicated instructions to staff on what to monitor or what care was needed for the resident's injuries and there was no documented evidence the facility reviewed fall interventions for effectiveness. The need to ensure interventions were developed in response to changes of condition, the interventions were communicated to staff on all shifts, and were monitored for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.
2 Resident 6 was admitted to the facility in March of 2020 with diagnoses including dementia and chronic kidney disease.a. The resident's clinical records, dated 12/20/21 through 01/19/22, indicated the following:* 12/31/21 "According to the patient, sustained an injury to [her/his] hand [s/he] stated a cut ... Pt. [patient] was examined and it was determined hands were free from cuts /abrasions"; * On 01/05/22 a home health note documented "please continue to re-dress left top of hand as needed for bleeding and for healing process as well as to keep covered and protected, wound care supplies are in brown box in pt's [patient's] room...wound left top of hand/wrist area ½ inch length, skin tear"; and* On 01/08/22 the MAR was updated to include "monitor top of left hand". The facility lacked documented evidence the resident's skin tear was evaluated, consistently monitored, and interventions identified from the incident until 01/08/22 when monitoring of the wound was initiated.The need to ensure the facility evaluated and monitored the resident's wound was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Service) on 01/20/22. They acknowledged the findings.b. The resident's clinical records, dated 12/20/21 through 01/19/22, indicated the following:* Resident 6's weight was monitored with weekly weights. On 01/04/22 Resident 6 was weighed and documented as 97 lbs (pounds);* On 01/11/22 his/her weight was documented as 86.4, a loss of 10.6 lbs (10% of body weight in one week); * On 01/14/22 a home health note documented "weight 86.4 lbs eating small amounts"; and* On 01/18/22 Resident 6's weight was recorded as 92 lbs, a loss of five lbs (5%) from 01/04/22.Resident 6 was observed eating lunch independently on 01/19/22 and again on 01/20/22, with less than 50% of the meal eaten on both days. On 01/20/22 Resident 6's weight was confirmed as 92 lbs.The loss of over 10 lbs between weekly weights constituted a change of condition. The facility lacked documented evidence the resident's change of condition related to weight loss and weight fluctuation was evaluated.The need to ensure the facility evaluated the resident's changes of condition and referred significant changes to the RN was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Service) on 01/20/22. No further information was provided.
3. Resident 4 was admitted to the facility in 2015 with diagnoses including diabetes.The resident's clinical records, dated 12/01/21 through 01/18/22, indicated the following:a. On 12/29/21 staff documented on a facility progress note that the resident had a fall. Review of the incident report, dated 12/29/21 stated "Resident was found on the floor during the breakfast...found lying on the floor on [his/her] left side ..."There was no documented evidence the facility thoroughly reviewed the incident to determine the circumstance of the fall and development of interventions to prevent further falls. There was also no documented evidence the resident's short-term change of condition related to the fall was monitored and progress documented weekly through resolution.The need to ensure short term changes were evaluated, specific resident interventions determined and documented, and monitored until resolution was discussed with Staff 1 (Executive Director) on 01/20/22. She acknowledged the findings. b. Staff documented on a facility progress note on 12/29/21 that the resident had "a big scratch mark on [his/her] back" from a fall.On 12/30/21 staff documented the "scratch" on the back was "more a redness..."There was no documented evidence the resident's short-term change of condition related to the skin injury was monitored and progress documented weekly through resolution.The need to ensure the facility monitored the resident's changes of condition weekly through resolution was discussed with Staff 1 (Executive Director) and Staff 18 (Director of Health Service) on 01/20/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed ensure changes of condition were evaluated, referred to the facility RN when appropriate, monitored through resolution, and interventions identified and implemented for 3 of 4 sampled residents (#s 4, 6 and 8) reviewed for changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 2018 with diagnoses including hypertension and macular degeneration.The resident's clinical record, dated 12/20/21 through 01/19/22, indicated the following:* 12/26/21: The resident experienced symptoms of constipation and became non-responsive. S/he was sent to the emergency department and was diagnosed with constipation and syncope, and returned to the facility on 12/26/21. * An after visit summary from the emergency department, dated 12/26/21, was reviewed and instructed the facility to have the resident follow-up with his/her primary care physician (PCP) within a week. The resident was seen by the PCP on 01/14/22. The PCP ordered Colace (stool softener) to be given as needed twice per day for constipation - no bowel movement within two days.* The 12/27/21 through 01/20/22 MAR was reviewed. The resident received Colace per MD order once on 01/18/22 and staff marked it as "not effective". * A review of facility communication logs from 12/27/21 through 01/19/22 revealed staff were inconsistently documenting the resident's bowel pattern. Direct care staff interviewed on 01/19/22 and 01/20/22 stated they did not document bowel monitoring but would sometimes write down whether the resident had a bowel movement or not. Staff 6 (MT) stated there was no documentation of the resident's last bowel movement and was unsure when to give the PRN Colace.During interviews with Staff 1 (Executive Director), Staff 3 (RN) and Staff 18 (Director of Health Services) on 01/19/22 and 01/20/22, staff stated the facility did not do bowel monitoring, had not identified other interventions to address the constipation, nor provided clear direction to staff on how and when to administer the PRN Colace.The facility lacked documented evidence the resident's short-term change of condition related to constipation was consistently monitored, and interventions identified and implemented.The need to ensure the facility monitored the resident's change of condition, identified and implemented interventions, and documented at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 3 (Regional RN) and Staff 18 (Director of Health Services) on 01/20/22. Staff 3 stated she would contact the resident's PCP to discuss the PRN medication and provide additional direction to direct care staff. Staff 18 completed an Interim Service Plan instructing staff on signs and symptoms to be monitored.

2. Resident 3 was admitted to the facility in June of 2019 with diagnoses including Parkinson's Disease and dysphagia (difficulty swallowing).A review of Resident 3's clinical records revealed the following:* 05/01/21 weight recorded was 168 lbs.;* 06/01/21 weight recorded was 156 lbs., (a loss of 12 lbs. or 7% weight loss in 30 days);* 07/01/21 weight recorded was 157 lbs.;* 07/26/21 weight recorded as 145 lbs. (a loss of 12 lb. or 7.5% weight loss in 25 days); and* 07/27/21 Resident 3's quarterly service plan was developed with no mention of the weight loss.Resident 3 experienced a significant weight loss from 5/1/21 to 6/1/21, when s/he lost 7% of body weight. There was no RN assessment to address the weight loss.The resident continued to lose weight, an additional 7.5% of body weight from 7/1/21 to 7/26/21 with no RN assessment of the weight loss. The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment for significant changes of condition was discussed with Staff 1 (Executive Director) and Staff 2 (Operational Specialist) on 10/21/21. Staff 1 and Staff 2 confirmed the lack of an RN assessment of Resident 3's significant weight loss.Refer to C270, example 1 a.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 3 sampled residents (#s 3 and 5) who experienced significant changes of condition related to weight loss. Resident's 3 and 5 continued to experience weight loss over several months. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in December 2020 with diagnoses including dementia with behavioral disturbance. Weight records, dated 5/1/21 - 10/18/21, indicated Resident 5 experienced a 18-pound weight loss from 6/1/21 to 8/24/21. This constituted a 12.8% total body weight loss in three months and represented a significant change of condition. The facility failed to ensure an RN assessment was completed for the weight loss which documented findings, resident status and interventions made as a result of the assessment.The record indicated Resident 5 continued to lose weight as follows:* Between 8/24/21 and 9/23/21, Resident 5 lost 14 pounds or 11.4% body weight over one month;* Resulting in a total of 33.2 pounds or 23.85% over six months.An RN assessment, completed 7/29/21 related to a change of condition and return to the facility, did not address the weight loss. An RN progress note, dated 8/20/21, documents the need for staff to escort Resident 5 to the dining room and encourage him/her to eat. During an interview on 10/19/21, Staff 3 (Regional RN) confirmed there was no RN assessment completed and no interventions (with the exception of adding finger foods) were implemented related to Resident 5's weight loss.The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment for significant changes of condition was discussed with Staff 1 (Executive Director) and Staff 2 (Operational Specialist) on 10/21/21. They acknowledged the findings.Refer to C270, example 2a.
Based on observations, interviews and record review, it was determined the facility failed to ensure an RN assessment was performed for residents who had significant changes of condition for 1 of 3 sampled residents (#6) who experienced a significant change. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in March 2020 with diagnoses including dementia with behavioral disturbance and kidney disease.Review of the resident's record showed Resident 6 was weighed once a week to monitor weight. The weekly weight record showed a severe weight loss between weekly weights on 01/04/22 (97 lbs) and 01/11/22 (86.4 lbs) of 10.6 lbs or 10% of his/her total body weight. A hospice note dated 01/14/22 documented "weight 86.4, eating small amounts". On 01/18/22, Resident 6's weight was recorded as 92 lbs, a five lb (5.2%) loss from 01/04/22 (97 lbs). The weight loss constituted a significant change of condition.There was no documented evidence of an RN assessment of the weight loss.Resident 6 was observed eating lunch on 01/19/22 and again on 01/20/22, with less than 50% of the meal consumed on both days. On 01/19/22, Staff confirmed Resident 6's weight as 92 lbs.The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (Executive Director) and Staff 3 (Regional RN) on 01/20/22. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure outside service providers left written information in the facility that addressed on-site services being provided to the resident, and followed recommendations from home health and hospice providers for 2 of 3 sampled residents (#s 3 and 5) who received outside services. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and Parkinson's Disease.During the survey, Resident 3 required assistance with toileting, grooming and bathing. S/he was unable to use utensils and required meals prepared as finger food to eat independently. Review of Resident 3's record revealed outside provider notes were not consistently documented as reviewed and/or recommendations were not implemented as follows:* Outside provider visit notes were not consistently left in the facility - hospice provided service twice a week, however, only two notes were left onsite between 7/1/21 and 10/15/21, other notes were faxed to the facility up to four weeks after the service was provided.* Hospice recommended all meals served as finger food to allow independent eating on 7/20/21, however, progress notes dated 9/22/21 indicated the hospice nurse observed Resident 3 being served mashed potatoes and soup.* Hospice note dated 10/14/21 documented "concerned with heavy blood during bms [bowel movement]", and requested the facility to monitor for blood during bowel movements. There was no documented evidence this was done. The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/21. They acknowledged the findings.
2. Resident 5 was admitted to the facility in January 2020 with diagnoses including dementia. During the acuity interview on 10/18/21, Resident 5 was identified as receiving outside provider services previously of physical therapy and currently of hospice. Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 07/28/21 through 10/18/21 were completed. The resident received physical therapy visits and notes were reviewed from 8/3/21 through 8/31/21. The resident was then admitted to hospice services on 08/31/21. Hospice nursing visits were to occur at least weekly and as needed for comfort and general care. Outside provider visit notes were not consistently documented as reviewed and/or recommendations were not implemented as follows: * Physical therapy recommendations on 08/03/21 instructed staff to provide frequently scheduled toileting and a lowered bed height. The resident was not put on scheduled toileting and the bed height was not lowered until 10/11/21;* Nursing recommendations on 09/13/21 instructed staff to educate staff on a scheduled toileting regimen and to remove all breakable items for the resident's room to prevent injuries. Items were not removed until after 9/29/21 ; and* Nursing recommendations on 09/21/21 documented hospice provided music therapy, a weighted blanket and a thera-bear to use. However, the facility did not obtain information for staff to follow on how/when to use these interventions. During interviews with caregiving staff on 10/21/21, staff were not aware of where to locate some of the items provided and how/when to use them. The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place for residents and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 2015 with diagnoses including Type II Diabetes.Resident 4's current physician orders, dated 4/14/21, included:* Check CBG (blood sugar level) four times daily; and* To administer Humalog insulin before each meal based on the resident's CBGs;: 141 - 180 = 8 units: 181 - 220 = 12 units: 221 - 260 = 16 units: 261 - 300= 20 units: 301 - 340 = 25 units: 341 - 380 = 30 units: 381 - 420 = 35 units: Greater than 420 = 40 units* To administer Humalog insulin before bedtime based on the resident's CBGs;: 141 - 180 = 4 units: 181 - 220 = 6 units: 221 - 260 = 8 units: 261 - 300= 10 units: 301 - 340 = 12 units: 341 - 380 = 15 units: 381 - 420 = 18 units: Greater than 420 = 20 unitsResident 4's CBGs (blood sugar level) record from 9/01/21 through 10/18/21 indicated the resident's CBGs were between 145 and 381 except on two occasions, on 9/9/21 before breakfast, CBG of 114 and on 9/25/21 before breakfast, CBG of 112.The 09/01/21 - 10/18/21 MAR revealed there was no documentation for the administered insulin amount when CBGs were greater than 141.In an interview on 10/18/21 at 3:35 pm, Staff 12 (MT) stated the facility switched their electronic medication record system in July of 2021. Staff 12 further stated there was no section to document administered insulin amounts when CBGs were greater than 141 with the current electronic record system and therefore, did not document it. This represented an unsafe medication administration system because it did not address documentation of the correct amount of insulin when unlicensed staff administered, which may result in substantially lower or higher blood sugar levels.The need to ensure the facility had a safe medication administration system and oversight of the overall medication and treatment administration systems was reviewed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings.On 10/21/21, during the exit interview, Staff 2 stated facility addressed the above issue and provided evidence of the corrected system prior to exiting the facility.
2. Resident 6 was admitted to the facility in 3/2020 with diagnoses including dementia with behavioral disturbance.A review of current physician orders and 10/1/21 through 10/18/21 MAR was reviewed during the survey. Resident 6 had physician orders, dated 9/24/21, that prescribed acetaminophen 325 mg tablet, PRN every six hours and acetaminophen 650 mg suppository, PRN every six hours. The clinical record indicated the resident had a drug allergy to acetaminophen. Resident 6's MAR also identified a drug allergy to acetaminophen. According to the MAR, the Resident was not administered either of the PRN acetaminophen orders. During an interview on 10/19/21, Staff 4 (Health Service Specialist), reported she was unaware of the drug allergy or that the resident was prescribed a medication that s/he was allergic to. Staff 4 stated that the pharmacy should have caught the issue and consulted with the prescriber. On 10/20/21, the findings were reviewed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). On 10/21/21, Staff 4 stated she discussed the drug allergy with the prescriber and provided an order to discontinue both acetaminophen medications.3. During the survey, administrative oversight of the medication and treatment administration system was found to be ineffective based on deficiencies in the following areas:* C 303: Medication and Treatment Orders;* C 310: Accuracy of Medication Administration Records;* C 315: Accuracy of Treatment Administration Records; * C 325: Self Administration of medications ; and * C 330: Psychotropic Medication Administration.

Based on observation, interview and record review, it was determined the facility failed to ensure physician's orders were followed for 3 of 5 sampled residents (#s 2, 3 and 4) whose orders were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and difficulty moving due to Parkinson's Disease.Resident 3's most current physician orders, dated 10/15/20, included the direction to "obtain monthly vitals and weight," and "notify RN for weight loss/gain of greater than 3 lbs in a month."Resident 3's record documented no weights taken in August, September, or October of 2021. Resident 3's record also documented weight loss of more than 3 lbs for the months of June and July, however, there was no documentation the RN was notified per the physician order.On 10/20/21, the physician orders and current MARs were reviewed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.
2. Resident 2, who had diagnoses including hypertension, had physician orders, dated 7/27/21, to obtain monthly vitals and weight on "Day 2 of every month" and notify RN for blood pressure greater than 160/80 or less than 80/60, heart rate greater than 100 or less than 55 per minute, respiratory greater than 20 or less than 10 per minute and weight loss/gain greater than 3 pounds in a month.Resident 2's 10/1/21 through 10/20/21 MAR revealed there was no documented evidence facility staff obtained the vital signs and weight on 10/2/21 as prescribed.3. Resident 4 was admitted to the facility in 2015 with diagnoses including essential hypertension and edema.a. Resident 4 had physician orders, dated 4/14/21, to obtain blood pressure daily. Resident 4's 09/01/21 through 10/18/21 MAR revealed eight occasions, on 09/04/21, 09/17/21, 09/18/21, 09/19/21, 10/02/21, 10/03/21, 10/06/21 and 10/08/21, the blood pressure was not obtained as prescribed.b. Resident 4 had physician orders, dated 4/14/21, to obtain the resident's weight weekly and notify physician if weight gain of five pounds in one week.Resident 4's 09/01/21 through 10/18/21 MAR revealed five occasions, on 09/04/21, 09/11/21, 09/18/21, 10/02/21 and 10/09/21, the weight was not obtained as prescribed.On 10/20/21, the need to ensure staff followed physician orders was reviewed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.
2. Resident 8 had physician orders, dated 01/14/22, to administer "Colace 50 mg twice daily as needed for constipation, give if no bowel movement for 2 days."Resident 8's 01/01/22 through 01/20/22 MAR revealed the Colace was administered once on 01/18/22 and documented as "not effective".During an interview with Staff 6 (MT) on 01/20/22, the electronic MAR system was viewed. Staff 6 stated the resident did not receive a second dose of Colace after the initial dose on 01/18/22 despite not having had a bowel movement (bm). Staff 6 administered one dose of the Colace on 01/20/22 at 9:26 am "because [s/he] still had not had a bm". Staff 6 stated it appeared the resident had gone at least four days without a bm (01/17/22 through 01/20/22). The facility failed to follow physician order's on 01/18/22 and 01/19/22 when the resident had gone more than two days without a bowel movement. On 01/20/22, the need to ensure staff followed physician orders was reviewed with Staff 1 (Executive Director) and Staff 3 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician's orders were followed for 2 of 4 sampled residents (#s 4 and 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 2015 with diagnoses including diabetes and edema.a. Resident 4 had physician orders, dated 12/09/21, to obtain the resident's blood sugar level before bedtime daily and to administer insulin as needed.Resident 4's 01/01/22 through 01/18/22 MAR revealed eight occasions that the blood sugar level was not obtained as prescribed.b. Resident 4 had orders, dated 12/09/21, to obtain the resident's weight weekly and notify physician if there was a weight gain of five pounds in one week.Resident 4's 12/01/21 through 01/19/22 weight record and 01/01/22 through 01/18/22 MAR revealed two occasions, on 01/01/22 and 01/15/22, that the weight was not obtained as prescribed.On 01/20/22, the need to ensure staff followed physician orders was reviewed with Staff 1 (Executive Director) and Staff 18 (Director of Health Service). They acknowledged the findings.

4. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia.A review of Resident 5's 10/1/21 through 10/18/21 MAR revealed the administration record contained blanks for the following medications:* Asmanex (inhaler for asthma) on two occasions;* Diclofenac gel (for pain management) on one occasion; and* Lantanoprost drops (for glaucoma) on five occasions.On 10/20/21, the need to ensure accurate documentation on the MAR was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility, for 4 of 4 sampled residents (#s 3, 4, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 3/2020 with diagnosis including dementia with behavioral disturbance.Resident 6's 10/1/21 through 10/18/21 MAR was reviewed during the survey. The following inaccuracies were identified:a. Resident 6's MAR noted Haldol PRN every four hours. There were no orders in the facility to administer Haldol; andb. Resident 6 was prescribed lorazepam PRN every four hours. The MAR indicated to give lorazepam PRN every two hours. The medication was inaccurately transcribed to the MAR. The MAR indicated the lorazepam had not been administered from 10/1/21 through 10/18/21. The need to ensure MARs were reviewed for accuracy was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings.
2. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and difficulty moving due to Parkinson's Disease.Resident 3 was prescribed Carbidopa/Levidopa for Parkinson's Disease.Review of Resident 3's MAR between October 1st and October 19, 2021 showed the administration record of the Carbidopa/Levidopa was left blank six times. On 10/20/21, the need to ensure accurate documentation on the MAR was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.
3. Resident 4 was admitted to the facility in 2015 with diagnoses including Type II diabetes mellitus and edema.a. Resident 4 was prescribed Humalog insulin 20 units to administer every day before lunch and dinner for diabetes mellitus.Review of Resident 4's 10/1/21 through 10/18/21 MAR revealed one occasion on 10/06/21, the administration record of the insulin was left blank. b. Resident 4 was prescribed Nystatin powder three times daily to treat a rash.Review of Resident 4's 10/1/21 through 10/18/21 MAR revealed five occasions the administration record was left blank on 10/01/21, 10/05/21, 10/06/21, 10/07/21 and 10/08/21. On 10/20/21, the need to ensure accurate documentation of the MAR was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

3. Resident 3 was admitted to the facility in June of 2019 with diagnoses including dysphagia (difficulty swallowing) and difficulty moving, due to Parkinson's Disease.A progress note dated 10/10/21 revealed Resident 3 had a fall with injury, including skin abrasions on head and right arm,treated and bandaged by facility staff. The TAR for October 2021 did not document that treatment was provided.The lack of a documented treatment record for Resident 4's treatments was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.
2. Resident 4 was admitted to the facility in 2015 with diagnoses including a diabetic ulcer and edema.Resident 4's progress notes, reviewed from 07/23/21 through 10/18/21, staff documented they provided skin care and applied cream to Resident 4 including on 09/25/21, 09/26/21 and 09/28/21.The 09/01/21 through 10/18/21 TARs were reviewed. House orders for wound care (cuts, abrasions and skin tears) and treatments were listed on the TAR. However, there was no documentation on the TAR by staff that any of the treatments were provided or cream was applied.The lack of a documented treatment record for Resident 4's treatments was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an accurate TAR, with clear instructions to staff, accurate documentation and specific treatment orders by a legally-recognized practitioner for 3 of 3 sampled residents (#3, 4 and 5) who received wound care. Findings include, but are not limited to:1. Resident 5 was admitted to the memory care unit in 2020 with diagnoses including dementia and had a history of frequent falls. Resident 5's progress notes, reviewed from 7/28/21 through 10/18/21, documented wound care was provided to various skin injuries including on 07/29/21, 07/30/21, 08/20/21, 09/10/21, 09/17/21, 09/29/21 and 10/18/21. The 09/01/21 through 10/18/21 MARs were reviewed. House orders for wound care (cuts, abrasions and skin tears) and treatments were listed on the TAR. However, there was no documentation by staff of any of the treatments provided on the TAR.The lack of a documented treatment record for Resident 5's wound care was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/21 at 12:40 pm. They acknowledged the findings.

Based on interview and record review, the facility failed to ensure residents had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 2) who self-administered medications. Findings include, but are not limited to:During the facility acuity review on 10/18/21, Resident 2 was identified to self-administer his/her medications.Review of the resident's signed physician orders and an evaluation related to self-administration revealed the following:* Physician order, dated 7/27/21, indicated there was no order to self-administer medications on multiple scheduled prescription eye drops, scheduled prescription oral regimen including potassium, seroquel (an antipsychotic medication) and as needed ventolin (to treat bronchospasm) inhaler; and * There was no current documented evidence the facility evaluated Resident 2's ability to safely self-administer the medications. The last evaluation for self-administration of medication was on 4/27/21.On 10/19/21 Staff 1 (Executive Director) confirmed there was no current evaluation related to self-administration for Resident 2. Staff 1 stated the most recent self-administration of medication for Resident 2 was in 4/2021 and had not been updated quarterly as required. The need for residents to have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications and quarterly evaluation of the residents' ability to safely self-administer the medications was discussed with Staff 1 and Staff 2 (Operational Specialist) on 10/20/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 1 of 1 sampled resident (#2) who self-administered medications. This is a repeat citation. Findings include, but are not limited to:During the facility acuity review on 01/19/22, Resident 2 was identified to self-administer his/her medications.Review of the resident's clinical record revealed no current documented evidence the facility evaluated Resident 2's ability to safely self-administer the medications. On 01/20/22, Staff 18 (Director of Health Service) confirmed there was no current evaluation related to self-administration for Resident 2. The need for a quarterly evaluation of the resident's ability to safely self-administer medications was discussed with Staff 1 (Executive Director) and Staff 18 on 01/20/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been attempted with ineffective results prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (#5) who was administered a PRN psychoactive medication for aggression. Findings include, but are not limited to:Resident 5's MAR, dated 10/1/21 - 10/18/21, was reviewed and indicated the resident was administered PRN lorazepam (an anti-anxiety medication) on 10/2/21. There was no documented evidence non-pharmacological interventions had been attempted with ineffective results prior to administering the PRN psychotropic medication. An interview with Staff 6 (Life Enrichment Director/MT) and Staff 7 (MT) on 10/21/21 revealed there was no place on the eMAR to document when/which interventions were attempted and may be ineffective prior to administering PRN medications. A discussion with Staff 4 (Health Services Specialist) verified the eMAR system required some additional information be entered into the system and Med Techs trained on how to enter the information accurately. The need to ensure staff documented non-pharmacological interventions had been attempted with ineffective results prior to administering a PRN psychoactive medication was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/20. They acknowledged the findings. Staff 4 entered the required information into the eMAR system for Resident 5 and other residents with a PRN psychotropic medication order and stated staff will be trained on entering the information accurately.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potential restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (# 4) who had a half-length side rail on their bed. Findings include, but are not limited to:Resident 4 was observed to use a half-length side rail to the right side of the bed. Review of the resident's clinical record revealed, there was no documented evidence of an assessment completed by a RN, Physical Therapist or Occupational Therapist for the use of the side rail.On 10/20/21, the lack of documented assessment and requirements for the use of the side rail was reviewed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:The facility was licensed as a Residential Care Facility (RCF). The RCF portion of the building housed 28 residents (with a capacity for 39 residents) on two floors. The memory care unit housed 16 residents (with the capacity for 20) on one floor of the building.1. During the entrance conference on 10/18/21, the following was identified regarding resident care needs: * The facility had a total census of 44 residents;* Five residents needed two-person assist with transfers or Hoyer;* Five residents were on hospice; and * Four residents were identified as needing meal assistance. 2. The staffing plan provided by the facility was as follows: * Dayshift - 2 MTs and 4 CGs; * Evening shift - 2 MT and 4 CGs; and * Night shift - 1 MT and 2 CGs. During an interview on 10/18/21 at approximately 10:00 am, Staff 9 (Wellness Director) stated she has worked nearly full time as Med Tech on the memory care unit due to difficulty scheduling staff for the memory care unit and acknowledged the facility had been running short staffed.3. The facility staffing schedule from 10/1/21 through 10/17/21 was reviewed. Multiple scheduling vacancies were reflected on the schedule. Staff from other positions such as Wellness Director and Life Enrichment Director were used to fill the vacancies.4. Observations and interviews conducted between 10/18/21 and 10/21/21 showed the following: * Multiple residents in the memory care needed cuing or full meal assistance;* Two residents on the memory care required the assistance of two staff for transfer and mobility;* During interviews, several staff confirmed the facility was often short staffed; * Several newly hired staff stated they had "not really been trained" because of staffing shortages; * On 10/18/21 at approximately 12:00 noon, one of two caregivers on the memory care unit left the facility for an appointment, leaving one caregiver and one MT providing care on the unit for the remainder of the shift;* On 10/19/21 at 10:10 am, a resident was observed walking slowly in one of the hallways in the memory care unit. The resident was removing and replacing his/her clothing and periodically stood without clothes on. At 10:17 am, a caregiver approached and assisted the resident to their room;* On 10/20/21 and 10/21/21 day shifts, two caregivers and one MT were observed working on the floor. A resident on the memory care required close supervision and assistance. The care staff working on the unit were unable to provide the 1:1 care and a staff person from the RCF section of the facility was called to provide the care;* On day shift 10/19/21 and 10/20/21, two caregivers and one MT were working on the memory care unit. A resident was observed pacing rapidly through the hallways and into the common areas. The resident approached the door to the outdoor courtyard and went outside. A caregiver passing by went out into the courtyard and brought the resident back inside the unit. When interviewed on 10/20/21, the caregiver reported they were providing care to other residents and could not supervise the resident outside, so they brought him/her inside; and* In an interview on 10/21/21, Staff 6 (Life Enrichment Director) was asked about the calendar of scheduled activities. Staff 6 stated some of the activities did not occur because she was assigned to provide MT duties and/or drive residents to appointments and other tasks of direct care in the facility. The facility's failure to ensure adequate staffing in order to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 and Staff 2 (Operations Specialist) on 10/21/21. No additional information was provided.
Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. This is a repeat citation. Findings include, but are not limited to:The facility was licensed as a Residential Care Facility (RCF). The RCF portion of the building housed 27 residents (with a capacity for 39 residents) on two floors. The memory care unit housed 15 residents (with the capacity for 20) on one floor of the building.During the entrance conference on 01/19/22, the following was identified regarding resident care needs: * The facility had a total census of 42 residents;* Three residents needed two-person assists with transfers or Hoyer lift;* Three residents were on hospice; and * Three residents were identified as needing meal assistance. The staffing plan provided by the facility was as follows: * Day shift - 2 MTs and 4 CGs; * Evening shift - 2 MT and 4 CGs; and * Night shift - 1 MT and 2 CGs. The facility staffing schedule, from 01/16/22 through 01/20/22, was reviewed. Multiple scheduling vacancies were filled using staff from other positions, such as Wellness Director. On 01/20/22 at 2:17 pm, Staff 1 (Executive Director) stated Wellness Directors, who usually filled the vacancies, were currently not working due to illness. She further stated there were three staff persons who were not on the schedule due to illness.Observations and interviews conducted between 01/19/22 and 01/20/22 showed the following: * Multiple residents in the memory care needed cuing or full meal assistance;* Two residents in the memory care required the assistance of two staff for transfers and mobility;* During interviews, several staff confirmed the facility was often short staffed; * On 01/20/22 at approximately 9:30 am the memory care unit had one MT and one caregiver on duty. Staff reported a second caregiver had been re-assigned to the "assisted living" area of the facility;* On 01/20/22 at 9:45 am, Resident 4 was observed in the bathroom alone. Resident 4 stated s/he was stuck in the bathroom and needed help. The surveyor was looking for staff to provide assistance but was not able to find caregiving staff. The MT was informed and s/he left med-tech duties to assist the resident; * On 01/20/22 at 11:30 am, approximately eight residents were observed in the memory care unit dining room for lunch without a staff person present;* On day shift on 01/20/22, one caregiver and one MT were working on the memory care unit. A resident was observed approaching the door to the outdoor courtyard and went outside. A caregiver went out into the courtyard and brought the resident back inside the unit. When interviewed, the caregiver stated they could not supervise the resident outside, so they brought him/her inside; and* In an interview on 01/20/22, Staff 6 (MT) and Staff 8 (CG) were asked about the calendar of scheduled activities. They stated some of the activities did not occur because there was only one staff that provided activities on both the memory care and the assisted living areas.The facility's failure to ensure adequate staffing in order to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Executive Director) on 01/20/22. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 8, 11 and 12) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 10/19/21 and revealed Staff 8 (CG), Staff 11 (CG) and Staff 12 (MT), hired on 04/29/21, 08/03/21 and 08/04/21, lacked documented evidence they had completed First Aid certification and abdominal thrust training.The need for staff to complete all required training was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 14, 15 and 21) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 01/20/22 and revealed Staff 14 (MA), Staff 15 (CG) and Staff 21 (CG), hired on 11/23/21, 09/28/21 and 12/16/21, respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Executive Director) on 01/20/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented all required components in accordance with Oregon Fire Code every other month, and Life Safety instruction was provided to staff on alternating months. Findings include, but are not limited to:Review of Fire and Life safety records on 10/19/21 for April 2021 through September 2021 lacked documentation of the following:* Fire and life safety instruction to staff on alternate months on different topics;* Fire drills conducted and recorded every other month at different times of the day;* The facility was not consistently relocating or evacuating residents during fire drills; and* Documentation was lacking or incomplete regarding: - Escape route used; - Evacuation time-period needed; - Resident evacuation problems encountered; and - Number of occupants evacuated.On 10/20/21, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drills included required components according to the Oregon Fire Code was reviewed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation that fire and life safety training was provided to residents within 24 hours of move-in; * Documentation that annual fire and life safety training was provided to residents, including evacuation methods, responsibilities during fire drills and designated meeting place outside of the building; and * Alternate exit routes were used during fire drills.The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, alternate exit routes were used during fire drills, and all staff were aware of the designated point of safety was discussed with Staff 1 (Executive Director) and Staff 2 (Operation Specialist) on 10/20/21. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to:Refer to Z 142, Z 155, Z 162, Z 164, C 231, C 242, C 260, C 262, C 270, C 280, C 303, C 325, C 360 and C 372.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 231, C 360, C 420 and C 422.
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 160, C 231, C 360, C 372 and C 455.

Based on interview and record review, it was determined the facility failed to ensure all required pre-service orientation for 3 of 4 newly hired staff (#s 8, 11 and 13) and pre-service dementia training for 4 of 4 newly hired staff (#s 8, 11, 12 and 13) was completed prior to beginning job responsibilities. The facility failed to ensure 30-day competency demonstration was completed for 3 of 3 newly hired staff (#s 8, 11 and 12), and failed to ensure documented evidence of the required 12 hours of annual in-service, including six hours of dementia care training for 1 of 2 long-term staff (# 6) whose training records were reviewed. Findings include, but are not limited to:Training records were reviewed with Staff 2 (Operations Specialist) on 10/19/21. The following deficiencies were identified:1. Staff 8 (CG), Staff 11 (CG) and Staff 13 (Cook), hired on 4/29/21, 8/3/21 and 5/25/21, did not have documented evidence that pre-service orientation had been completed in the following required areas:* Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control; * Food handler's certification (for Staff 13);* Fire safety and emergency procedures; and* Evidence Staff 8 and Staff 13 were provided a written job description.2. Staff 8 (CG), Staff 11 (CG), Staff 12 (MT), and Staff 13 (Cook), were hired on 04/29/21, 08/03/21, 08/04/21 and 05/25/21 respectively, did not have documented evidence of the required six hours of department approved pre-service dementia training in the following required areas:* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;* Techniques for understating, communicating and responding to distressful behavioral symptoms;* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;* Specific aspects of dementia car 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 required on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.3. Staff 8 (CG), Staff 11 (CG) and Staff 12 (MT), hired on 4/29/21, 8/3/21 and 8/4/21 respectively, did not have documented evidence of competency demonstration in the following: * 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.4. Staff 7 (MT), hired 04/09/2019, did not have documented evidence of completing the required 12 hours of annual training including six hours related to dementia care between 4/2020 and 4/2021.The need to ensure newly-hired direct care staff completed all required training prior to beginning their job duties and prior to working independently, documented methods to determine competency of direct care staff and on-going required 12 hours of annual training including six hours related to dementia care training was reviewed with Staff 1 (Executive Director) and Staff 2 on 10/20/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 6 sampled newly hired staff (#s 14 and 15) completed all required pre-service training prior to performing any job duties, and completed competency training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed with Staff 1 (Executive Director) on 01/20/22. The following deficiencies were identified:1. Staff 14 (MT) was hired 11/23/21. a. There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties: * Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control;* Fire safety and emergency procedures;* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms;* 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 (e.g. staff interactions, lighting, room temperature, noise, etc.)* 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's service plan; and* Use of supportive devices with restraining qualities in memory care communities.b. There was no documented evidence Staff 14 demonstrated competency in her job duties within 30 days of hire and prior to working independently in the following areas:* The 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.The surveyor informed Staff 1 that Staff 14 could not administer medications until documented training was completed. She acknowledged and stated documented medication training would be completed for Staff 14 before she administered medications. 2. Staff 15 (CG) was hired 09/28/21. a. There was no documented evidence he had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties: * Resident rights and values of CBC care;* Abuse reporting requirements;* Standard precautions for infection control;* Fire safety and emergency procedures;* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;* Techniques for understanding, communicating and responding to distressful behavioral symptoms;* 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 (e.g. staff interactions, lighting, room temperature, noise, etc.)* 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's service plan; and* Use of supportive devices with restraining qualities in memory care communities.b. There was no documented evidence Staff 14 demonstrated competency in his job duties within 30 days of hire and prior to working independently in the following areas:* The 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.The facility's failure to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 1 on 01/20/22. She acknowledged the findings. No further information was provided.

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 C 242, C 260, C 262, C270, C 280, C 290, C 300, C 303, C 310, C 315, C 325, C 330 and C 340.
Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 242, C 260, C 262, C 270, C 280, C 303 and C 325.

4. Resident 5 was admitted to the facility in July 2020 with diagnoses including dementia. The current service plan was reviewed during the survey and lacked information and staff instructions related to individualized nutrition and hydration status and needs. Observations made between 10/18/21 and 10/21/21 revealed the resident attended some meals in the dining room and slept through others. The resident required care staff to provide cueing, encouragement and physical assistance to eat. An entree was frequently provided that required staff to provide physical assistance as it was not a "finger food". On 10/19, 10/20 and 10/21, the resident slept through breakfast and was up with staff assistance at around 11:30 am each day. During an interview on 10/18/21, Staff 9 (Wellness Director) stated Resident 5 often would not get up for breakfast and would eat meals inconsistently, but usually ate better at lunch and dinner and was doing better at eating with finger foods. Staff 9 stated finger foods were not consistently being provided.The service plan, dated 8/3/21, stated the resident often wandered away from meals, does well with finger foods and having food cut up into bite sized pieces. The service plan lacked any information on the resident's preferred meal times, food and liquid preferences and need for staff intervention to ensure adequate nutrition and hydration was provided.The need to provide a daily meal program for nutrition and hydration based upon the resident's preferences and needs, available throughout each resident's waking hours and documented in the resident's service plan was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/21/21. They acknowledged the findings.
Based on observation, 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 residents' service plans and were followed for 3 of 3 sampled residents (#s 5, 6, and 7) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 3/2020 with diagnoses including dementia with behavioral disturbance.Resident 6's current service plan, dated 7/13/21, indicated s/he was at risk for dehydration and had a history of weight loss. The service plan directed staff to provide fluids four times per shift in addition to mealtimes, a full glass of water at med pass and noted staff should check to ensure fluids were within reach and encourage resident to drink the fluids. During observations from 10/19/21 through 10/21/21, Resident 6 was only offered fluids at mealtimes. Observations of Resident 6 while s/he was in their room on 10/19/21 and 10/20/21 identified the resident was not provided fluid within reach at bedside. There was no resident specific nutrition and hydration information within the service plan that addressed the weight loss or to provide the resident snacks throughout the day.2. Resident 7 was admitted to the facility in 12/2018 with diagnoses including Lewy body dementia.Resident 7's current service plan, dated 07/30/21, indicated s/he was at risk for dehydration and had a history of weight loss. The service plan and MAR directed staff to do the following:* Provide fluids four times per shift in addition to mealtimes;* Provide a full glass of water at med pass; * Check to ensure fluids were within reach, encourage resident to drink them;* Refill cup as needed to ensure there was fluids within reach at all times;* Provide organic protein powder once per day; and* Provide snacks four times per day.Resident 7's 10/1/21 through 10/20/21 MAR identified the following: * Organic protein powder was not administered on 10/2/21 and 10/3/21; * Snacks were not provided on 10/1/21 and 10/8/21 at 7:30 pm; and* On six occasions, meal consumption was not recorded on the MAR.During observations from 10/19/21 through 10/20/21, Resident 7 was only offered fluids at mealtimes and there were no observed snacks being offered throughout the day. 3. During observations on 10/21/21 at 10:37 am, multiple non-sampled residents were heard making the following comments:* " I'm waiting for something to eat ";* " Where is everyone, I guess we don't get coffee today "; and* A group of three non-sampled residents were observed to ask a direct care staff for coffee. The coffee was not provided. The need to ensure individualized nutrition and hydration plans were included in the resident service plans and were being followed by staff was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist) on 10/20/21. They acknowledged the findings.

2. Resident 5's service plan was reviewed during the survey. The service plan stated the resident "does better with one on one activities or a small group with low stimulation". The service plan contained some historical information on previous music preferences and current sleep patterns, however did not contain any information on the resident's current preferences; abilities and skills; emotional/social needs and patterns. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.On 10/21/21, the lack of an individualized activity plan was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 2 of 2 sampled residents (#s 5 and 6) whose activity plans were reviewed. Findings include, but are not limited to: 1. Residents 6's service plan was reviewed during the survey. The facility did not consistently document a quarterly activity evaluation. The evaluation lacked one or more of the following required components and was not included on the residents' service plan: * Abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.There was no specific individualized activity plan which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.The current service plan identified preferred activities of sing alongs, coffee hour, travel films. Observations on 10/19/21 through 10/21/21, showed Resident 6 was wheelchair bound and unable to successfully propel the wheelchair for long distances without staff assistance. Staff did not assist the resident to attend a singing activity occurring on the unit. The only activity offered to the resident was reading a newspaper in his/her room, alone.On 10/20/2021 the need to evaluate and develop individualized activity plans including all required components for each memory care resident was discussed with Staff 1 (Executive Director) and Staff 2 (Operations Specialist). They acknowledged the findings.

2. Residents 6's service plan was reviewed during the survey. The activity plan, located in the resident's 07/13/2021 service plan, lacked the following components:* Current abilities and skills; * Sensory stimulation activities; * Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions. There was no specific individualized activity plan which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.The July 2021 service plan identified preferred activities of playing golf, bridge and the stock market, and that Resident 6 was able to self propel using a manual wheelchair. Observations on 01/19/22 through 01/20/22, showed Resident 6 required staff assistance to propel a wheelchair, and was not encouraged to participate in the activities offered.On 01/20/2022 the need to evaluate and update individualized activity plans quarterly and as needed for each memory care resident 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 evaluate and develop individualized activity plans for 2 of 2 sampled residents (#s 6 and 8) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Residents 8's service plan was reviewed during the survey. The activity evaluation, dated Feb 2020, documented some historical information about the resident's activity preferences. The activity plan, located in the resident's 11/16/21 service plan, lacked the following components: * Current abilities and skills; * Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.There was no specific individualized activity plan which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.The current service plan identified preferred activities of listening to country music, playing bunco and socializing with other residents. Observations on 01/19/22 through 01/20/22, showed Resident 8 required staff assistance with walking and impaired vision. Staff did not encourage, invite or assist the resident to attend any activities on the unit.On 01/20/2022 the need to evaluate and update individualized activity plans quarterly and as needed for each memory care resident was discussed with Staff 1 (Executive Director). She acknowledged the findings.1. An Activity Assessment will be completed for all residents and the individualized plan will be updated in the resident service plan. 2. The Life Enrichment Director will receive additional training on the Activities Guide. 3. The Life Enrichment Director will review this area weekly per the Quality Assurance - Activities Review Schedule.4. The Executive Director will ensure the corrections are completed and monitored.