Edgewood Point Memory Care

Based on observation, interview, and record review it was determined the facility failed to ensure an outdoor recreational area was accessible for all residents and failed to ensure all exterior pathways and accesses to the facility's common use areas were maintained in good repair. Findings include, but are not limited to:

Observations of the secured courtyard on 10/15/24 and 10/16/24 showed the following:

Wood edging along pathway was rotted, damaged and missing in multiple areas. These areas created a potential tripping/fall hazard for residents.

A cement patio used by residents had two raised circular metal anchored plates, which created an uneven walking surface.

Access to the secured courtyard was not accessible to all residents, as the two doors that exited out to the courtyard required a code to unlock the doors. In addition, the weather stripping between the doors and along the perimeter was not sealed and peeling off, causing large gaps and openings where insects, debris, and other containments could enter the building.

The need to ensure residents had access to an outdoor recreation area and all exterior pathways and accesses to the facility’s common use areas were maintained in good repair was discussed with Staff 1 (MCC Director) and Staff 4 (Maintenance Director) on 10/17/24. They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to have the setting that was physically accessible to an individual. Findings include, but are not limited to:

During a tour of the MCC environment on 10/15/24 and 10/16/24 the following was identified:
There were two doors that exited out to a secure courtyard that required a code to unlock the doors. The doors were misaligned which caused difficulty with opening and closing the doors properly. This created a situation which limited resident's ability to freely access the recreation area.
The need to have the setting physically accessible to residents was discussed with Staff 1 (MCC Director) and Staff 4 (Maintenance Director) on 10/17/24. They acknowledged the findings.

Refer to C 510.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(b) The setting is physically accessible to an individual.

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 C 510

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:

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 03/30/2023. 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

The findings of the kitchen inspection, conducted 07/28/22, 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 07/28/22, conducted on 11/03/22, 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.

Based on observation, interview and record review, 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 facilities kitchen, food storage areas, food preparation, and food service on 07/28/22 revealed:* Splatters, spills, debris, and drips noted on: - Hand washing sink and towel dispenser; - Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen; - Food packages on open lower shelves; - Can opener blade and casing; - Wire rack storage shelves throughout the kitchen; - Walls throughout the kitchen; - Floors and drains; - The dishwashing area walls, floors, and equipment; - Both sides and the interior of the range, grill, and oven; - Behind and underneath appliances; - Food storage and delivery carts; - The surface and underneath the tray line steam table; - Cage of fan blowing in food preparation area; - Vent grate blowing from ceiling; - Interior of the microwave; - The stand mixer; - A timer on a food preparation counter; and - The interior of the refrigerator in the Memory Care Unit. * Food was stored on the floor of the freezer;* Scoops were left in bins of food;* Dish racks were stored directly on the floor;* Undated and unlabeled food items were noted in the refrigerator;* The wiping cloth sanitizer bucket was not monitored to ensure the sanitizer was dispensing at the correct parts per million, staff were not aware of where to locate the test strips;* Staff were observed to not change gloves between tasks or sanitize hands upon entering the kitchen; * Caregiving staff entering the kitchen did not have hair restrained; and * Caregiving staff assisting with meal service and delivery were not using aprons.The kitchen was reviewed with Staff 1 (Administrator). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 240.

The findings of the relicensure survey conducted 5/17/21 to 5/19/21 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, 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 dayA situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An immediate plan of correction was requested in the following area:OAR 411-54-0025 (4) Reasonable PrecautionsOAR 411-054-0070 (1) Staffing RequirementsThe facility put immediate plans of correction in place during the survey and the situations were abated.
The findings of the first re-visit to the re-licensure survey of 5/19/21, conducted 10/4/21 through 10/6/21, 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, 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 05/19/21, conducted on 12/8/21, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, for 2 of 2 sampled residents (#s 2 and 3) related to infection control. The failure of the facility to ensure staff were complying with universal precautions and proper infection control standards put residents at risk for serious harm. Findings include, but are not limited to: 1. Resident 3 moved into the facility 12/2019 with diagnoses including dementia and a history of bladder cancer. During the acuity interview, 5/17/21, Resident 3 was identified as needing assistance from staff to empty his/her ileostomy bag. On 5/18/21 at 9:05 am, the surveyor obtained permission to observe ADL care. During the observation, Staff 13 (CG) wheeled Resident 2 into his/her room next to the bed, put gloves on, assisted the resident to stand, removed the residents soiled pants and sat the resident back in the wheelchair. Staff 13 removed the resident's shoes and emptied the contents of the ileostomy into a urinal. Staff closed the ileostomy bag, put clean pants and shoes on the resident and wheeled him/her into the bathroom. Staff 13 again assisted the resident to stand, pulled the back of residents brief away from his/her body, reached into the resident's brief and used a wet wipe to clean the resident's bottom. Staff then walked to the front of the resident, pulled the front of the brief away from the resident's body and wiped the resident's perineal area with the same wet wipe. The residents brief was not changed during the observation. At no time during the observation did Staff 13 change her gloves or perform hand hygiene. The need to ensure staff exercised universal precautions and infection control standards was discussed with Staff 1 (Administrator, Staff 2 (RN) and Staff 4 (Regional Director) on 5/18/21 and 5/19/21. They acknowledged the findings. 2. Resident 2 was admitted to the facility 01/2020 with diagnoses including dementia with behavioral disturbances. * On 5/17/21 at 1:25 pm, the surveyor obtained permission to observe ADL care. During ADL care Staff 7 (CG) and Staff 13 (CG) assisted Resident 2 with a transfer to the bed and incontinent care, both staff members put gloves on before beginning care. Prior to transfer Staff 7 detached the resident's catheter bag and dropped it on the floor. Once the resident was positioned in bed Staff 7 picked up the catheter bag and dropped it on the floor next to the bed. Staff 13 began incontinence care with Staff 7 providing support for positioning and removing the soiled incontinence product. Once the resident's perineal area was cleaned, Staff 13 removed her gloves and put on a new pair. Both staff members repositioned the resident touching his/her clothing, bedding, and new incontinence brief. Staff 7 never removed or changed his gloves; and * On 5/18/21 at 9:30 am surveyor obtained permission to observe ADL care. During ADL care Resident 2 had his/her catheter bag drained by Staff 7. After emptying the resident's catheter bag, Staff 7 checked the resident to see if he/she had a bowel movement or would need an incontinent brief change, touching the resident's briefs and perineal area. Once done performing care Staff 7 took off her gloves and put them in the front pocket of her apron. The failure to ensure staff were using proper infection control precautions was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings. 3. During the survey, the following was observed:* On 5/17/21 a plastic garbage bag of soiled briefs had been placed, open, on a dresser in room 120;* On 5/17/21 and 5/18/21 staff were observed wearing gloves in the dining room, sitting between two residents, or walking between residents at different tables and providing bites of food. In between assisting residents to eat, staff would pick up dirty cups and plates and take them to the kitchen. The staff did not change gloves or do hand hygiene between residents or after picking up dishes; * On 5/18/21 during lunch meal, one staff member was assisting a male resident to eat. Staff scooped up a bite of food in a spoon and brought the spoon to the resident's mouth, spilling some of the food on the resident's face and shirt. Staff then used the spoon to clean the spill off the resident's face and shirt, then placed the spoon with the food on it back in the bowl, and proceeded to give the resident another bite; and* On 5/18/21 a staff member was observed carrying a resident's urine-soaked pair of shorts down the hall to the laundry room without placing the shorts in a plastic bag or other protective container. On 5/18/21 at approximately 3:15 pm survey requested the facility provide an immediate plan of correction to train staff in universal precautions and proper infection control. Survey received and accepted the plan at 3:48 pm, at which time the situation was abated. The need to ensure staff exercised universal precautions and infection control standards was discussed with Staff 1 (Administrator) and Staff 2 (RN) and Staff 4 (Regional Director) on 5/18/21 and 5/19/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#s 1 and 2) were treated with respect and dignity, free from neglect and resided in a safe and homelike environment. Residents 1 and 2 experienced multiple unwitnessed falls with injures requiring emergency medical care or hospitalization. Findings include, but are not limited to:1. Resident 2 was admitted to the MCC in 1/2020 with diagnoses including dementia with behavioral disturbances. Resident 2's service plan dated 1/17/21 included the following information under fall management:"I have fallen a few times due to increased weakness from recent hip fracture and me forgetting that I can no longer walk. When in bed, ensure my call light is within reach and that crash mat is in place to prevent injury. If I attempt to get out of bed or if....sitting on the edge of the bed, get me up and wheel me to the common areas." There were no changes made to the resident's fall management plan after 1/17/21, including review of previous interventions for effectiveness or the development of new interventions. The hip fracture referenced in the service plan occurred in December 2020. a. Between 3/11/21 and 4/30/21, the resident had eight unwitnessed falls with the resident being found on the floor, including a fall on 4/30/21 resulting in hospitalization for a left hip fracture.The facility's incident report form included a section for administrator investigation, immediate interventions, and what would prevent the incident from happening again in the future. The following was found in the resident's record: * Four falls occurred between 4/10/21 and 4/30/21, the facility failed to investigate the falls to rule out abuse and neglect or review the resident's fall prevention interventions;* Three falls occurred between 3/17/21 and 3/28/21, were not reviewed by the facility until 4/14/21, and failed to rule out abuse and neglect or review the residents fall prevention interventions;* Two falls occurred between 3/11/21 and 3/13/21, were not reviewed by the facility until 4/15/21, and failed to rule out abuse and neglect or review the residents fall prevention interventions.The facility's failure to ensure resident specific fall interventions were completed and updated following continued falls, and the interventions were monitored for effectiveness, resulted in a fall requiring hospitalization for hip fracture for Resident 2 and was considered neglect of care.b. On 5/18/21 at 9:23 am, Resident 2 was in the dining room at the end of breakfast service, and was approached by Staff 7 (CG) who said in the presence of other residents "I'm gonna take you to your room and change your catheter." The facility failed to treat the resident with respect and dignity concerning his/her care needs. The above findings were reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.Refer to C 270 and C 280.
2. Resident 3 was admitted to the facility 12/2019 with diagnoses including dementia. Review of resident's clinical records, including progress notes, incident reports and temporary service plans showed the resident had unwitnessed falls or "was found on floor" 13 times between 2/6/21 and 5/16/21. Falls with injuries included but were not limited to: * 3/15/21 "deep laceration to right side of [his/her] head". Resident was sent to the emergency department and received several staples to close head wound; * 4/13/21 "Bleeding from the back of head" sent to ER;* 4/18/21 "small skin tear to [his/her] right knee" and "redness" on his/her back. "..resident opened a older wound on [his/her] [right] arm."On 4/14/21 staff hand wrote updates to residents 1/29/21 service plan. The updates identified the resident as "a high fall risk." Staff to assist me." "I am unsafe." I need to be in sight for safety." Prior to 4/14/21 the residents service plan stated "I ambulate independently without assistance or assistive devices. I am steady on my feet." There was no evidence in the residents record any fall interventions had been developed or implemented prior to 4/14/21.There was no documented evidence the facility had thoroughly investigated the root cause of the falls or developed new interventions to prevent future falls and injuries. This constituted neglect and was considered abuse. The above findings were reviewed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.3. During the survey several observations were made that showed residents failed to receive services in a manner that protected their privacy and dignity in a homelike environment. The following interactions between staff and residents were observed: * On 5/17/21, Staff 13 (CG) walked up to a female resident in the dining room and stated in front of other staff and residents "let's see if you are wet, ok?";* On 5/17/21, the 2:00 pm shift change report was conducted in the dining room. Five residents were sitting in the dining room, two of which were sitting at the table where staff were reporting on other resident's care needs. One staff was overheard saying she was assigned to "section 3" with all the "trouble makers.";* On 5/18/21 at 9:05 am, staff walked up to Resident 3, who was seated in wheelchair next to the memory care main entrance and stated, "your pants are wet, lets go get you changed". Three other residents were seated in the same area; * On 5/18/21 at 9:27 am, Staff 10 (MT) walked up to Resident 2 in the dining room and said to the resident "we need to go change your catheter ok?"; and * At 9:32 am, Staff 8 (MT) walked up to an unsampled resident sitting in the dining room, (identified during the acuity interview as needing full assistance with meals), and began feeding the resident eggs and hash browns from the residents plate. The breakfast plate had been sitting in front of the resident since approximately 8:20 am. Staff 8 did not check to see of the food was still warm or offer to heat the food up. The need to ensure all residents received services in a manner that protected their privacy and dignity in a homelike environment was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility 3/2020 with diagnoses including dementia. The resident was observed during the survey to need full assistance with ADL care. A review of Resident 4's clinical records, including progress notes and incident investigations, showed staff had identified the resident with an abrasion to the left calf on 5/6/21.There was no other documentation in the resident record to indicate the injury had been investigated to rule out abuse.The need to ensure injuries of unknown cause or any incidents of abuse or suspected abuse were immediately investigated was discussed with Staff 1 (Administrator), Staff 2 (RN) and on 5/19/21. No further information was provided.
Based on interview and record review, it was determined the facility failed to report injures of unknown cause to the local SPD office as suspected abuse unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, for 2 of 3 sampled residents (#s 3 and 4) with injuries of unknown cause. Findings include, but are not limited to:1. Resident 3 was admitted to the facility 12/2019 with diagnoses including dementia. Resident 3 was observed during the survey to need full assistance with ADL care. A review of Resident 3's clinical records, including progress notes and incident investigations, showed staff had identified the following injuries of unknown cause: * 2/7/21 Bruising on the back of right arm;* 2/11/21 Bruise to right lower lip;* 3/1/21 Skin tear above right elbow;* 3/14/21 Bruise to left side of residents "bottom"; and * 4/18/21 resident was found on the floor with "small skin tear to [his/her] right knee" and "redness" on his/her back. "..resident opened a older wound on [his/her] [right] arm." Although staff who discovered the injuries filled out a facility incident report form for each injury, the back of the forms, containing sections for "Administrator Investigation of Incident", "immediate intervention" and "what might prevent this from happening in the future" were blank. There was no other documentation in the resident record to indicate the injuries had been investigated to rule out abuse, or if abuse could not be ruled out reported to the local SPD as an injury of unknown cause. The facility was directed to self-report these incidents to the local SPD office. Confirmation the incidents were reported was received on 5/19/21, prior to survey exit.The need to ensure injuries of unknown cause or any incidents of abuse or suspected abuse were immediately investigated or reported if necessary was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. On 5/18/21 at 9:07 am, the facility's main kitchen was toured with Staff 16 (Executive Chef). Observations of the kitchen, identified the following areas were in need of cleaning or repair: * A tall rectangular table located to the right of the kitchen door had splintered wood on the table's surface, edges, and corners; * Light switches to the dining room had brown/black smudges and dried food particles; * Entrance door to the kitchen had chipped paint and exposed wood on both sides and around the door handle; * Ceiling vents throughout the kitchen were coated with thick layers of dirt and dust; * Areas of cracked and peeling paint on the ceiling and walls of the kitchen; * Lower shelf of the beverage station had chipped wood along the edges; * The hood vent above the stove had grease and dust build-up; * Black residue on walls along the steal edge of the dishwashing area; and * Dried food splatters on the wall behind the garbage receptacle located next to the stove.At 9:30 am, the above findings were reviewed with Staff 1 (Administrator) and Staff 16 on 5/18/21. They acknowledged the findings. 2. During a tour of the Memory Care Unit on 5/18/21 at 9:37 am, it was determined the following areas were in need of cleaning or repair:* All of the kitchen cabinets and drawers were chipped with rough corners and edges; * The interior and exterior of cabinets and drawers throughout the kitchen had a build-up of dried food spills and crumbs;* Baseboards throughout the kitchen had black accumulation along the floor edges;* The refrigerator shelves had food spills and drips;* There was food found in the fridge that was unlabeled and not dated;* The floor space between the side of the of the refrigerator and the wall had an accumulation of food debris, dirt and dust; * Food splatters and particles inside the microwave; * Build-up of burnt food debris inside the oven; and* Food splatter on the wall behind the kitchen garbage receptacle. The areas needing cleaning and repair were discussed and toured with Staff 1 on 5/18/21. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:During a tour of the Memory Care Unit kitchenette on 10/4/21 at 11:00 am, it was determined the following areas were in need of cleaning:* The interior and exterior of cabinets and drawers throughout the kitchen had a build-up of dried food spills and crumbs;* The floor space between the side of the of the refrigerator and the wall had an accumulation of food debris, dirt and dust; * Build-up of burnt food debris inside the oven; and* Food splatters on the wall behind the kitchen garbage receptacle. The areas needing cleaning were discussed and observed with Staff 19 (Resident Care Coordinator/LPN) on 10/04/21. She acknowledged the findings.

3. A review of Resident 2's clinical record revealed a quarterly evaluation had been completed on 1/29/21. The next quarterly evaluation would have been due three months later, on or about 4/29/21. There was no documented evidence a recent quarterly evaluation had been completed as of 5/19/21. The need to ensure quarterly evaluations were completed timely and included documented changes of condition was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#1) and failed to complete quarterly evaluations for 2 of 2 sampled residents (#s 2 and 3), whose records were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 4/2021. Resident 1's move-in evaluation failed to address the following:* Customary routines, including eating and bathing;* Hobbies;* Mental health issues including behavior or mood problems, history of treatment and effective non-drug interventions;* Personality, including how the person copes with change or challenging situations; * Personal hygiene;* Environmental factors that impact the residents behavior;* History of dehydration or weight loss; and* Unsuccessful prior placements. The facilities failure to complete all required elements for Resident 1's new move -in evaluation was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings. 2. A review of Resident 3's clinical record revealed a quarterly evaluation had been completed on 1/29/21. The next quarterly evaluation would have been due three months later, on or about 4/29/21. There was no documented evidence a recent quarterly evaluation had been completed as of 5/19/21. The need to ensure quarterly evaluations were completed timely and included documented changes of condition was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director) on 5/19/21. They acknowledged the findings.

3. Resident 2's 1/17/21 service plan had not been updated quarterly, was not reflective or lacked clear direction to staff in the following areas:* Dressing;* Bathing;* Personal hygiene;* Toileting;* Transfers;* Evacuation assistance; * Assistive devices;* Environmental factors that impact the resident; * Mental health diagnoses and history of treatment;* List of treatments; and* Pain including indicators and non-drug interventions. The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, updated with changes, and provided clear direction to staff for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1's service plan, dated 4/29/21, failed to reflect the residents care needs and lacked specific instruction to staff in the following areas:* Two person assist for all ADL cares; * Specific hygiene needs and instruction on how to assist resident;* Finger foods and eating habits;* Hospital bed with side rails; * Two person assist for emergency evacuation;* Sleep patterns;* Environmental factors that impact behavior; * Bathing assistance; and* Bedside table. The need to ensure resident service plans were reflective of current care needs and provided specific instruction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings. 2. Resident 3's service plan, dated 1/29/21, and subsequent temporary service plans reviewed during survey failed to reflect the residents care needs and lacked specific instruction to staff in the following areas: * Glasses;* Behavior interventions;* Dressing assistance;* Oral care and hygiene;* Partial lower denture;* Specific instruction on emptying ileostomy bag;* Falls and interventions;* Ambulation devices; and * Environmental factors that impact the residents behavior. The need to ensure resident service plans were reflective of current care needs and provided specific instruction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. 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 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:Resident 1, 2 and 3's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the facility RN and service plans updated, and failed to monitor, and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift and made part of the resident's record and weekly progress noted through resolution for 2 of 3 sampled residents (#s 2 and 3) who experienced changes of condition. Resident 2 and 3 experienced multiple falls resulting in serious injuries. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in January 2020 with diagnoses including dementia with behavioral disturbance. a. During the survey, s/he was identified to have a history of falls, with a recent fall resulting in a left hip fracture. Review of Resident 2's clinical records revealed the following:Resident 2's 1/17/21 service plan stated "I have fallen a few times due to increased weakness from recent hip fracture and me forgetting that I can no longer walk. When in bed, ensure my call light is within reach and that crash mat is in place to prevent injury. If I attempt to get out of bed or if you [see me] sitting on the edge of the bed, get me up and wheel me to the common areas." Observations of Resident 2 throughout survey confirmed the resident was a two person transfer at all times with the use of a hoyer, was dependent on staff for all ADLs, and used a foley catheter. * On 3/11/21 the resident had an unwitnessed fall. In a Temporary Service Plan (TSP) staff were instructed to monitor for any injuries as a result of the fall, however there was no evidence previous fall interventions had been reviewed for effectiveness. The incident report, for the fall was not reviewed until 4/15/21 by Staff 17 (Administrator assisting from a sister facility) the fall intervention noted on the review was to "encourage resident to get up during meals"; On 4/14/21 and 4/15/21 Staff 17 reviewed incident reports for 3 additional unwitnessed falls, and documented on the incident reports the following fall interventions:*3/11/21 "encourage resident to get up during meals";*3/13/21 "resident is to remain in common area during meal times and last one to put to bed due to safety"; and *3/28/21 "when resident is going to room-needs to be escorted for safety and floors need to be clean from clutter." None of the fall interventions written on the incident reports were transferred to the resident's service plan or communicated to staff. Resident 2 experienced five more unwitnessed falls on 3/19/21; 4/10/21; 4/11/21; 4/18/21; and 4/30/21. The fall on 4/30/21 resulted in left hip fracture. There was no documented evidence the facility investigated the falls, determined or developed actions or interventions, and communicated the information to staff. According to the incident report completed the same day, on 4/30/21 at 7:10 pm the resident was found on the floor by his/her bed laying on his/her crash mat. "No injuries or bruising found." The resident was put on alert charting, and a TSP instructed staff to monitor for pain, bruising, redness and a change in mobility. There was no evidence the fall had been investigated by the facility, fall interventions had been reviewed, or new interventions implemented. On 5/1/21 at 6:00 pm, almost 24 hours after the fall, the resident was sent to the hospital due to "leg is crooked and swollen, left leg looks broken." The resident's fall on 4/30/21 resulted in a hip fracture for which the resident had to have surgery, returning to the facility on 5/7/21. The resident had broken the same hip on 12/4/20 as s/he did on 4/30/21.A TSP dated 5/7/21 for return from the hospital advised staff to monitor for "pain, mobility, appetite, confusion and left hip swelling. Resident able to feed self with set-up assistance. Resident is a two-person hoyer lift for transfers. Resident needs to be repositioned four times per shift with incontinent care and peri care."In an interview, 5/19/21, Staff 12 (MA) confirmed he had written the incident report for the fall on 4/30/21 and had sent the resident to the hospital the evening of 5/1/21. When asked if Staff 12 had checked on the resident prior to 6:00 pm the evening of 5/1/21, he stated ""no I don't believe so, but even if I did he was in bed and covered up." In and interview, 5/18/21, Witness 2 (HHPT) stated the resident had been ambulatory prior to the resident's first hip fracture at the facility in December, and after the fracture had been able to walk approximately 25 feet. Witness 2 further stated that with the second fracture "I don't see him walking again." Witness 2 said that at each appointment HHPT asks the facility about recent falls, and was only aware of three falls since December. The facility's failure to have a system in place to monitor, evaluate, develop actions or interventions and communicate those actions and interventions to staff, and the failure to report a resident's significant change of condition to the RN for assessment resulted in a fall with hip fracture for Resident 2 on 4/30/21. This injury required surgery with the resident returning to the facility on 5/7/21. The failure to monitor, evaluate, and develop interventions for changes of condition was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings. No further information was provided. b. On 3/4/21 Resident 2 began taking antibiotics for a urinary tract infection. The following information was found in the resident's clinical chart:* Alert charting and a TSP were put in place and staff began to monitor for "nausea, vomiting, diarrhea, abdominal upset, rash, and pain/burning on urination ....staff to offer resident water four times per shift and encourage the resident to drink water." On 3/8/21 alert charting and the TSP were discontinued by the RN. There was no documented evidence the facility had monitored the resident for possible adverse reactions or effectiveness of the medication through resolution. 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 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.
2. Resident 3 was admitted to the facility 12/2019 with diagnoses including dementia. a. Review of the resident's clinical records, including progress notes, incident reports and temporary service plans (TSP) showed the resident had unwitnessed falls or "was found on floor" 13 times between 2/6/21 and 5/16/21. Eight of the thirteen falls occurred prior to 4/14/21, two falls occurred between 4/14/21 and 4/30/21, and three falls occurred between 5/1/21 and 5/14/21. Documented injuries resulting from the falls included: * 3/15/21 "deep laceration to right side of [his/her] head" with possible concussion; * 4/13/21 "Bleeding from the back of head"; and;* 4/18/21 "small skin tear to [his/her] right knee" and "redness" on his/her back. "..resident opened a older wound on [his/her] [right] arm."Resident's 1/29/21 service plan stated the resident ambulated independently "without assistance or assistive devices. I am steady on my feet". A TSP written 3/12/21 instructed staff to do safety checks eight times a shift. Handwritten updates to the service plan, dated 4/14/21, identified the resident was a "high fall risk", instructed staff to keep the resident "in sight" and to keep his/her door open at night "for safety". TSP's written 4/30/21 and 5/1/21 instructed staff again to do safety checks eight times a shift. There was no documented evidence the facility had determined the resident was a fall risk, or had determined or documented actions or interventions and communicated the actions or interventions to staff regarding the residents falls prior to 4/14/21. There was also no evidence the facility reviewed the fall interventions implemented on 3/12/21, 4/14/21 or 5/1/21 for effectiveness or developed new interventions when the resident continued to fall. b. On 3/15/21 the resident had an unwitnessed injury fall and was sent to the emergency department. Resident was diagnosed with a "deep laceration to right side of [his/her] head" with possible concussion. There was no documented evidence the facility had monitored the resident for signs and symptoms of a concussion. c. On 4/30/21 the resident was prescribed 2.5 mg's of Onlanzapine (antipsychotic), one tablet by mouth at bedtime for "agitation". On 5/10/21 the dose was increased to 5 mg's. Though staff consistently documented the specific behaviors the resident was exhibiting, such as biting, kicking, hitting and care refusals, there was no evidence the facility had monitored whether the medication was effective on treating the behaviors. d. Resident 3's 1/29/21 service plan indicated the resident was able to dress, shower, perform hygiene tasks and ambulate independently. Review of resident's clinical records, 2/6/21 through 5/17/21, indicated the resident had experienced an overall decline in his/her health status and an increase in care needs, requiring full assistance with ADL's. There was no documented evidence the facility had evaluated the resident's change in condition, updated the service plan to reflect all areas of the residents significant decline in ADL abilities, or referred to the facility RN for a significant change of condition assessment. e. On 3/24/21 staff wrote a TSP stating resident had a nosebleed. Staff were to monitor for further bleeding, pain, difficulty breathing, nausea or vomiting. There was no other mention of the nosebleed and no evidence in the residents record the condition had been monitored to resolution. The facilities failure to have a system in place to monitor, evaluate, develop actions or interventions and communicate those actions and interventions to staff, and the failure to report a residents significant change of condition to the RN for assessment was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. No further information was provided.

2. Resident 3 was admitted to the facility in 12/2019 with diagnoses including dementia.Review of Resident 3's clinical records, observations made during survey and interviews with staff indicated the resident had experienced multiple falls, an overall decline in physical health and increased need for ADL assistance in several areas. Three of the residents falls resulted in serious injuries.Refer to C270, example 2a.There was no evidence the facility RN had completed a significant change of condition assessment to include documented findings, resident status, and interventions made as a result of the assessment. On 5/19/21 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director). They 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 2 of 2 sampled residents (#s 2 and 3) who experienced a significant change of condition. Residents 2 and 3 experienced an overall decline in health status and multiple falls resulting in serious injuries. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 1/2020 with diagnoses including dementia. During the entrance conference, the resident was identified to have a decline in condition in multiple areas including mobility and ADL assistance due to a fall with fracture on 4/30/21. The resident's clinical record was reviewed, and revealed the following:* Resident 2 had a previous fall with left hip fracture on 12/4/20. The RN did not completed a change of condition assessment until 12/15/20; * In the service plan dated 1/17/21 the resident was described as being wheel chair bound and "depending on my mood, pain, or willingness to participate, I require 1-2 person transfer with gait belt and two wheeled walker ....my PT has okayed for me to use the 2-person sit-to-stand machine";* On 2/27/21 a temporary service plan was completed stating that the resident was no longer able to use the sit-to-stand, and would now need to utilize a hoyer with a two person transfer at all times;* During the survey, the resident was observed several times hanging off the edge of his/her bed, yelling for help; and* The resident continued to experience multiple unwitnessed falls, an increase in behaviors, and an increased need for ADL assistance. On 4/30/21 resident had an injury fall and was diagnosed with a left hip fracture. This constituted a significant change of condition. There was no evidence the facility RN had completed a thorough significant change of condition assessment after 12/15/20 when the resident continued to decline or after the 4/30/21 hip fracture, to included documented findings, resident status, and interventions made as a result of the assessment. On 5/17/21 Staff 2 (RN) said "we don't have time to update [documents] and provide care, the service plans and evaluations are out of date." Failure to ensure a facility RN assessment was completed for Resident 2's significant changes of condition, that included documented findings, resident status and interventions made as a result of the assessment, was discussed on 5/19/21 with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director). They acknowledged no RN assessment had been completed.

3. Resident 4 was admitted to the facility in 3/2020 with diagnoses including dementia.The record indicated Resident 4 was readmitted to the facility from the local hospital and began receiving hospice services on 4/07/21. In an interview on 5/18/21, Staff 2 (RN) acknowledged the hospice service provider had not been leaving summaries of each visit and Staff 2 had not reviewed the services that were being provided by hospice.The need to ensure the facility had a system for coordinating on-site services with outside providers was discussed with Staff 1 (Administrator) and Staff 2 on 5/18/21. Staff 1 and Staff 2 acknowledged they needed to improve their coordination with Resident 4's hospice provider.
2. Resident 2's outside provider notes revealed the following: HH wound and catheter care provided recommendations to staff between 2/18/21 and 3/30/21.* Continue to offload and use Prevalon boot, change bandages as needed if soiled or dislodged;* Resident should wear Prevalon boots at all times;* Continue with wound treatment 2-3 days and as needed; and* Use of a STAT lock (attaches catheter to resident) to keep the catheter in place, as it was not present at the HH visit. There was no evidence that the facility's RN reviewed these notes or communicated to staff until 3/30/21. * 5/14/21 HH PT provided recommendations to staff about the resident's mobility, bathing, and safety. This document was not reviewed or communicated to staff. There was no documented evidence the recommendations were reviewed by the facility timely, communicated to staff or incorporated into Resident 2's service plan. The need to review recommendations from outside providers to coordinate care and services was shared with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 3 of 3 sampled residents (#s 2, 3 and 4) who received services from an outside provider. Findings include, but are not limited to:1. Resident 3's clinical record was reviewed and indicaed the following:a. On 4/13/21 resident was sent to the emergency department after an unwitnessed fall resulting in a "contusion of scalp." Instructions on the "After Visit Summary" provided to the facility included using acetaminophen (pain reliever) and applying ice to reduce swelling. Monitoring instructions for a concussion were also provided, including but not limited to monitoring for nausea, vomiting, dizziness, unusual sleepiness or grogginess and loss of consciousness. There was no documented evidence the discharge instructions, including the care of the wound and monitoring for possible concussion, had been communicated to staff. b. On 5/8/21 staff documented resident had a "large" bruise to the left "elbow through the forearm with swelling." Resident was sent to the emergency department for evaluation and x-rays. Discharge instructions on the "After Visit Summary" provided to the facility included:* Rest the injury;* Elevate the "inured limb above heart level";* Ice the injury for "20 minutes at a time"; and to* Take acetaminophen as needed for pain. There was no documented evidence these instructions had been communicated to staff. On 5/19/21 the need to ensure recommendations from outside providers to coordinate care and services were communicated to staff was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 1/2020 with diagnoses including dementia with behavioral disturbances. Resident 2's clinical record was reviewed and showed the following:* Resident 2 was prescribed 200 mg Trazadone for sleep. On 2/26/21 the prescription was changed from PRN to routine at bedtime. The medication continued to be given PRN until the time of survey;* The most recent prescription order was documented correctly on the bubble pack filled on 2/26/21, and stated to administer "100 mg tablet, take two by mouth at bedtime";* The prescription filled had 18 doses taken from the pack, with only 11 doses administered in the MAR since 2/26/21. This left seven doses of Trazadone unaccounted for;* On 5/10/21 Staff 2 (RN) passed the medication to the resident, listing quantity as "2." From the bubble pack, which would equal 400 mg, instead of the 200 mg prescribed. When Staff 2 was interviewed on 5/18/21 about the discrepancy, as it was the only dose listed as "2," she stated "I believe the card says they're 50 mg each" and went to check; upon reviewing the card with this surveyor was unsure why her entry was different than the other dispensed doses on the MAR; * Further, the facility's system for processing new medications prescriptions was described by Staff 2 as "the med techs get the orders and fax them to the pharmacy or Propac. The RN or LPN [was] then supposed to sign off. Unfortunately I don't have time to monitor [all the medications]". Staff were unable to account for the seven missing doses of Trazadone.The need to have a safe medication and treatment system with adequate professional oversight was discussed with Staff 1 (Administrator), Staff 2 and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:1. During the relicensure survey, conducted 5/17/21 through 5/19/21, the survey team identified the following concerns:* C 302: Tracking Controlled Substances;* C 303: Medication and Treatment Orders;* C 310: Medication Administration;* C 315: Treatment Administration; and* C 330: PRN Psychotropic Medications.During the exit meeting on 5/19/21, Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) were informed the overall medication and treatment administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas.

2. Resident 3 was prescribed PRN Oxycodone 2.5 mg for "breakthrough pain."Resident 3's 5/1/21 through 5/17/21 MAR and the Controlled Substance Disposition Log from 5/1/17 to 5/1/17 were reviewed. The following discrepancies were noted: * Staff documented the Oxycodone was dispensed on the Controlled Substance Disposition log on three occasions, 5/2/21, 5/14/21 and 5/15/21. There was no documented evidence on the MAR the dispensed medication was administered to the Resident.Comparison of the medication dosing card to the disposition log showed the amount of medication left was reflected accurately on the disposition log. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 5/19/21 with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 2 and 3) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in January 2020 with diagnoses including dementia with behavioral disturbances. Resident 2's signed physician orders dated 1/21/21 included the following orders:* Hydrocodone 5/325 mg one tab three times daily as needed for pain with doses at least six hours apart. Resident 2's Controlled Substance Disposition logs and MARS, reviewed from 4/1/21-5/17/21 showed the following:* A 4/3/21 dose of Hydrocodone at 7:27 am was reflected on the disposition log but not on the MAR; * A 4/17/21 dose of Hydrocodone at 11:00 am was reflected on the disposition log but not on the MAR;* A 4/19/21 dose of Hydrocodone at 5:06 pm was reflected on the disposition log but not on the MAR;* A 4/10/21 dose of Hydrocodone at 9:00 am was reflected on the disposition log, but recorded as dispensed at 10:36 am on the MAR;* A 4/11/21 dose of Hydrocodone at 4:30 pm was reflected on the disposition log, but recorded as dispensed at 7:48 pm on the MAR; and* A 4/16/21 dose of Hydrocodone at 8:00 am was reflected on the disposition log, but recorded as dispensed at 8:42 am on the MAR.Comparison of the medication dosing card to the disposition log, showed the amount of medication left was reflected accurately on the log. The need to ensure an accurate narcotic disposition log was maintained for all controlled substances was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director). They acknowledged the findings.

3. Resident 4 was admitted to the facility in 3/2020 with diagnoses including dementia.Resident 4's clinical records revealed s/he was diagnosed with a stroke with swallowing difficulties on 4/7/21. During the survey, the resident was observed to receive assistance with ADL's and meal assistance. The resident was unable to answer questions. During lunch on 5/17/21 and 5/18/21, the resident was observed to receive assistance with meals in the dining area and was provided pudding thick consistency liquids. The surveyor asked Staff 13 (CG) what thickened consistency the resident should receive and staff answered "nectar to pudding depending on how well [the resident] is swallowing ". Review of Resident 4's clinical records revealed no order for thickened liquids. In an interview on 5/18/21, Witness 1 ( Hospice RN), provided the surveyor with the order dated 4/7/21 for Resident 4 to receive nectar thick consistency to prevent aspiration- choking risk, and notify hospice if s/he has swallowing issues.In an interview on 5/18/21, Staff 2 (RN) was unaware staff were not providing the correct thickened liquid consistency to Resident 4. She stated she would observe the resident during meals and have the kitchen prepare the thickened liquids for the the resident.The need to ensure Resident 4 received the ordered thickened liquid consistency was discussed with Staff 1 (Administrator) and Staff 2 on 5/19/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 4 sampled residents (#s 2, 3 and 4) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 had a physician order, dated 2/26/21, to administer Trazadone 200 mg daily at bedtime for sleep. Prior to 2/26/21 the resident had a PRN prescription for the medication. Resident 2's 4/1/21 through 5/17/21 MAR, medications and dispensation log were reviewed and revealed the routine order for Trazadone had not been transcribed to the MAR, and staff had been administering the medication on a PRN basis only. On 5/19/21, the physician orders and current MARs were reviewed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director). They acknowledged the findings.
2. Resident 3 was admitted to the facility in 12/2019 with diagnoses including dementia. Resident 3's 5/1/21 through 5/17/21 MARs and physician orders were reviewed. The resident's record had several signed physician orders for specific routine medication changes or new medications, however the physician recap, April 2021, was not legible, therefore there was no way to verify medication and treatment orders were being carried out as prescribed for the following routine medications: * Acetaminophen (for pain);* Docusate (bowel care);* Melatonin (insomnia);* Methimazole (hyperthyroidism);* Setraline (behaviors); * Vitamin D3 (supplement);* Aspercreme 4% patch (left leg pain); and* Diclofenac gel (hip pain). Survey requested a legible copy of the residents physician orders on 5/18/21. The facility failed to provide a copy of the signed physician orders prior to survey team exit. These findings were reviewed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (# 6) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 2019 with diagnoses including Alzheimer's disease.Resident 6 had a physician order, dated 09/02/21, to administer Ensure (Nutritional supplement) three times daily with meals.During observations of breakfast and lunch on 10/05/21 and breakfast on 10/06/21, the Ensure was not administered to Resident 6 as prescribed. On 10/05/21 and 10/06/21, the physician orders were reviewed with Staff 18 (Director of Operations for Hawthorne), Staff 19 (Resident Care Coordinator/LPN), Staff 20 (Administrator) and Staff 21 (Regional Director of Operations). They acknowledged the findings.

1. Resident #6 is currently receiving ensure as ordered by physician.2. Education completed with Med Tech with emphasis on following physician orders and completing the six right with medication/treatment administration.3. Meal service observation will be done daily by manager on duty.4. Memory Care Coordinator and Administrator.

2. Resident 2's /1/21 through 5/17/21 MAR was reviewed and revealed the following:Resident 2 was receiving Trazadone 200 mg as needed for sleep. A physician's order was received on 2/26/21 to dispense the medication routinely at bedtime, but was not transcribed to the MAR or communicated to staff. The resident was still receiving Trazadone PRN at the time of survey. The above information was shared with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. 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 ordered by a legal prescriber and administered by the facility, for 2 of 3 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1's 5/1/21 through 5/17/21 MARs and current physician orders were reviewed during survey. The following deficiencies were identified:* Instructions for PRN Acetaminophen documented on the MAR were "take 1 to 2 tablets by mouth every 8 hours as needed for pain", providing unclear instructions to unlicensed staff on when to administer one dose versus two; * PRN bowel medications Polyethylene glycol and a Bisacodyl suppository prescribed to treat constipation lacked clear instruction on which medication should be administered first; and * Cephylexin (antibiotic) ordered to treat a urinary tract infection instructed staff to administer one capsule by mouth every 12 hours for seven days. Staff signed on the May 2021 MAR they had administered 15 doses of the medication instead of the prescribed 14 doses. The need to ensure resident MARs were accurate and included specific instructions to staff administering medication was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director). 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 2 of 3 sampled residents (#s 2 and 5) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 2 and 5's 9/18/21 through 10/4/21 MARs were reviewed during the survey. The following deficiencies were identified:1. Resident 2's MAR was blank on 9/26/21 for the 5:00 pm dose for the following medications: * Cal-Gest 500 mg (supplement);* Memantine 5 mg (dementia);* Omeprazole 20 mg (Gerd); and* Pradaxa 110 mg (atrial fibrillation). The facility failed to document if they had administered the medication and/or the reason for the missed dosage. 2a. Resident 5's MAR contained blanks for the following medications:*Olanzapine 2.5 mg (dementia) on 9/26/21 at 5:00 pm; and*Albuterol nebulizer (breathing treatment) on 9/25/21 at 12:00 pm and 9/26/21 at 5:00 pm.The facility failed to document if they had administered the medication and/or the reason for the missed dosage. b. Resident 5's MAR reflected a physician's order for the resident to be weighed every two weeks. When the weights were not reflected on the MAR, a record of the resident's weights and the corresponding physician order were requested. On 10/5/21 at 10:00 am physician orders dated 8/11/21 were provided, in which the weights every two weeks were discontinued by the provider. The MAR was not updated to reflect this change in orders and therefore constituted an inaccurate MAR. The need to ensure MARs were reviewed for accuracy was discussed with Staff 19 (Resident Care Coordinator/LPN) and Staff 21 (Director of Nursing Services) on 10/5/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate treatment record, with clear instructions to staff, accurate documentation and specific treatment orders by a legally-recognized practitioner for 1 of 1 sampled resident (# 4) who received wound care. Findings include, but are not limited to:Resident 1 was admitted to the facility in 3/2020 with diagnoses including dementia.Resident 1's clinical record noted the following:* On 5/6/21, Resident 4 sustained an abrasion to the left calf area. The facility RN cleaned the wound with cleanser, patted the wound dry, applied a non-adhesive pad and wrapped it with Kerlix. Hospice was notified to request wound care orders and supplies. There was no specific instruction or physician's order as to what kind of wound treatment was to be administered to Resident 4.In an interview on 5/18/21, Witness 1 revealed Resident 4's treatment order, dated 5/6/21 was to cleanse the wound with cleanser, pat dry, apply antibiotic ointment, and cover with a non-adhesive dressing every other day. Staff were to provide the treatment on the days hospice did not come in to provide wound care. The May 2021 MARs from 5/6/21 through 5/17/21 noted an incorrect treatment order to be completed twice daily starting on 5/11/21. There were three occasions the treatment was documented as completed. The need to ensure the facility obtained signed physician's orders for treatments, included clear instructions for staff and documented treatments administered on the treatment record was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 5/19/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure psychotropic medications to treat a resident's behavioral symptoms were ordered in consultation with a physician, nurse practitioner, registered nurse or mental health professional for 2 of 3 sampled residents (#s 2 and 3) reviewed for psychotropic medications. Findings include, but are not limited to: Review of Resident 2 and 3's clinical records, including progress notes, MAR's, service plans and physician communications indicated the following: * On 4/7/21 Staff 12 (unlicensed MA) sent a fax to Resident 2's physician stating "may we please get a PRN Rx [prescription] for anxiety?....may we also get [his/her] sleep med increased?"; and * On 2/5/21 Staff 12 (unlicensed MA) sent a fax to Resident 3's physician requesting a "PRN for anxiety, agitation [and] behaviors ..." There was no documented evidence the above requests were made at the request of or in consultation with a physician, nurse practitioner, registered nurse or mental health professional. The need to ensure psychotropic medications to treat a resident's behavioral symptoms were ordered in consultation with a physician, nurse practitioner, registered nurse or mental health professional was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed at least quarterly for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (#1) reviewed who had a supportive device. Findings include, but are not limited to:Resident 1 was admitted to the facility in 4/2021 with diagnoses including dementia.During the entrance conference, 5/17/21, Resident 1 was identified as having bilateral side rails on his/her hospital bed. Observations of the resident and the residents room showed the side rails were in the up position throughout the survey. There was no quarterly assessment for the bilateral side rails completed by the RN, PT or OT for use of the assistive devices with potentially restraining qualities. There were no instructions to staff in the resident's service plan regarding the use or safety precautions of the side rails. The need to complete assessments of supportive devices with restraining qualities at least quarterly was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to employ a full-time Administrator scheduled to be on-site at least 40 hours per week. Findings include, but are not limited to:On 5/17/21 at 9:00 am the survey team entered the building to conduct a relicensure survey. Upon entrance, there were no staff present at the front office. At 9:10 am Staff 15 (Administrative Assistant) stated Staff 1 (Administrator) was unavailable because she was "working on the floor" assisting residents. In an interview, 5/17/21, at approximately 3:00 pm, Staff 1 acknowledged she and Staff 2 (RN) had been working on the floor as caregivers or med techs to cover shifts because they were short staffed. Staff 1 confirmed she was not able to spend 40 committed hours a week in the Memory Care Community. The need to employ a full-time Administrator scheduled to be on-site at least 40 hours per week was discussed with Staff 1, Staff 2 and Staff 4 (Regional Director) on 5/19/21. 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. This put several residents at risk for serious harm. Findings include, but are not limited to: 1. During the entrance conference on 5/17/21 the following was identified: * The facility had 22 residents;* Seven residents needed two person assist with transfers or Hoyer;* Six residents were on hospice; * Five residents needed full assistance with meals; * Seven residents were identified with behavioral issues needing constant cueing and redirection. 2. The staffing plan provided by the facility was as follows: * Day shift 1 MA and 4 CG's;* Evening shift 1 MA and 3 CG's; and * Night shift 1 MA and 1 CG. 3. Observations and interviews at the time of survey showed the following: * On 5/18/21 during the breakfast meal, three unsampled residents identified during the entrance conference as needing full assistance with meals sat in the dining room with full plates of food, no staff assistance or cueing was observed throughout the meal;* On 5/17/21 and 5/18/21 multiple unsampled residents and Resident 3 were observed to have been incontinent and were wearing soiled clothing;* On 5/18/21 during the lunch meal, staff were observed standing between two residents or walking back and forth between residents to provide meal assistance;* On 5/17/21 and 5/19/21 the day shift MA did not complete the morning 8:00 am medication pass until 9:45 am, having assisted with redirecting residents and resident care; * Multiple times throughout the survey Resident 2 was observed sitting at the edge of his/her bed yelling "help", "help me" for more than five minutes before staff responded. Resident 2 was a known fall risk and had recently re-fractured his/her hip because of a fall; and * During an interview, 5/17/21, Staff 1 (Administrator) and Staff 2 (RN) confirmed the facility was "short staffed" and they had been working the floor as caregivers or med aides to cover shifts on both the assisted living and memory care sides of the building.4. Time clock records, 5/1/21 through 5/17/21, were requested, reviewed, and compared to the facility's staffing plan and May 2021 staff schedule. * Day shift was short one staff four times, two staff seven times, and three staff three times;* Evening shift was short one staff 13 times; and * Night shift was short one staff 3 times. The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 1, Staff 2, and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.

Based on interview and record review, it was determined 3 of 3 sampled newly-hired direct care staff (#s 7, 10 and 13) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed with Staff 1 (Administrator) on 5/18/21. Staff 7 (RA) was hired 4/02/21, Staff 10 (RA) was hired 1/04/21 and Staff 13 (RA) was hired 2/24/21.The facility did not have documentation that Staff 7, 10 and 13 completed the required First Aid and abdominal thrust training.The need to ensure all training was completed within required timeframe's was discussed with Staff 1. She acknowledged Staff 7, 10 and 13 had not completed First Aid training.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:Fire drills and fire and life safety training records for the previous six months were requested.Review of the documentation provided identified the following: * There was no documented evidence unannounced fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts; and * There was no documented evidence fire and life safety instruction to staff was provided on alternate months. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) and Staff 14 (Maintenance Director) on 5/18/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to keep a written fire drill record that included all required information. This is a repeat citation. Findings include, but are not limited to:Fire drill records were reviewed on 10/05/21 with Staff 19 (Resident Care Coordinator/LPN) and Staff 21 (Director of Nursing Services). A fire drill was conducted on 9/27/21. The form used by the facility to document the fire drill lacked the following required information:* Location of the simulated fire origin;* The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and* Number of occupants evacuated.The fire drill record was reviewed with Staff 19 and Staff 21. They acknowledged the form used lacked all the required information and stated the facility would begin using a revised and more complete form to document future fire drills.

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:On 5/18/21, the facility's fire and life safety records were requested for review.There was no documented evidence of the following general fire and life safety requirements: * Evidence alternative exit routes were used during fire drills; * Evidence staff and residents participated in fire drills and training to assess ongoing evacuation capabilities of both residents and staff; and* Documentation of interventions and resolution related to resident evacuation concerns identified during fire drills.The need to ensure all general fire and life safety requirements were implemented and followed was discussed with Staff 1 (Administrator) and Staff 14 (Maintenance Director) on 5/18/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240, C 303, C 310, C 420, C 513 and Z 164.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean, repaired and free of unpleasant odors. Findings include, but are not limited to:Tour of resident rooms, dining area, living room and other common areas on 5/18/21 through 5/19/21 revealed the following:* A urine odor in the hallways and common areas that did not dissipate;* Dining room furniture/chairs had an odor, food spills and crumbs;* Cloth chairs were odorous, had dried brown matter, stains and spots; and * Wood furniture in common areas were gouged exposing splintered wood.The areas in need of cleaning and repair were shown to and discussed with Staff 1 (Administrator) and Staff 14 (Maintenance Director) on 5/18/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the interior areas were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:On 10/4/21, 10/5/21 and 10/6/21 the following was observed:* Tables and chairs in the resident dining area contained wood that was exposed, gouged and splintered;* The fabric of two arm chairs in the common area had stains and dried matter; and* The rocking chair in the quiet activity room had dried brown matter and stains on the cushions and base.On 10/6/21 the need to ensure the interior areas were kept clean and in good repair was discussed with Staff 19 (Resident Care Coordinator/LPN), Staff 20 (Administrator), Staff 21 (Director of Nursing Services) and Staff 18 (Director of Operations). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant was used when washing residents' soiled linens and clothing. Findings include,but are not limited to:During a tour of the facility, washers utilized by staff to wash residents' linens and clothing were noted to have a cold water rinse setting only. Commercial grade laundry detergent was noted in the laundry room, but did not contain a disinfecting agent.Staff 14 (Maintenance Director) was unaware that the rinse temperature needed to be 140 degrees Fahrenheit or a chemical disinfectant agent was needed. Staff 14 stated, he would call ECO Lab chemical company and inquire about a disinfectant to be used in the rinse cycle. The lack of a hot rinse option and/or use of a disinfectant was discussed with Staff 1 (Administrator) on 5/18/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence and comfort. That includes the supervision and overall conduct of the staff.During the relicensure survey, conducted 5/17/21 through 5/19/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the citations issued during the survey. Refer to deficiencies in 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 C160, C200, C231, C240, C350, C360, C372, C420, C422, C513 and C530.
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 240, C 420 and C 513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 7, 10 and 13) completed all required orientation, pre-service and competency training within required timelines, and 2 of 2 sampled direct care staff (#s 9 and 12) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:Training records were reviewed with Staff 1 (Administrator) on 5/19/21. The following deficiencies were identified:a. Staff 10 (MT) was hired 1/4/21 and Staff 13 (RA) was hired 4/2/21. There was no documented pre-service training prior to beginning job duties and no documented 30 competency training prior to working;Staff 7 (RA) was hired 4/2/21 did not complete orientation training pre-service dementia training on the following topics:* Providing food and fluids, preventing wandering and the dementia disease process prior to working independently;* Family support and the role the family may have in the care of the resident;* Environmental Factors that are Important to a resident's well-being and Use of supportive devices with restraining qualities in MCC's prior to working independently; and * Strategies for addressing social needs and engaging person with dementia in meaningful activities.b. Staff 9 (MT) was hired 5/28/19 and Staff 12 (MT) was hired 1/8/19. For the calendar year 2020, Staff 9 and 12 had no documentation of annual in-service training's.The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, and that veteran direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 1 on 5/19/21. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C252, C260, C262, C270, C280, C290, C300, C303, C302, C310, C315, C330 and C340.
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 303 and C 310.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans, or were followed for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident's 1, 2 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/2. They acknowledged the findings.

Based on observation, 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 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:Though Resident 1, 2 and 3's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's: * 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. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. No individualized activities were observed during the survey. The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Administrator), Staff 2 (RN) and Staff 4 (Regional Director) on 5/19/21. They acknowledged the findings.
Based on observation, 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 3 of 3 sampled residents (#s 2, 5 and 6) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 2, 5 and 6's service plans offered some information about the resident's interests and the facility completed an activity evaluation on each resident. However, the facility had not fully developed specific activity plans which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. No individualized activities were observed during the survey. On 10/05/21 and 10/06/21, the need to have an individualized activity plan for Resident 2, 5 and 6 was discussed with Staff 18 (Director of Operations), Staff 19 (Resident Care Coordinator/LPN), Staff 20 (Administrator) and Staff 21 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it has been confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include but are not limited to:During an unannounced inspection on 03/29/2021; the Compliance Specialist (CS) reviewed the facilities Uniform Disclosure Statement and Posted Staffing Plan; which revealed the facility is to have 4 caregivers and 1 Med Tech on Day shift; 3 Caregivers and 1 Med Tech on Evening shift; and 1 Med Tech/1 Caregiver on NOC shift.CS interviewed Staff #1, Staff #2, Staff #3, Staff #4 and Witness #1; separately. It was stated that the facility recently had a mass amount of staff members quit at once. The facility is bringing in staff from both a sister community and staffing agencies. Staff stated that the staffing is not where it needs to be, and residents are missing needs, to include showers due to the short staffing.CS reviewed the facilities Staffing Schedules for 02/2021 and 03/2021; and timecards from the time period of 03/12/2021-3/26/2021; which revealed dates where the appropriate staffing was not met.CS reviewed residents needs with Staff #4; which revealed the facility has 4 residents on hospice; 4- 2 person transfers and that a majority of the facilities 24 residents require assistance with incontinence care; to include bowel and bladder. The above information was shared with Staff #1. Facility Plan of Correction: Staff will be brought in from agencies, sister communities in addition to hiring for any open positions to adequately staff the community. Ongoing recruitment will be done for Resident Assistants and Medication Technicians. The Resident Services Coordinator and Memory Care Coordinator will monitor staffing levels daily and recruit, hire and train as needed. Administrator will be responsible for compliance.