Marjorie House Memory Care Community

The findings of the re-licensure survey, conducted 01/08/24 through 01/09/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with 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 revisit to the relicensure survey of 01/09/24, conducted 03/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was documented in the resident's service plan, restrictive alternatives prior to use were documented, and instruction was provided to caregivers on the correct use of and precautions for the device, for 1 of 1 sampled resident (#2) who had a side rail on his/her bed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia.Observation of the resident's room 01/08/23 revealed a half-length side rail on the left side of the resident's bed. During an interview on 01/09/23, Staff 9 (Resident Aide) stated the resident used the side rail for bed mobility.There was no documented evidence the following required elements were completed:* Documentation of less restrictive alternatives evaluated prior to use of the device; * Instruction provided to staff on the correct use and precautions related to the device; and* Documentation of the side rail in the resident's service plan.The need to ensure the use of a supportive device with potentially restraining qualities included documentation of all required elements and was included in the resident's service plan was discussed with Staff 2 (Administrator) on 01/09/23. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, conduct fire drills consistently every other month, and to document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements. Findings include, but are not limited to:Fire and life safety records were reviewed with Staff 2 (Administrator) and Staff 6 (Maintenance Manager) on 01/09/24 at 11:00 am.The facility provided documentation of two fire drills in the last six months, which occurred on 10/24/23 and 12/28/23. Fire drills were not consistently conducted every other month at different times of day, and written fire drill documentation did not include the evacuation time period needed. There was one documented example of fire and life safety instruction to staff on alternating months, which occurred on 12/15/23. During an interview on 01/09/23, Staff 6 confirmed the fire drills and fire and life safety instruction to staff had not occurred consistently over the last six months.The need to provide fire and life safety instruction to staff on alternate months, to consistently conduct fire drills every other month, and to document all required elements for fire drills as required by the OFC was discussed with Staff 2 and Staff 6. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 420.

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 340.

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose records were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, and 4's service plans, assessments, and evaluations were reviewed. There was some information included, but the records lacked documented evidence the facility evaluated the sampled residents activities to include: * Past and current interests;* Current abilities and skills;* Emotional and social needs and patterns;* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Activities that could be used as behavioral interventions, if necessary.On 01/09/24, the need to ensure all residents had individualized activity plans based on the evaluation to engage residents in meaningful activities was discussed with Staff 2 (Administrator) and Staff 3 (RN). They acknowledged the findings.

Based on interview and observation, it has been confirmed that the facility failed to provide reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. Findings include; but are not limited to:During an unannounced site visit on 02/23/2021; Compliance Specialist (CS) observed Staff #4 to be walking through the facility with a cloth mask on and wearing no eye protection. CS later observed Staff #2 to leave the facility for a break wearing full PPE; and re-enter the facility wearing the same mask and eye protection.During an interview with Staff #1; it was stated that Staff #3 is in charge of keeping an eye on employees PPE; and doing facility walkthroughs to ensure compliance. The above information was shared with Staff #1.Facility Plan of Correction: The facility will assign a designated individual to do walkthroughs and remind staff to wear PPE correctly. The facility Administrator will also be re-training staff involved.

The findings of the Health and Safety Monitoring survey conducted 12/15/20 through 12/18/20 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 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

The findings of the first re-visit to the re-licensure survey of 12/18/20, conducted 3/22/21 through 3/23/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services 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. Failure to follow infection control guidelines to prevent the spread of COVID-19 put residents in serious risk. Findings include, but are not limited to:During the Health and Safety Monitoring survey, conducted 12/15/20 through 12/18/20, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. At the time of the survey, there were residents who had either tested positive for or were showing symptoms of COVID-19. Deficiencies that were identified included, but were not limited to:* The facility was not consistently obtaining and documenting resident temperatures, screening residents for symptoms of COVID-19 or obtaining and monitoring oxygen saturations for residents who tested positive or showed symptoms of COVID-19.* The facility did not cohort staff. Staff were not specifically assigned to work only with COVID-19 positive or only with COVID-19 negative residents to prevent cross-contamination and further spread of infection between residents as well as staff.* Multiple staff were observed entering the rooms of residents who had been placed on droplet precautions without donning adequate Personal Protective Equipment (PPE).Infection control practices that had been issued by the Oregon Department of Human Services were reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 12/15/20. They acknowledged the need for increased oversight of infection control practices in the building. A written list of infection control areas to address was provided to Staff 1.

Based on observation, interview and record review, it was determined the facility failed to protect residents from abuse, failed to immediately notify the local SPD office of any incident of abuse or suspected abuse and failed to promptly investigate all reports of abuse or suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse, for 10 of 12 sampled residents (#s 1, 2, 3, 4, 6, 7, 8, 9, 10 and 11). The facility failed to monitor service-planned fall interventions for Residents 1 and 2, failed to implement ordered wound care and failed to respond to a severe weight loss for Resident 3, failed to administer prescribed blood pressure medication for Resident 4 and a critical seizure medication for Resident 8, and failed to ensure the facility RN completed assessments of skin wounds for Residents 4, 6, 7, 9, 10 and 11. This constituted neglect and was considered abuse. Findings include, but are not limited to:1. During the survey, conducted 12/15/20 through 12/18/20, it was determined the facility failed to provide the basic care or services necessary to maintain the health and safety of multiple residents. This constituted neglect and was considered abuse.Refer to:C 270, examples 1 and 2;C 280, examples 2 and 4; andC 303, examples 1, 2 and 3.2. Progress notes and a facility Incident Report, both dated 11/23/20, indicated Resident 4 was found on the floor of his/her apartment and the resident acknowledged having fallen while trying to go to the restroom.A home health physical therapy visit note dated 11/24/20 documented "Fall yesterday am found on ground 6:45. [Patient] noted being dizzy and on ground for a few hours." Resident 4's statement of being on the ground "a few hours" constituted suspected neglect, for which the facility had the responsibility to report to the local APD office.The facility RN initialed the visit note on 11/27/20 as having reviewed the note. However, there was no documented evidence the facility notified the local SPD office of the incident, investigated the incident or took measures to address the fall and prevent further falls.The facility's failure to provide basic care and services necessary to maintain the health and safety of the residents and to notify the local APD office of an incident of suspected neglect and take steps necessary to prevent further neglect, was reviewed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings. The facility was asked to report the incident to the local APD office following the survey.
3. Resident 1 was admitted to facility 10/2020 with a diagnosis including dementia. Resident 1's current service plan noted the resident was at risk for falls.Review of Resident 1's record noted multiple unwitnessed falls between 11/17/20 and 12/12/20. There was no documented evidence the facility investigated the falls to determine if staff were following Resident 1's service plan at the time of the falls, whether existing fall interventions were adequate and how the facility determined the fall was not the result of neglect.The need to thoroughly investigate all incidents, to rule out suspected abuse and/or neglect, was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings. 4. Resident 2 was admitted to the facility in September 2020 with diagnosis including neuropathy and epilepsy. Resident 2's current service plan noted the resident had a history of falls and epileptic seizures effected his/her neuropathy.Review of Resident 2's record noted multiple unwitnessed falls between 9/15/20 and 11/14/20. There was no documented evidence the facility investigated the falls to determine if staff were following Resident 2's service plan at the time of the falls, whether existing fall interventions were adequate and how the facility determined the fall was not the result of neglect.The need to thoroughly investigate all incidents, to rule out suspected abuse and/or neglect, was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the initial service plan was reviewed within 30 days of move-in and resident service plans were completed quarterly after the resident moved into the facility, for 3 of 4 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 2, 3 and 4's service plans were reviewed during the survey. The following deficiencies were identified:1. The record indicated Resident 2 was admitted in 9/2020. The resident's initial service plan had not been reviewed within 30 days of move-in.2. The record indicated Resident 4 was admitted in 10/2020. The resident's initial service plan had not been reviewed within 30 days of move-in.3. Resident 3's service plan had last been reviewed on 6/29/20, not completed quarterly as required.The need to ensure resident service plans were reviewed timely was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the deficiencies.

4. Resident 3 was admitted to the facility in 2/2019 with diagnoses including dementia, hypertension and paroxysmal atrial fibrillation. Review of Resident 3's records revealed the following:On 12/9/20 the hospice RN left a communication that Resident 3 had a Stage 1 pressure ulcer and staff were to apply barrier cream twice a day and PRN. On 12/14/20, a hospice nurse communication indicated the resident had a pressure ulcer that needed to be assessed.There was no documented evidence the facility determined and documented what action or interventions were needed, communicated the actions or interventions to staff on each shift, and monitored and documented on the progress of the condition at least weekly until the condition resolved.The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.5. Resident 4 was admitted to the facility in 10/2020 with diagnoses including Alzheimer's dementia, history of cerebellar stroke, recent left shoulder fracture and hypertension. Review of Resident 4's records revealed the following:Resident 4 was readmitted to the facility from the hospital on 12/8/20 with a Stage 2 pressure ulcer.There was no documented evidence the facility determined and documented what action or interventions were needed, communicated the actions or interventions to staff on each shift, and monitored and documented on the progress of the condition at least weekly until the condition resolved.The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.6. Resident 6 was admitted to the facility in 3/2020 with diagnoses including hypertension and Alzheimer's disease. Review of Resident 6's records revealed the following:Resident 6 sustained a skin tear on the right pointer finger on 11/23/20 and developed a Stage 2 pressure ulcer on the left buttocks on 12/15/20.There was no documented evidence the facility determined and documented what action or interventions were needed and communicated the actions or interventions to staff on each shift. The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.7. Resident 7 was admitted to the facility in 7/2016 with diagnoses including Alzheimer's disease. Review of Resident 7's records revealed the following:On 12/8/20 Resident 7 developed two Stage 2 pressure ulcers. There was no documented evidence the facility determined and documented what action or interventions were needed and communicated the actions or interventions to staff on each shift. The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.8. Resident 8 was admitted to the facility in 9/2020 with diagnoses including history of stroke and dementia. Review of Resident 8's records revealed the following:On 12/14/20, Resident 8 was documented to have a Stage 1 pressure ulcer on the coccyx.There was no documented evidence the facility determined and documented what action or interventions were needed and communicated the actions or interventions to staff on each shift.The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.9. Resident 9 was admitted to the facility in 1/2020 with diagnoses including dementia and hypertension. Review of Resident 9's records revealed the following:On 12/3/20, Resident 9 developed two Stage 2 pressure ulcers on the right and left buttocks and on 12/7/20 was documented to have an open area on the penis.There was no documented evidence the facility determined and documented what action or interventions were needed and communicated the actions or interventions to staff on each shift.The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.10. Resident 10 was admitted to the facility in 6/2018 with diagnoses including dementia and anxiety. Review of Resident 10's records revealed the following:On 10/31/20, Resident 10 developed two Stage 2 pressure ulcers on the right and left buttocks.There was no documented evidence the facility determined and documented what action or interventions were needed and communicated the actions or interventions to staff on each shift.The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.11. Resident 11 was admitted to the facility in 5/2020 with diagnoses including dementia and A-fib. Review of Resident 11's records revealed the following:On 11/16/20, Resident 11 developed an infection on the second toe of the left foot and on 11/27/20 s/he developed a fluid-filled blister on the top of the right foot. The resident developed a second blister on the right foot on 12/7/20.There was no documented evidence the facility determined and documented what action or interventions were needed and communicated the actions or interventions to staff on each shift.The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.12. Resident 12 was admitted to the facility in 10/2018 with diagnoses including dementia and GERD. Review of Resident 12's records revealed the following:On 10/31/20, Resident 12 sustained an abrasion to the left knee and skin tear on the left elbow. On 11/30/20, s/he sustained a skin tear to the right elbow.There was no documented evidence the facility determined and documented what action or interventions were needed, communicated the actions or interventions to staff on each shift, and monitored and documented on the progress of the condition at least weekly until the condition resolved.The need to ensure interventions developed in response to changes of condition were adequate, communicated to staff, monitored for effectiveness, and that the facility documented on the progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.
3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including Alzheimer's dementia, history of cerebellar stroke, recent left shoulder fracture and hypertension. Prior to admission, the resident had fallen and sustained a shoulder fracture, for which s/he was receiving home health physical therapy to regain strength. The current service plan indicated the resident used a quad cane for ambulation, required one-person assistance for transfers and ambulation and understood the use of the call light when it was explained to him/her at move-in.a. The record indicated Resident 4 fell on 10/7/20 while trying to get up to walk to the restroom in the apartment without calling for assistance. The Incident Report identified "Actions taken to minimize" as "Remind resident to use walker."There was no documented evidence the determined intervention was added to the service plan and communicated to staff.b. On 11/23/20, the record indicated Resident 4 slipped and fell while trying to get up from bed and to the bathroom without calling for assistance. The Incident Report identified "Actions taken to minimize" as "Remind resident to ask for assistance."There was no documented evidence the determined intervention was added to the service plan and communicated to staff. Further, under the Incident Report item "Was the service plan being followed" staff wrote only "Resident was being offered assistance every few hours." There was no monitoring of whether other previous fall interventions (use of quad cane or walker, ability to use call system) were being followed at the time of the fall and were effective, or whether new interventions needed to be developed.The facility's failure to ensure new interventions were added to the resident's service plan and communicated to staff, and that previous interventions were monitored for effectiveness following changes of condition, was reviewed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, the service plan updated and weekly progress noted until the condition resolved for 11 of 11 sampled residents (#s 1, 2, 3, 4, 6, 7, 8, 9, 10, 11 and 12) who had changes of condition. Resident 1 had repeated falls, no fall prevention interventions were developed and implemented and s/he sustained an arm fracture. Findings include, but are not limited to:1. Resident 1 was admitted to the MCC in 10/2020 with diagnoses including history of rib and vertebral fractures, osteoporosis with pathological fractures, dementia and spinal stenosis. Resident 1 was identified as a fall risk and had a history of falls. Review of Resident 1's record revealed the following:Between 11/17/20 and 12/12/20, the resident had four documented falls. The facility failed to determine and document what actions or interventions were needed for the resident following three of the falls. Following one fall, the Incident Report indicated "Remind resident to use call light" those instructions were not added to the service plan or communicated to staff. No fall prevention interventions were added to Resident 1's service plan.Resident 1 had a fall on 12/12/20 which resulted in elbow pain. The resident was sent out to the hospital on 12/14/20 and diagnosed with an elbow fracture. The facility's failure to determine, document and implement fall interventions resulted in undue pain and injury.The need to ensure interventions developed in response to changes of condition were adequate and monitored for effectiveness, and the facility documented on the progress of injuries at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.2. Resident 2 was admitted to the facility in 9/2020 with diagnoses including epilepsy and neuropathy. The service plan noted a history of falls and directed staff to encourage the resident to use a walker while ambulating. The service plan also noted the resident preferred to ambulate independently around the facility without the use of any assistive devices.Review of Resident 2's records revealed the following:Between 9/15/20 and 11/14/20 the resident had six documented falls, including one fall with injury. There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated instructions for staff, monitored and documented on the progress of the resident following each fall and monitored existing interventions for effectiveness.The need to ensure actions or interventions were determined, documented in the resident's record and communicated to staff following a change of condition, existing interventions were monitored for effectiveness, and the facility documented on the progress of injuries at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.

4. Review of Resident 4, 6, 7, 9, 10 and 11's records indicated each resident had developed a skin wound or skin condition between 10/31/20 and 12/18/20 as follows:a. Resident 4 was readmitted to the facility from the hospital on 12/8/20 with a Stage 2 pressure ulcer.b. Resident 6 sustained a skin tear on the right pointer finger on 11/23/20 and developed a Stage 2 pressure ulcer on the left buttocks on 12/15/20.c. Resident 7 developed two Stage 2 pressure ulcers on 12/8/20. d. On 12/3/20 Resident 9 developed two Stage 2 pressure ulcers on the right and left buttocks and on 12/7/20 was documented to have an open area on the penis.e. On 10/31/20 Resident 10 developed two Stage 2 pressure ulcers on the right and left buttocks.f. On 11/16/20 Resident 11 developed an infection on the second toe of the left foot and on 11/27/20 s/he developed a fluid-filled blister on the top of the right foot. The resident developed a second blister on the right foot on 12/7/20.Each of those skin issues was considered a significant change of condition, for which an RN assessment was required. There was no documented evidence the facility RN completed an assessment for each resident which including findings, resident status, and interventions made as a result of the assessment. There was no update to the service plan that communicated the actions or interventions to staff on each shift.The need to ensure RN assessments were completed timely, updates made to the service plan and/or monitoring for effectiveness and progress at least weekly until resolved was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for significant changes of condition for 9 of 9 sampled residents (#s 1, 2, 3, 4, 6, 7, 9, 10 and 11) related to weight changes, falls, skin conditions and COVID-19 status. The facility failed to complete an RN assessment when Resident 2 was diagnosed with COVID-19. Resident 3 lacked an RN assessment for severe weight loss. Findings include, but are not limited to: 1. Resident 2 was sent to the hospital on 11/26/20 and returned to the facility on 12/4/20 with a new diagnosis of COVID-19. Being identified as COVID-19 positive represented a significant change of condition and required an facility RN assessment. There was no documented evidence an RN assessment was completed for Resident 2.In an interview on 12/16/20 at 12:15 pm, Staff 2 (RN) acknowledged no change of condition had been completed.The failure to conduct a RN assessment for a significant change of condition was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the deficiency.2. Resident 3 was admitted to the facility in 2/2019 with diagnoses including dementia, hypertension, atrial fibrillation and a history of constipation. At the time of the survey, the resident had recently begun receiving hospice services. The service plan, dated 6/29/20, identified the resident needed minimal assistance for eating and could feed him/herself, could make his/her needs known to others and was on a mechanically altered diet. A 12/14/20 visit note written by a hospice nurse noted "Weight loss from 155 lbs on 11/05 [2020] 136 lbs today 12/14 [2020]." This was a loss of 19 pounds in a little over one month or loss of 12.25% body weight. This represented a severe weight loss and was considered a significant change of condition.Though the facility RN initialed the document as having reviewed it, there was no documented evidence the RN assessed the weight loss reported by hospice or implemented interventions to address the weight loss.On 12/16/20, the facility implemented daily meal tracking for all residents in the facility. Review of Resident 3's intake log indicated the resident's intake was minimal, as follows:12/16/20:Breakfast: 10%Lunch: 0%Dinner: 25%12/17/20:Breakfast: 0%Lunch: 0%Dinner: 25%12/18/20:Breakfast: 10%Lunch: declined mealThe surveyor observed the lunch meal on 12/17/20 and 12/18/20. On 12/17/20, the resident was brought to the community dining room by staff. She was provided a plate with chicken nuggets, french fries, mixed vegetables and chocolate ice cream. The resident ate a couple of spoonful's of ice cream and drank approximately 8 ounces of milk, and then asked to return to his/her apartment. Afterwards, Staff 11 (Agency CNA) reported she was aware Resident 3 had not been eating and had offered to feed the resident the previous day, but the resident refused assistance. Staff 11 stated she would continue to offer the resident snacks during the afternoon. On 12/18/20, the resident again dined in the community dining room. The meal consisted of meatballs, mixed vegetables, a roll and ice cream. Staff 8 (Activities Assistant) spent time sitting with and talking to Resident 3 about the importance of eating and offered to have the kitchen prepare something different for the resident if desired - the resident declined the offer and stated s/he wasn't hungry. In an interview with the surveyor during lunch, Resident 3 stated s/he's never been a big eater and said s/he wasn't hungry. The resident drank approximately 8 ounces of milk. Again, Staff 11 was observed in the afternoon offering Resident 3 snacks.A weight was obtained for Resident 3 on 12/18/20. The resident's weight was 138 lbs.Resident 3 experienced a severe weight loss and observations and interviews indicated the resident was not eating much. The facility failed to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment.The facility's failure to ensure an RN assessment was completed for Resident 3's weight loss and interventions developed and implemented, was reviewed with Staff 1 (Administrator) on 12/18/20. She acknowledged no assessment was completed and no interventions were implemented to address the weight loss.3. Resident 1 was identified to have a decline in condition in multiple areas including mobility, difficulty eating, and ADL assistance due to a fall with fracture on 12/12/20.The resident's decline in multiple areas and the fracture constituted a significant change of condition and required a facility RN assessment. There was no documented evidence of an RN assessment and no interventions developed or implemented as a result of the RN assessment.Failure to ensure a facility RN assessment was completed for Resident 1's significant changes of condition, that included documented findings, resident status and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator). Staff 1 acknowledged no RN assessment had been completed.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and ensure staff are informed of new interventions, the resident's service plan is adjusted and interventions are implemented, for 2 of 3 sampled residents (#s 3 and 4) who received hospice or home health services. Findings include, but are not limited to:Resident 3 and 4's records were reviewed during the survey. The following deficiencies were identified:1 a. Resident 3 received hospice services. A 12/9/20 visit note written by a hospice nurse directed the facility to "Apply barrier cream 2 X [2 times] daily and PRN" in response to the identification of Stage 1 wound areas on the resident's coccyx.There was no documented evidence the facility reviewed the new interventions, updated the resident's service plan. informed staff of the new interventions or implemented the treatment.b. A 12/14 20 visit note written by a hospice nurse noted "decubital pressure injury = skin is compromised. Wound care nurse on site please assess."Though the facility RN (also a wound care nurse) initialed the document as having review it, there was no documented evidence the RN assessed the pressure wound as requested by hospice.c. A 12/14/20 visit note written by a hospice nurse noted "Weight loss from 155 lbs on 11/05 [2020] 136 lbs today 12/14 [2020]"Though the facility RN initialed the document as having review it, there was no documented evidence the RN assessed the weight loss reported by hospice.2a. Resident 4 received home health physical therapy services in the facility. The following recommendations were made by HHPT:* 10/5/20: Keep foam cushion on recliner chair.* 10/13/20: Resident should exercise 2 -3 times per day. A list of exercises was provided.* 10/19/20: Please encourage movement (encourage the resident to stay active).* 11/4/20: Encourage walking to and from meals.* 11/17/20: Encourage daily walks with cane.There was no documented evidence these recommendations were added to the resident's service plan and communicated to staff to implement.b. Resident 4 was hospitalized from 11/25/20 - 12/8/20. The hospital discharge documents included wound care instructions and nutrition recommendations.There was no documented evidence these recommendations were added to the resident's service plan and communicated to staff to implement.The need to ensure recommendations from outside providers were reviewed, added to the resident's service plan and implemented by staff was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 12/17/20 and with Staff 1 on 12/18/20. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to carry out orders as prescribed for 4 of 5 sampled residents (#s 2, 3, 4 and 8) whose orders and MAR were reviewed. Residents 4 and 8 were not administered blood pressure and seizure medications respectively, and wound care treatment was not provided to Resident 3, which put the residents at serious risk. Findings include, but are not limited to:Resident 2, 3, 4 and 8's orders and MAR, from 12/1/20 to 12/15/20, were reviewed. The following deficiencies were identified:1. Resident 4 was admitted to the MCC in 10/2020 with diagnoses including Alzheimer's dementia, history of cerebellar stroke and hypertension. Upon Resident 4's return to the facility from the hospital on 12/8/20, orders were provided to the facility to discontinue olmesartan-amplodipine-HCTZ once daily (to treat high blood pressure) and to start amplodipine once daily (to treat high blood pressure).The facility administered the former medication until 12/11/20 and then stopped administering. However, the facility failed to begin administering the new medication as ordered. In an interview on 11/18/20, Staff 6 (Lead MA) reported the new medication was delivered to the facility while the resident was still hospitalized so it was not added to the MAR and the medication was not placed in the medication cart. She acknowledged the facility neglected to add the medication to the MAR and begin administering it as ordered when Resident 4 returned from the hospital.2. Resident 8 was admitted to the facility in 9/2020 with diagnoses including dementia. Resident 8 had signed physician orders dated 11/24/20 to administer Keppra 750 mg BID (to treat seizures).The 12/1/20 - 12/15/20 MAR, and surveyor's observation of the medication package, indicated the facility failed to administer the evening doses of the medication on 12/8/20 and 12/9/20 as ordered.3. Resident 3 was admitted to the facility in 2/2019 with diagnoses including dementia. On 12/9/20, a hospice nurse directed the facility to "Apply barrier cream 2X [2 times] daily and PRN" in response to the identification of Stage 1 wound areas on the resident's coccyx.There was no documented evidence the facility administered the barrier cream twice daily and as needed as ordered by the hospice nurse.4. Resident 2 was admitted to the facility in 9/2020 with diagnoses including acute metabolic encephalopathy, history of subdural hematoma and history of acute respiratory failure with hypoxia. The resident had signed physician orders dated 12/4/20 for the facility to administer a multivitamin daily and Nexium every morning (to treat heartburn and acid reflux).Resident 2's 12/4/20 - 12/15/20 MAR indicated the facility failed to administer the medications as ordered.The issues with Resident 2, 3, 4 and 8's orders and the need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the deficiencies.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a legal prescriber and administered by the facility, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:Resident 1, 2, 3 and 4's MARs, between 12/1/20 and 12/15/20, were reviewed during the survey. The following deficiencies were identified:1. Resident 1, 2, 3 and 4's MARs all had blanks where the facility MA failed to document whether the medication was administered.2. Resident 2, 3 and 4's MARs each included multiple medications for which no diagnosis or reason for use was documented.3. Resident 2 had signed physician orders for multiple PRN medications that were not listed on the 12/2020 MAR.4. Resident 3 had hospice orders for PRN lorazepam "for anxiety/dyspnea" (labored breathing) and PRN morphine "for pain/dyspnea." The MAR lacked resident-specific instructions for how Resident 3 expressed anxiety and parameters for which medication to administer for dyspnea.5. Resident 4 had orders for PRN Senna and PRN Dulcolax suppository - both to treat constipation. The MAR lacked parameters as to which medication to administer first.6. Residents 3 and 4 were administered several PRN medications between 12/1/20 and 12/15/20. There was no documented evidence the facility followed up to determine whether the medication was effective.The need to ensure resident MARs are accurate was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 12/17/20 and with Staff 1 on 12/18/20. Staff 1 acknowledged the facility needed to improve its auditing of resident MARs.

Based on interview and record review, it was determined the facility failed to ensure an accurate treatment administration record (TAR) was maintained for all treatments the facility provided, for 9 of 9 sampled residents (#s 3, 4, 6, 7, 8, 9, 10, 11 and 12) who were reviewed for wound care. Findings include, but are not limited to:Review of Resident 3, 4, 6, 7, 8, 9, 10, 11 and 12's records indicated each resident had developed a skin wound or skin condition between 10/31/20 and 12/18/20 as follows:1. On 12/9/20 the hospice RN left a communication that Resident 3 had a stage one pressure ulcer and staff were to apply barrier cream twice a day and PRN. 2. Resident 4 was readmitted to the facility from the hospital on 12/8/20 with a stage two pressure ulcer.3. Resident 6 sustained a skin tear on his/her right pointer finger on 11/23/20 and developed a stage two pressure ulcer on his/her left buttocks on 12/15/20.4. Resident 7 developed two stage two pressure ulcers on 12/8/20. 5. On 12/14/20 Resident 8 was documented to have a stage one pressure ulcer on the coccyx.6. On 12/3/20 Resident 9 developed two stage two pressure ulcers on the right and left buttocks and on 12/7/20 was documented to have an open area on the penis.7. On 10/31/20 Resident 10 developed two stage two pressure ulcers on the right and left buttocks.8. On 11/16/20 Resident 11 developed an infection on the second toe of the left foot and on 11/27/20 s/he developed a fluid-filled blister on the top of the right foot.9. On 10/31/20 Resident 12 sustained an abrasion to the left knee and skin tear on the left elbow. On 11/30/20 s/he sustained a skin tear to the right elbow.For each of these skin issues, there was no documented evidence the facility consistently documented the type of treatments it provided, date and time of treatment, instructions for PRN treatments including resident specific parameters and/or initials of person providing treatment. The need to ensure an accurate treatment administration record (TAR) was maintained for all treatments the facility provided was discussed with Staff 1 (Administrator) on 12/18/20. She acknowledged the findings.

Based on observation, interview and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff. Findings include, but are not limited to:During the survey, conducted 12/15/20 through 12/18/20, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.Refer to deficiencies in this report.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 160 and C 231.

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 260, C 270, C 280, C 290, C 303, C 310 and C 315.