Touchmark In The West Hills

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were readily available to staff, reflective of residents' current care needs, and service plans provided clear directions to staff regarding the delivery of services for 4 of 6 sampled residents (#s 1, 2, 4 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2024 with diagnoses including chronic diastolic heart failure and chronic kidney disease. Additionally, the resident’s hospital discharge notes included a diagnosis of type 2 diabetes mellitus, which was not on the facility’s list of primary diagnoses.

Observations were made of the resident's care on 02/10/25 and 02/11/25, interviews with the resident and facility staff were conducted, and the service plan dated 01/11/25 was reviewed. The facility completed a service plan dated 02/08/25 following a significant change of condition while the survey team was on site and provided a copy to the surveyor on 02/12/25.

Resident 4's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Instructions on signs and symptoms of hypo- and hyperglycemia to report;
* Instructions for proper maintenance of blood sugar monitor on right upper extremity and how to monitor for malfunctions;
* Instructions to staff on blood glucose monitoring protocol when resident slept late and skipped meals;
* Instructions for bleeding precautions and interventions while on anticoagulation therapy (Xarelto);
* Recent losses related to separation from a family member;
* Instructions for aspiration precautions and interventions while choking; * Incontinence care and maintenance of supplies;
* Instructions on what types of skin impairments to report and to whom;
* Instructions for signs and symptoms of infection to report while monitoring the wound site;
* Number of staff needed to assist with dressing and emergency evacuations;
* Incorrect reference to use of transfer pole;
* Electric scooter equipment precautions and instructions for proper maintenance;
* Instructions on to whom to report weight gain or loss; and
* Pharmaceutical interventions for pain, including how the resident expressed pain or discomfort.

The facility made service plans available to staff by storing them in a binder located at the staff station on the floor where the resident resided. However, Resident 4’s current service plan was not included in the binder and not available to facility staff at the time of the survey.

The need to ensure service plans were readily available to staff, reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 3 (Memory Care Administrator) and Staff 7 (LPN) on 02/12/25 at 3:18 pm. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 11/2023 with diagnoses including anxiety and memory loss.

During the survey, the resident was observed to require two staff members to assist with ADL tasks including incontinence care.

Observations of the resident, interviews with the staff, and the 01/31/25 service plan was reviewed during the survey.

The service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Bathing;
* Dressing;
* Eating including where resident preferred to dine;
* Weight gain and parameters;
* Toileting; and
* Behaviors including resident specific interventions.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 1:15 pm. She acknowledged the findings.

3. Resident 2 moved into the facility in 09/2023 with diagnoses including frontotemporal brain disease and left femoral neck fracture.

During the survey, the resident was observed in a hospital bed with an alternating pressure mattress. The resident required two staff members to assist with ADL tasks, including dressing, incontinence care, and bed mobility.

Observations of the resident, interviews with the staff, and the 12/31/24 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:

* Number of staff required to assist with ADL tasks, including dressing, meals, bed mobility, toileting, and transfers;
* Ambulation ability;
* Pain after femoral neck fracture;
* Use of fall mat;
* Use of a Drive air mattress;
* Continence status; and
* Instructions on use of Geri chair.

The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 2:20 pm. She acknowledged the findings.

4. Resident 6 was admitted to the facility in 05/2021 with diagnoses including dementia.
During the survey, the resident was observed in a wheelchair, able to self-propel. The resident required staff assistance for transfer, incontinence care and feeding assistance as needed.
Observation of the resident, interviews with staff, and the 01/16/25 service plan reviewed during the survey showed the service plan was not reflective and/or lacked resident-specific direction for staff in the following areas:
• Conflicting information regarding the resident’s use of a wheelchair and/or walker;
• One to two staff member assist with transfer;
• Meal assistance;
• Use of arm sling status; and
• Bathing or shower.

The need to ensure the service plan reflected the resident’s current care needs and provided clear instructions for staff was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 12:00 pm. The staff acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for short-term changes of condition, communicated actions and interventions to staff on each shift, and monitored the change of condition at least weekly until resolved for 2 of 6 sampled residents (#s 4 and 5) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 11/2023 with diagnoses including Sjogren syndrome.

The resident's current service plan dated 12/30/24, progress notes dated 11/19/24 through 02/03/25, and interim service plans (ISPs) were reviewed.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:

* 12/08/24 - Rectal bleeding; and
* 12/15/24 - Medication change.

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, the interventions were communicated to staff on all shifts and were monitored at least weekly through resolution was discussed with Staff 3 (Memory Care Administrator) on 02/12/25. She acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2024 with diagnoses including chronic diastolic heart failure and chronic kidney disease. Additionally, the resident’s hospital discharge notes included a diagnosis of type 2 diabetes mellitus, which was not on the facility’s list of primary diagnoses.

Clinical records, including the current service plan and charting notes from 12/11/24 through 02/10/25 were reviewed, and interviews with the resident and facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 12/13/24 – “Resident is having a difficult time being separated from his/her [family member].”;
* 12/13/24 – missed insulin injection administration;
* 12/15/24 – order to start tramadol (for pain);
* 12/20/24 – order to start gabapentin (for pain);
* 01/07/25 – order to start hydrocodone-acetaminophen as needed for pain;
* 01/13/25 – “has new bruise of self infected [sic] injury during noc [night] shift.”;
* 01/16/25 – returned to the facility following hospitalization for witnessed fall with injuries and a heart failure exacerbation;
* 01/22/25 – “had a choking episode…this writer was able to perform abdominal thrust.”;
* 01/22/25 – “continued to show difficulty swallowing, unsure if it’s a new behavior.”;
* 01/22/25 – order to start Keflex (antibiotic therapy) for infected toe;
* 01/23/25 - order to discontinue vitamin D (supplement);
* 01/24/25 – order to reduce furosemide (for edema) to 10 mg a day;
* 01/28/25 – returned from ER following unwitnessed fall resulted in left eyebrow laceration and multiple skin tears;
* 01/29/25 - …s/he “c/o [complains of] constipation. [S/he] is unable to recall the last time [s/he] had a BM [bowel movement].”;
* 01/31/25 – “had a significant weight gain in January.”; and
* 02/08/25 – returned to the facility following hospitalization for small bowel obstruction with multiple medication changes.

The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 3 (Memory Care Administrator) and Staff 7 (LPN) on 02/12/25 at 3:18 pm. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

(1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 2 and 6) and multiple unsampled residents for meal service. Findings include, but are not limited to:

a. Resident 2 moved into the facility in 09/2023 with diagnoses including frontotemporal brain disease and left femoral neck fracture.
At 10:50 am on 02/11/25, Staff 32 (CG) and Staff 38 (CG) were observed providing incontinence care for Resident 2. During the observation, both staff donned gloves without performing hand hygiene, assisted the resident in turning side to side and removed his/her soiled brief. Staff 32 provided perineal care and applied barrier cream. Both staff failed to doff soiled gloves, perform hand hygiene and don clean gloves before touching the resident's body and applying a clean brief, clothing, and new bedding for the resident.

b. Observations of meal service were conducted for breakfast meal on 02/11/25 in Devonshire 2. Caregiving staff were observed serving food and feeding residents without wearing a protective covering over potentially contaminated clothing and assisting multiple unsampled residents with meal service without performing hand hygiene or glove changes in between assisting different residents with their meal.
The need to maintain effective infection prevention and control protocols was discussed with Staff 3 (Memory Care Administrator) on 02/12/25. The findings were acknowledged.

c. Resident 6 was admitted to the facility in 05/2021 with diagnoses including dementia.
The surveyor observed on 02/23/25 at 10:10 am, Staff 38 (CG) provided incontinence care for Resident 6. During the observation, Staff 38 donned gloves without performing hand hygiene. Staff 38 then assisted the resident in turning side to side, removed the resident’s soiled brief, wiped and cleaned the resident’s perineum area and touched the resident’s body, clean incontinent product, the resident’s clean clothing and wheelchair while using the soiled gloves. Staff 38 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donned gloves.

The above observation was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 12:00 pm. The staff acknowledged the appropriate infection control practices were not implemented.

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

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

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated upon move-in and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 4) who was reviewed for self-administration. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 12/2024 with diagnoses including chronic diastolic heart failure and chronic kidney disease. Additionally, the resident’s hospital discharge notes included a diagnosis of type 2 diabetes mellitus, which was not on the facility’s list of primary diagnoses.

During the acuity interview on 02/10/25, Resident 4 was not identified as self-administering any of his/her medications. Resident 4’s charting notes from 12/11/24 through 02/10/25 and MARs from 12/11/24 through 02/10/25 were reviewed. It was noted s/he was self-administering his/her insulin and Ozempic subcutaneous injections (to control blood glucose level), and Miralax powder (bowel care) medications from the initial admission to the facility until hospitalization on 01/30/25 for a small bowel obstruction. This was confirmed by Staff 6 (LPN) in an interview on 02/10/25 at 12:50 pm and by Resident 4 in an interview on 02/11/25 at 11:07 am. Facility assumed the medication management when Resident 4 was discharged from the hospital on 02/08/25.

Review of Resident 4’s medical records revealed there was a physician's or other legally recognized practitioner's written order given at the time of admission to the facility stating, “Patient may self administer over the counter meds if [s/he] choose.” Insulin and Ozempic injections were not over the counter medications. On 02/12/25, Staff 3 (Memory Care Administrator) acknowledged no physician or other legally recognized practitioner’s written order was available for the injections.

There was no documented evidence the resident was evaluated upon move-in for his/her ability to safely self-administer medications.

The need to ensure residents who chose to self-administer their medications were evaluated upon move-in and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 3 and Staff 7 (LPN) on 02/12/25 at 3:18 pm. They acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds

(5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure they accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 6 sampled residents (#s 1, 2, and 6) whose ABST were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 11/2023 with diagnoses including anxiety and memory loss.

Observations of the resident, interviews with the resident and staff, the 01/31/25 service plan and Temporary Service Plan (TSPs), from 12/01/24 through 02/10/25, and Resident 1’s ABST data was reviewed.

The following areas were not reflective of the resident’s current ADL assistance:

* Bathing;
* Toileting;
* Dressing;
* Behavior; and
* Behavior Management.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 1:15 pm. The staff acknowledged the findings.

2. Resident 2 moved into the facility in 09/2023 with diagnoses including frontotemporal brain disease and left femoral neck fracture.

Observations of the resident, interviews with the resident’s family and staff, the 12/31/24 service plan, and Temporary Service Plans (TSPs), from 12/16/24 to 02/08/25, and Resident 2’s ABST data was reviewed.

The following areas were not reflective of the resident’s current ADL assistance:

* Time spent assisting with eating.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 3 (Memory Care Administrator) on 02/12/25 at 2:25 pm. She acknowledged the findings.

3. Resident 6 was admitted to the facility in 05/2021 with diagnoses including dementia. During the survey, the resident was observed requiring staff assistance along with multiple prompts or encouragement to initiate and maintain meal intake. At one point, the resident required physical feeding assistance.

Observations of the resident, interviews with the resident and staff, the 01/16/25 service plan and Temporary Service Plan (TSPs), from 02/01/25 through 02/10/25, and Resident 6’s ABST data were reviewed.

The following areas were not reflective of the residents current ADL assistance:

• Time spent cueing or redirecting due to cognitive impairment; and
• Time spent assisting with eating.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 3 (MC Administrator) on 02/12/25 at 12:00 pm. The staff acknowledged the findings.

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

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

This Rule is not met as evidenced by:

Based on 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 limited to:

Refer to C362

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

Based on observation, interview and record review, it was determined the facility failed to ensure health service were consistently provided. Findings include, but are not limited to:

Refer to C260, C270, C295 and C325

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 10/22/24 at 11:30 am, the facility kitchen was observed to need cleaning in the following areas:

* Hood vents above cooking equipment – dusty/greasy;

* Wall behind cooking equipment – drips of grease;

* Exterior of deep fat fryer – drips of grease;

* Side of convection oven (next to deep fat fryer) – drips of grease;

* Ceiling vent, ceiling area surrounding the vent and wall above spice shelf – heavy build up of dust; and

* Walk in refrigerator fans and cooling unit – black dust build up.

Other areas of concern included:

* Colored cutting boards – finish worn off/uncleanable;

* Three garbage cans did not have lids when not in use; and

* Kitchen staff with beards lacked use of beard restraints.

The areas of concern were observed and discussed with Staff 1 (Dining Services Director) and discussed with Staff 2 (Resident Care Manager) on 10/22/24. The findings were acknowledged.

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

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.

Findings include, but are not limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

The findings of the on-site investigation, conducted 10/18/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review, conducted during a site visit on 10/18/23, it was confirmed the facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST). Findings include, but not limited to: During an interview on 10/18/23, Staff 1 (Administrator) stated the ABST pulls data from the residents' service plans and updated nightly. Staff 1 stated the 22 ADLs are not individually listed in the tool, or if it was listed s/he did not have access to the report. A review of Resident 1, Resident 2 and Resident 3s' ABST on 10/18/23, lacked the number of minutes allocated in every ADL as is required. Resident 1's ABST was last updated on 07/12/23, which was not updated quarterly as required. The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RCC) on 10/18/23.It was determined the facility failed to fully implement and update the ABST.

The findings of the kitchen inspection, conducted 08/29/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 08/29/23, conducted 10/27/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 08/29/23 at 11:10 am, the following concerns were observed in the kitchen: * The sandwich bar refrigerator had uncovered tray of plates with sliced fruit;* The walk in refrigerator had trays of uncovered/unlabeled food items (breaded meat, chicken) on a rolling cart and a pan of uncovered/unlabeled jello on a refrigerator shelf; *At least five garbage cans throughout the kitchen were uncovered when not in use, including areas just outside of dishwashing room, between steam table and stove/grill, and prep area near the office; and * The dishwashing area floor had standing water and no anti-slip covering for staff safety. The areas of concern were observed and discussed with Staff 1 (Dining Services Director) and Staff 2 (Executive Chef) on 08/29/23. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

The findings of the re-licensure survey conducted 05/09/22 through 05/13/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area: * OAR 411-054-0070 (1)(a) Staffing Requirements. The facility put an immediate plan of correction in place during the survey and the situation was abated.
The findings of the first re-visit to the relicensure survey of 05/13/22, conducted 10/03/22 through 10/05/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily 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 05/13/22, conducted 01/25/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality care and services were provided. Findings include, but are not limited to:The licensee is responsible for the operation of the facility and the quality of services rendered in the facility, including the supervision and training of staff.During the relicensure survey, conducted 05/09/22 through 05/13/22, administrative oversight to ensure adequate resident care and services, including ensuring a sufficient number of trained caregivers to meet the care and supervision needs of each resident and the development, implementation and monitoring of systems for responding to resident changes of condition, 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 maintain complete and accurate records for 2 of 12 sampled residents (#s 1 and 3) whose records were reviewed, and multiple unsampled residents whose weight records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the memory care in 12/2019 with diagnoses including late onset Alzheimer's disease. His/her record was reviewed during the survey and found to be incomplete or inaccurate in the following areas: a) An incident report, provided by the facility as part of Resident 1's record review, indicated the resident had a fall on 05/05/22 at 12:46 am. The report stated the resident had been walking in the living room pushing a chair. During the survey, Resident 1 was observed to be bedbound and "had been for some time," which was confirmed by facility staff interviews. On 05/11/22, Staff 25 (Resident Care Manager) confirmed the wrong resident's name had been put on the incident report and she did not know which resident it should have been written for. b) On 05/09/22 survey requested a copy of Resident 1's current physician orders. Staff 2 (Clinical Care Manager/RN) stated she was sure the orders "where in a pile somewhere" and it would be quicker to have a copy faxed over from the resident's primary care office. c) On 05/09/22, a copy of the resident's service plan, obtained from the service plan binder located on the Maple MCC, and available to staff, was missing the first page. The last page of the service plan was the first page of a service plan for another resident. There was no date to indicate when the service plan had been completed. 2. Resident 3 was admitted to the memory care 08/2020 with diagnoses including mixed vascular and neurodegenerative dementia.His/her record was reviewed during the survey and found to be incomplete or inaccurate in the following areas:a) A form labeled "Cornell Scale for Depression in Dementia" was completed 05/08/22 by a visiting RN from another Touchmark facility. The "scoring system" included "a=unable to evaluate, 0=absent, 1=Mild to intermittent, 2=Severe." Questions 16 through 19 on the form, under "Ideational Disturbances," included questions that would require a response from the resident, such as "suicidal, feels life is not worth living," "Poor self-esteem: ...feeling of failure," "Pessimism: anticipation of the worst," and "Mood congruent delusions: delusions of poverty, illness or loss." Each of the four questions had been scored a "0=Absent." Facility staff and Resident 3's daughter confirmed in interviews the resident could maybe understand some English, but had reverted back to speaking only Japanese, therefore would not have been able to answer the questions. b) On 05/10/2022, a copy of the resident's service plan, obtained from the service plan binder located on the Oak MCC, and available to staff, was missing the first page. The last page of the service plan was the first page of a service plan for another resident. 3. On 05/11/22 at approximately 1:31 pm, survey requested copies of weight records for all unsampled residents from both the Oak and Maple MCC's. For one unsampled resident, weight taken on 04/22/22 was recorded as 100.4 pounds, but had also been recorded on 04/05/22 as 100.4 pounds with a note indicating "weight completed 4/22." Multiple other residents' monthly weight records were incomplete, missing one or more entries where weights had not been recorded, and no additional documentation stating why the weight might not have been taken. On 05/13/22, the need to ensure facility records were complete and accurate was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN). They acknowledged the findings. No further information was provided.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against conditions that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: 1. Observations were made during the survey to determine adherence to universal precautions for infection control.On 05/11/22 at 8:08 am, the surveyor observed Staff 23 (CG) and Staff 24 (MT) provide incontinent care to Resident 6. During the observation, Staff 23 failed to clean or wipe the resident before applying barrier cream. Staff 23 removed a soiled incontinence product, then applied barrier cream to the resident's bottom area without cleaning and wiping the bottom area after the resident was lying in the wet incontinence product over a period of time.The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN) on 05/11/22 and 05/13/22. Staff acknowledged the findings.
8. On 05/10/22 at 8:49 am during a tour of the exterior portion of the Maple MCC, this surveyor observed an unlocked gate between the courtyard of the Maple MCC and an unsecured passageway. This passageway was surrounded by a large stone retaining wall on one side and the building on the other. The walkway was unpaved and was an uneven dirt surface which could be a potential tripping or fall hazard for residents.This surveyor immediately communicated the finding to Staff 20 (MT) who unsuccessfully attempted to lock the gate with her set of keys. Staff 20 then called Staff 1 (Health Services Director) to alert him to the unlocked gate. Initially Staff 1 was unable to locate the appropriate key, but it was found and the gate was secured at 9:39 am.During an interview with Staff 20 at 9:27 am on 05/10/22, it was confirmed that there was no alarm or other suitable system to alert staff when a resident opened the door to the exterior courtyard. The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety, or welfare of residents was discussed with Staff 1 on 05/10/22 at 11:29 am. He acknowledged the findings.
2. On 05/11/22 at 8:30 am Staff 21 (CG) and Staff 25 (Resident Care Manager) were observed providing incontinent care to Resident 1. Staff 21 was providing care while wearing disposable gloves with a large tear between the thumb and pointer finger on the right hand. During provision of care, when it became appropriate to doff gloves and don another pair, Staff 21 commented she was having difficulty donning a 2nd pair of gloves, due to dampness of her hands. While donning this second pair of gloves a hole was torn in the right glove again and she began to continue with care, until this surveyor intervened. The need to ensure staff consistently used universal precautions was discussed with Staff 21 and Staff 25 on 05/11/22, and with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. Staff acknowledged the findings.
3. Resident 3 was on hospice, was primarily bedbound, relied on staff for all ADL care, and had been prescribed 2 liters continuous oxygen. On 05/11/22 at 8:44 am the resident was observed lying in bed with his/her oxygen tubing and nasal cannula on the floor next to the bed. At 8:51 am surveyor requested staff assist the resident with his/her oxygen, and check for a sanitized nasal cannula. The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/09/22 and 05/13/22. They acknowledged the findings. 4. On 05/09/22 at 1:32 pm, an unsampled resident was observed standing in the kitchenette on the Maple MCC. The resident appeared to be chewing on something s/he had picked out of a white bin located next to the sink in the kitchenette. This surveyor approached the resident and discovered s/he had been taking bites out of an orange-colored bar of soap, then spitting the soap out in the sink. Surveyor intervened and alerted staff of the situation. No staff were present in the common area during the observation.The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/09/22 and 05/13/22. They acknowledged the findings. 5. On 05/11/22 at 12:32 pm, an unsampled resident was observed sitting at a table in the dining room of the Oak MCC. During the observation, the resident ate part of a paper napkin, then reached across the table and grabbed another resident's lunch plate and started eating from it with his/her fingers, while the other resident was still eating. No staff were present during the observation. The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/09/22 and 05/13/22. They acknowledged the findings. 6. On 05/11/22, during the lunch meal observation on Oak MCC, staff assisted residents from the common areas to the dining room. Staff did not wash residents hands, offer hand sanitizer or provide hand hygiene prior to serving the meal. Multiple residents were observed eating with their fingers during lunch. The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/09/22 and 05/13/22. They acknowledged the findings. 7. On 05/09/22, surveyor observed the cabinet under the sink in the Maple MCC to be unlocked. The cabinet contained cleaning chemicals and could be easily accessed by residents. The need to ensure the facility exercised reasonable precautions against conditions that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/09/22 and 05/13/22. They acknowledged the findings.

2. During the survey, 05/09/22 through 05/13/22, staff were observed to address residents as "sweetie" or "honey," discussed their personal lives in front of residents while assisting with meals and without engaging residents in conversation.3. Staff 23 (CG) was observed on 05/11/22 between 08:08 am and 08:24 am to provide morning care to Resident 6. The resident was lying in bed and Staff 23 put a wet towel to the resident's face to clean without explaining the process of the care. The resident had a startled movement when Staff 23 put the wet towel on the resident's face. Staff 23 continued to clean the resident's face and applied moisture cream on the face. During the morning care, Staff 23 failed to provide resident services in a respectful and dignified manner.The need to ensure residents were treated in a manner that promoted dignity and respect in a homelike environment was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN) on 05/11/22 and 05/13/22. Staff acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents received services in a manner that promoted privacy, respect and dignity in a homelike environment. Findings include, but are not limited to:1. Observations of non-sampled residents and interviews with family and staff conducted during the survey revealed the following: a) During an interview on 05/09/22, an unsampled residents' family member stated that on 04/24/22, she found her parent sitting on the edge of his/her bed without "underwear." No staff were present, and she was unable to determine how long her parent had been sitting undressed. The family member also stated that on several occasions, her parent was wearing the same clothes that s/he had worn the day before.b) On 05/10/22 at approximately 2:30 pm, a staff member in the Oak MCC was observed walking rapidly while pushing a resident in his/her wheelchair. The resident yelled out "oh ...," with a startled look on his/her face. The staff member then laughed and stopped pushing the resident. c) The following observations were made during lunch on 05/11/22 on the Oak MCC: * Several residents were attempting to eat lunch (rice and ground beef) with their fingers, often spilling the rice and beans on the table or in their lap. Staff present did not cue residents in the use of silverware or offer residents an alternative finger food.* At 12:19 pm, staff placed a second plate of food in front of a male resident who had already finished his/her lunch. The resident stated "More, I have plenty!" Staff responded, "You don't have to eat it!" to which the resident replied, "yes I do!" The resident's tone of voice was raised, and s/he appeared agitated. The same staff member then sat down at the resident's table and began looking at her phone and laughing. The resident asked, "What are you laughing about?", staff replied "Rather not say." * At 12:30 pm, a staff member yelled across the dining room that she was "going to change her," while wheeling a resident backwards in his/her wheelchair into the resident's room. * Several times during this time-period staff were observed laughing at different residents' behaviors; no behavioral redirection or cueing was provided to residents. d) During an interview with Staff 22 (Agency Certified Nursing Assistant) on 05/10/22 at 9:40, Staff 22 referred to Resident 1 as "a feeder" twice.The need to ensure residents were treated in a manner that promoted dignity and respect in a home-like environment was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/10/22 and 05/13/22. They acknowledged the findings.

4. Resident 2 was admitted to the facility in 03/2019 with diagnoses including Alzheimer's dementia. The resident was on hospice and dependent on staff for all ADL care, including changing incontinence briefs.On 04/18/22 staff initiated a "Temporary Problem - Skin Integrity" form which noted "testicle - skin tear and redness." On 04/29/22 Staff 2 (Clinical Care Manager/RN) documented in progress notes "Evaluated skin concern to residents scrotum area." "They reported a small scratch." There was no documented evidence the facility conducted an immediate investigation to rule out abuse or potential abuse or reported the injury of unknown cause to the local SPD office. The facility was directed to self-report the incident to the local SPD office. Confirmation the report had been sent was received on 05/14/22, post survey exit.The need to ensure injuries of unknown cause were immediately and thoroughly investigated to rule out abuse and neglect or reported to the local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1 (Health Services Director) and Staff 2 on 05/13/22. They acknowledged the findings.5. Resident 3 was admitted to the facility in August 2020 with diagnoses including mixed vascular and neurodegenerative dementia. The resident resided in a memory care community and only spoke Japanese. A review of resident progress notes and incident reports, 02/08/22 through 05/03/22, showed the resident had experienced the following unwitnessed falls with injuries:* 02/06/22 staff documented resident "was heard screaming", staff found resident "face down on the floor ..." with abrasions to the forehead, bridge of nose, tip of nose and upper lip;* 03/11/22 a housekeeper found resident on the floor, s/he had swelling to the left upper cheek and eyebrow; resident was unable to bear weight on his/her right knee. Resident was subsequently diagnosed with a right knee fracture on 03/12/22; and * 03/16/22 resident was found on the floor bleeding from the top of his/her head and "yelling out in pain." There was no documented evidence the facility promptly investigated the incidents to rule out abuse or potential abuse, promptly took measures to protect the resident and prevent future reoccurrence, documented any follow-up action, or that the Administrator had reviewed the incidents. The facility was directed to self-report the incidents to the local SPD office. Confirmation the report had been sent was received on 05/14/22, post survey exit.The need to ensure injuries of unknown cause were immediately and thoroughly investigated to rule out abuse and neglect or reported to the local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure an injury of unknown cause and repeated incidents of being found on the floor were promptly investigated to rule out abuse/neglect and were reported to the local SPD office when unable to reasonably conclude the incidents were not the result of abuse and/or neglect for 5 of 5 sampled resident (#s 2, 3, 5, 6 and 7). Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 07/2018 with diagnoses including dementia. Resident 6 was mostly non-verbal, relied on staff for all ADL care, was a two-person transfer and required physical meal assistance.Review of the resident's progress notes and incident reports during the survey revealed the following:a. On 03/03/22 staff documented the resident had a skin tear. Staff further documented "when the caregivers went to pull [his/her] pants down. Resident's pant leg was stuck to [his/her] leg so therefore when resident's pants were pulled down, it pulled [his/her] skin and caused a skin tear." There was no evidence the facility conducted an immediate investigation to rule out potential abuse or rough handling of the resident or reported the incident to the local SPD office. The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 05/14/22 after the survey team exited.b. On 03/09/22 staff documented the resident had a skin tear on the left middle shin area. Staff further documented "No witnesses ...Resident can not voice [his/her] concern". There was no evidence the facility conducted an immediate investigation to rule out potential abuse or reported the injury of unknown cause to the local SPD office. The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 05/14/22 after the survey team exited.c. On 03/24/22 staff documented the resident had "No witnesses ...3 cm laceration on [the] resident's R [right] thigh." Staff further documented it was an injury of unknown cause.There was no evidence the facility conducted an immediate investigation to rule out potential abuse or reported the injury of unknown cause to the local SPD office. The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 05/11/22 prior to when the survey exited.The need to ensure injuries of unknown cause or any incidents of suspected abuse were immediately investigated or reported was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN) on 05/11/22 and 05/13/22. They acknowledged the findings.2. Resident 7 was admitted to the facility in 2019 with diagnoses including leg length discrepancy and abnormality of gait. Resident 7 was primarily bed bound, relied on staff for all ADL care and was a two-person transfer with Hoyer lift.Progress notes and incident reports dated 02/01/22 through 04/11/22 showed the following:* On 03/11/22 staff documented on the facility progress notes that the resident had an unwitnessed fall and had reported an abrasion to left elbow.* On 03/11/22 staff documented on the facility incident report that "Resident unable to make a statement ...resident on ground by [his/her] bed with [his/her] head inside [his/her] night stand." Abuse ruled out due to the resident spouse/roommate was in the room. * The resident's 03/01/22 Temporary Service Plan indicated "Resident requires two-person transfers. Please use two people to transfer to bed and to toilet."There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result of abuse or neglect due to the possibility of not providing transfer assistance or not providing oversight for a two-person transfer.The need to investigate an incident of suspected abuse or neglect of care and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN) on 05/11/22 and 05/13/22. The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 05/14/22 after survey exited.
3. Resident 5 was admitted to the facility in 05/2019. The resident was noted to be at risk for falls and had experienced a change in cognition. Clinical records were reviewed and revealed the following incidents:* 03/10/22 "...Found [him/her] on the floor by the bathroom ...skin tear on [his/her] right cheek";* 03/14/22 "Resident has bruising to [his/her] right side ..."; and* 03/29/22 "Resident had fallen in [his/her] bathroom. Med tech asked how it happened [resident] stated someone pushed [him/her]."In an interview with Staff 2 (Clinical Care Manager/RN) on 05/11/22, she confirmed the incidents were not investigated to rule out abuse and neglect.The facility lacked documented evidence the incidents were thoroughly investigated to rule out abuse or neglect or reported to the local SPD office.The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 05/14/22 after the survey team exited.The need to ensure incidents and injuries of unknown cause were immediately and thoroughly investigated to rule out abuse and neglect or reported to the local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1 (Health Services Director) and Staff 2 on 05/13/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen and four neighborhood kitchenettes were clean and maintained in good repair and pasteurized eggs were kept in stock for menu items, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:The kitchen and kitchenettes were toured on 05/09/22 and 05/10/22. The following deficiencies were identified:1. The facility's main kitchen was toured on 05/09/22 with Staff 9 (Head Chef) and on 05/10/22. a. Observations of the kitchen identified the following areas were in need of cleaning:* Thick layer of dust on ceiling vents outside the walk-in cooler;* Dust on a vent inside the cooler, with dust strands blowing near racks of uncovered pies;* Food splatters on walls behind racks in the cooler and dry storage area;* Black build-up on floor along edges of cooler ramp;* Food splatters on pot rack above prep counter;* Dust on ice machine surfaces; and* Paper signs throughout kitchen, creating an uncleanable surface.b. Observation and interview with Staff 9 identified the weekly menu offered "2 eggs cooked as you like" and that eggs in the cooler were not pasteurized.2. A tour of the kitchenette in each of the four neighborhoods identified the following areas in need of cleaning or repair:* Food debris and dust on interior and exterior cabinetry surfaces in all four kitchenettes:* Worn varnish on exterior cabinetry in all four kitchenettes, leaving an uncleanable surface;* Food debris in bottom of food warmers in Cedar neighborhood; * Broken sink and dishwasher in Maple MCC; and* Broken food warming drawers, held shut with tape, in Elm neighborhood.These findings were reviewed on 05/11/22 during a walkthrough of the kitchen and kitchenettes with Staff 5 (Dining Services Director) and Staff 9. They acknowledged the areas in need of cleaning and repair, and the need to use pasteurized eggs according to the Food Sanitation Rules.

Based on observation, interview and record review, it was determined the facility failed to provide services to assist the residents in activities of daily living for 1 of 4 sampled residents (#6) and failed to provide unsampled residents who required oversight, cueing, supervision and assistance with ADL's. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 07/2018 with diagnoses including dementia. Resident 6 was dependent on staff for all ADL cares, including toileting and repositioning. The resident was unable to toilet or reposition independently. On 05/10/22 Resident 6 was observed sitting in his/her wheelchair from approximately 8:10 am until 2:48 pm. Staff did not provide incontinent care or reposition the resident during the observation.The failure to ensure assistance with ADLs was shared with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN) on 05/11/22 and 05/13/22. Staff acknowledged the findings.
2. Observations conducted on both Maple and Oak MCC's, 05/09/22 - 05/12/22, showed the following:* On several occasions residents on both units were left unsupervised in the common areas for 10 to 15 minutes, while staff provided care to other residents in their rooms; * On 05/11/22, multiple residents in the Oak MCC went without toileting assistance from approximately 9:30 am until after 1:00 pm, and did not receive any assistance with hand hygiene prior to or after lunch;* Residents of both units were seen wandering in and out of other residents' rooms, wearing other residents' clothing or taking other residents' belongings;* During meals, residents were observed eating non-finger food items with their fingers, spilling food onto themselves, attempting to eat off other resident's plates, wandering during meals without staff redirection, or not eating at all. The need to ensure staff provided assistance to resident in performing ADLs on a 24-hour basis was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.

7. Resident 11 was admitted to the facility in 02/2022 with diagnoses including chronic depression. Observations of the resident and interviews with staff from 05/09/22 to 05/12/22, review of the service plan, dated 03/10/22, and temporary service plans indicated the service plan was not reflective of the resident's current care needs and lacked specific instruction to staff in the following areas: * Shower refusals and interventions;* Increased confusion and wandering; and* Home Health PT and OT services and schedule.The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
5. Resident 6 was admitted to the facility in 07/2018 with diagnoses including dementia.Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 05/09/22 thru 05/13/22, revealed Resident 6's service plan was not reflective of the resident's status, did not provide specific directions to staff and staff did not follow the plan in the following areas:* Activity status;* Ambulation status: use of wheelchair and ability to self-propel the wheelchair;* Ability to use the call system;* Emergency evacuation ability;* Use of heel protective boots at night; and* Providing incontinent care as outlined.On 05/11/22 and 05/13/22, service plans were discussed with Staff 1 (Health Service Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN). They acknowledged the service plans were not reflective of the resident's status, did not provide clear direction and staff did not follow incontinent care as outlined.6. Resident 7 was admitted to the facility in 10/2019 with diagnoses including leg length discrepancy and abnormality of gait. Resident 7 was observed in bed at all times and relied on staff for all ADL cares. Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 05/09/22 thru 05/13/22, revealed Resident 7's service plan was not reflective of the resident's status and did not provide instruction to staff in the following areas:* Activity status;* Ambulation status: use of wheelchair vs. bed bound;* Use of an air mattress;* Shower instruction: bed bath vs. shower;* Ability to use call system;* Fall risk and interventions; and* Emergency evacuation ability.On 05/11/22 and 05/13/22, service plans were discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN). They acknowledged the service plans were not reflective of the resident's status and did not provide clear direction.
4. Resident 5 was admitted to the facility in 05/2019 with diagnoses including Lupus. The resident's 03/17/22 service plan and temporary service plans were reviewed and were not reflective of the resident's needs and lacked clear direction to staff in the following areas:* Hospice services and schedule; and* Weight loss interventions.The need to ensure service plans were reflective of resident's needs and provided clear instruction to staff was discussed with Staff 1 (Health Service Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN) on 05/13/22. 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 needs and status, included a description of services to be provided and/or were followed for 7 of 11 sampled residents (#s 1, 2, 3, 5, 6, 7 and 11) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in December 2019 with diagnoses including Alzheimer's disease. S/he had been discharged from hospice services 04/06/22 and according to the facility was readmitted to hospice services on 05/09/22. Resident 1 was observed in bed at all times during the survey and was fully dependent on staff for all care.Observations of the resident and interviews with staff from 05/09/22 to 05/12/22, and review of the service plan, dated 02/09/22, indicated the service plan was not reflective of the resident's current care needs and/or lacked specific instruction to staff in the following areas: * Hospice services discharge;* Ambulation status;* Bedbound; * Bathing;* Feeding assistance;* Pain: monitoring and location;* Left hand skin issues;* Contractures;* Monthly weights;* Use of fall mat; * Communication, including the ability of resident to understand and be understood; * Ability to use call system;* Repositioning; and* Emergency evacuation ability.The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 03/2019 with diagnoses including Alzheimer's dementia.a) Observations of the resident, interviews with staff, review of the clinical record and the most recent service plan dated 01/19/22, indicated the service plan failed to reflect the resident's current care needs, lacked specific instruction to staff, and/or was not followed in the following areas: * Repositioning in bed;* Weight bearing status;* Resident specific needs during evacuation;* Ability to use the call light;* Use of Hoyer for transfers;* Fall risk history or interventions;* Assistive devices, including hospital bed, bedside table, fall mat;* Meal assistance;* Hospice bath aid;* Float heels and place arm pillow when in bed;* Memory, orientation, and decision-making capability; * Ability to understand or be understood; and* Place water within reach while in bed.b) There was no documented evidence the facility had completed a quarterly service plan for the resident, which would have been due on or around 04/19/22.3. Resident 3 was admitted to the facility in August 2020 with diagnoses including mixed vascular and neurodegenerative dementia. Observations of the resident, interviews with staff, review of the clinical record and the most recent service plan dated 04/20/22, indicated the service plan failed to reflect the resident's current care needs, and lacked specific instruction to staff in the following areas: * Resident-specific needs during evacuation;* Ability to use the call light;* Fall risk or interventions;* Assistance of two staff for transfers; * Unsteady gait;* Ambulation status;* Areas of pain, pain monitoring, non-pharmaceutical interventions;* Dressing assistance;* Glasses;* Transfer precautions;* Eating habits; and* Non-verbal signs of pain.The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the resident service plan was developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident, for 11 of 11 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) whose service plans were reviewed. Findings include, but are not limited to:During the review of resident service plans, it was noted that each service plan was only signed by one of the LPNs assigned to that resident, or the RN.In an interview on 05/12/22, Staff 8 (Resident Care Manager) explained the RCMs were responsible for facilitating service plan reviews. She stated a nurse reviewed the service plan and then it was sent to the resident's legal representative for review. The legal representative is given the option of meeting in person to discuss the service plan. Staff 8 acknowledged she was not aware the service plan needed to be developed by a service planning team and that the resident should be included as much as possible. She acknowledged there was no documentation of who was involved in the development and periodic review of the residents' service plans.The need to develop service plans with the involvement of a Service Planning team was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the facility needed to review its process for developing service plans.

5. Resident 7 was admitted to the facility in 10/2019 with diagnoses including leg length discrepancy and abnormality of gait. Resident 7 was observed during the survey, from 05/09/22 to 05/13/22, in bed at all times, relied on staff for all ADL care and bowel and bladder management.a. Progress notes and incident reports dated 02/01/22 through 04/11/22 indicated the following:* 03/11/22 staff documented on the facility progress note and incident report the resident had an unwitnessed fall and had reported an abrasion to left elbow. The resident was unable to make a statement regarding the fall. Staff further documented that staff changed the resident's pants because the resident had urinated in the pants.* 03/14/22 staff documented on the facility progress note and incident report the resident had an unwitnessed fall. [S/he] was sitting on [his/her] buttocks in front of the toilet in the bathroom. The resident stated [he/she] tried self transferring to the toilet. Staff further documented the resident required three people to pick the resident up from the floor.* 03/17/22 staff documented on the facility incident report the resident had a fall. The resident pants were down, and [his/her] spouse had placed a pillow under the resident's head. The resident stated [he/she] was getting off the toileting and [his/her] legs gave out.* 04/11/22 staff documented on the facility incident report the resident was found in the bathroom, on [his/her] back with [his/her] head in between the toilet and the sink. [His/her] spouse and the resident did not recall how [s/he] fell. * 04/16/22 staff documented on the facility incident report the resident was found on in the bathroom on [his/her] back with [his/her] upper body next to the sink. It appeared [his/her] spouse had attempted to transfer the resident and dropped [him/her].The resident's 03/01/22 Temporary Service Plan indicated "Resident requires two-person transfers. Please use two people to transfer to bed and to toilet."The resident had seven falls between 02/2022 and 05/2022. There was no documented evidence the facility thoroughly reviewed the incidents to determine the circumstances of the falls or if service planned interventions were followed in the area of transfer assistance and bladder and bowel management, and the interventions were evaluated for effectiveness.On 05/11/22 and 05/13/22, Resident 7's progress notes and incident reports were reviewed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN), including evaluation and monitoring the effectiveness of the current service-planned interventions. Staff acknowledged the findings.b. Reviewed the resident's progress notes from 02/22/22 to 05/07/22 and skin logs and revealed the following:* On 03/11/22 staff documented in a facility progress note the resident had an unwitnessed fall and had reported an abrasion to left elbow.* Review of the skin log showed there was no documented evidence the abrasion on left arm was monitored through resolution.On 05/13/22, the failure to monitor the abrasion on left arm for Resident 7 was reviewed with Staff 1 (Health Service Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN). Staff acknowledged the findings.
6. Resident 9 was admitted to the facility in 2019 with diagnoses including atherosclerosis of aorta, chronic kidney disease and macular degeneration.The resident's service plan, Temporary Service Plans, Incident Reports, Charting Notes and the facility Alert Charting - Nursing Log were reviewed during the survey.Resident 9's 12/04/21 service plan indicated the resident was independent for transfers and mobility using a four-wheeled walker for support. The service plan also noted the resident had a history of falls and "requires a fall-management program" which involved "monitoring activity/trends and individualize interventions after each incident."* On 02/05/22, the resident fell while bending over to remove pants from a low dresser drawer. The resident was not injured. The fall was documented on the Alert Charting - Nursing Log and the condition was documented as resolved on 02/08/22.The facility failed to document what actions or interventions were needed for the resident in a way that could be made part of the resident's record and failed to provide instructions for staff as to what to monitor following the fall.* On 03/11/22, the resident fell forward out of his/her recliner and sustained pain to the ribs. There was no documentation of the fall on the Alert Charting - Nursing Log. Staff documented the resident continued to experience rib pain on 03/12/22, 03/13/22, 03/14/22 and 03/15/22. An LPN documented on 03/18/22 that the resident was not reporting pain, but it is unclear if the condition was considered resolved.The facility failed to document what actions or interventions were needed for the resident, failed to provide instructions for staff as to what to monitor following the fall and failed to document monitoring of the condition at least weekly until resolved.The need to ensure actions or interventions were documented for staff, that they included resident-specific instructions for staff and that the staff documented on the progress of the condition until resolved was reviewed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the facility needed to review its system for responding to changes of condition.
4. Resident 11 was admitted to the facility in 02/2022 with diagnoses including chronic depression and osteoporosis.During the survey, Resident 11 was identified as having experienced weight loss. The resident's 02/10/22 through 05/04/22 progress notes, weight records from 02/03/2022 through 05/04/2022, service plan dated 03/10/22, additional temporary service plans, and 04/01/22 through 05/09/22 MARs were reviewed.Resident 11's weight record indicated the following:* 02/03/22 126 pounds;* 03/16/22 116.2 pounds;* 03/23/22 117 pounds;* 04/13/22 115.8 pounds;* 04/20/22 116.4 pounds;* 04/27/22 115.1 pounds; and* 05/04/22 114.3 pounds.Between 02/03/22 and 05/04/22, there were two occasions when severe weight loss occurred:* 02/03/22 to 05/04/22: 12 pound loss in three months or 9.2% total body weight; and* 02/03/22 to 03/16/22: 9.8 pound loss in one month or 7.7% total body weight.On 03/15/22, Staff 3 (Regional RN) documented the resident's Home Health PT notified nursing that the resident's weight was 117 pounds, and according to the resident, s/he was usually 130 pounds. Staff 3 put the resident on weekly weights for further monitoring and requested an order for high calorie Ensure shakes from the doctor. A temporary service plan dated 03/17/22 documented the resident had a significant weight loss in the past three months. The resident was to be weighed weekly, and the resident's doctor was asked for a Boost supplement order. A temporary service plan dated 03/18/22 instructed staff to weigh the resident weekly on the 5th floor large scale.On 03/19/22, Staff 2 (Clinical Care Manager/RN) completed a significant weight loss assessment and ordered supplemental drinks during the day, and weekly weights. Staff 2 further documented she had faxed weights and plans to the resident's doctor and reported that it was possible the resident had an increase in depression since moving in. If further weight loss occurred, Staff 2 would discuss with the doctor about reordering mental health services. The 04/2022 MAR identified the order for Ensure to be given to the resident twice a day was initially ordered on 03/27/22. The 04/01/22 through 05/09/22 MARs showed the resident received Ensure twice a day at 8 am and 8 pm. There were no directions to staff to monitor the percentage of Ensure consumed, and there were no directions to staff about who or when to notify if the resident did not drink the Ensure.A charting note dated 04/03/2022 indicated the resident was not drinking their Ensures, and there were three full containers of Ensure on the resident's nightstand. A charting note dated 04/14/22 reported the resident left food and Ensure containers untouched.A temporary service plan dated 04/14/22 instructed staff to encourage the resident to eat breakfast, check back to see if s/he ate and report to the MT if the resident had not eaten. MTs were directed to document in the resident's profile. During an interview on 05/09/22, Staff 10 (MT) stated that she delivers the Ensure to the resident in the morning, but was unaware if the resident drinks it. She also stated staff were not monitoring the percentage of Ensure consumed but signing off on the MAR that Ensure was delivered. When asked if the resident's meals were monitored, Staff 10 stated they were not monitoring the resident's meals.Throughout the survey from 05/09/22 through 05/12/22, the resident was observed on numerous occasions in their apartment lying in bed with uneaten food beside the resident. The staff was not observed to encourage the resident to eat their breakfast. There was no documented evidence the facility consistently monitored Resident 11's weight loss, followed determined interventions, monitored interventions for effectiveness, or developed and implemented additional interventions to prevent further weight loss between 03/16/22 and 05/04/22. The resident had ongoing severe weight loss from 02/2022 through 05/2022.The facility's failure to monitor the resident's weight loss and develop and implement additional interventions to prevent further weight loss was discussed with Staff 1 (Health Services Director) and Staff 2 on 05/13/22. They acknowledged the findings.
7. Resident 5 was admitted to the facility in 05/2019.The resident's 02/09/22 through 05/09/22 Charting Notes, Alert Charting Notes, 03/17/22 Service Plan and Temporary Service Plans were reviewed and revealed the resident experienced the following changes of condition: * 02/16/22 The resident was found on the floor in his/her apartment; * 03/10/22 The resident was found on the floor in his/her bathroom and was noted to have a skin tear on his/her cheek;* 03/14/22 Staff noted bruising along the right side of the resident's body;* 03/19/22 The resident was noted to have experienced significant weight loss; and* 03/29/22 The resident was found on the floor in his/her bathroom.The facility lacked documented evidence it monitored the resident's skin concerns with progress noted at least weekly through resolution and lacked documented evidence it evaluated the resident's fall interventions for effectiveness.The facility implemented a daily supplemental drink as an intervention for the resident's weight loss. The supplemental drink was later discontinued as it was not covered by the resident's hospice provider. The facility lacked documented evidence it developed additional interventions to address the resident's continued weight loss. On 05/13/22 the need to ensure interventions were determined, documented and communicated to staff on all shifts for Resident 5's changes in condition, conditions were monitored and progress noted at least weekly through resolution and interventions were evaluated for effectiveness was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure interventions developed resulting from a significant change of condition were monitored for effectiveness for 1 of 11 sampled residents (#11) who experienced weight loss, and failed to monitor and document weekly progress of short-term changes of condition to resolution, determine and document actions or interventions were needed for the resident, communicate the actions, interventions, and monitoring instructions to staff, or monitor previous interventions for effectiveness for 6 of 11 sampled residents (#s 1, 2, 3, 5, 7 and 9) whose records were reviewed. Resident 11 experienced continued weight loss. Resident 3 had multiple falls with injuries. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 08/2020 with diagnoses including mixed vascular and neurodegenerative dementia.A review of the resident's service plan, signed by Staff 2 (Clinical Care Manager/RN) on 04/20/22, progress notes and facility incident reports indicated the resident had fallen or was "found on the floor" seven times between 02/06/22 and 03/31/22. The following incidents were documented:* 02/06/22 resident "was heard screaming", staff found resident "face down on the floor ..." with abrasions to the forehead, bridge of nose, tip of nose and upper lip;* 03/02/22 "unwitnessed fall", "unable to say how fell"; * 03/03/22 resident was "running" from a carpet shampoo machine, tripped, and hit his/her head;* 03/06/22 Resident was found on the floor holding his/her head, complained of knee pain, had abrasion to left knee;* 03/11/22 resident was found on the floor with swelling to the left upper cheek and eyebrow; unable to bear weight on his/her right knee. Resulting diagnosis was right knee fracture; and* 03/16/22 resident was found on the floor bleeding from the top of his/her head and "yelling out in pain." * On 03/03/22, a previously employed RN requested a urinary analysis for possible infection. There was no follow up documentation indicating the request was completed. * On 03/03/22 and 03/06/22 the same RN recommended PT. As of 05/12/22 no PT services had been provided to the resident. * On 03/09/22 Staff 2 documented "Daughter and PCP agree to changing [his/her] blood pressure medication with hopes this may have been a contributing factor since recent BP's are running low." There was no documentation in the resident's record the facility monitored the decrease in medication and the effect of the decrease on the residents fall risk.Throughout the survey, the resident was observed sitting in a wheelchair. During interviews, 05/11/22 and 05/12/22, Staff 20 (MT) and the resident's daughter confirmed s/he had been independent with ambulation prior to his/her right knee fracture on 03/11/22. Resident's family member also stated the resident experienced "significant" pain during transfers immediately after the fracture. There was no documented evidence the facility had evaluated the residents fall risk until 05/08/22, no evidence fall interventions had been implemented for any of the falls noted above, and no evidence the facility evaluated or consistently monitored the residents pain level. The facility's failure to evaluate the residents fall risk, determine and document actions or interventions to potentially decrease the risk of future falls, or to monitor clinical interventions to completion put the resident at risk for repeated falls and serious injury. The need to ensure residents who experienced a change of condition were evaluated, resident specific actions or interventions were developed, communicated to staff, and monitored was discussed with Staff 1 (Health Services Director) and Staff 2 on 05/13/22. They acknowledged the findings.2. Resident 1 was admitted to the facility 12/2019 with diagnoses including Alzheimer's disease. The resident was bedbound, non-verbal, and relied on staff for all ADL care. Resident was readmitted to hospice on 05/09/22. A review of the resident's clinical record, 03/01/22 - 05/09/22 MARs and progress notes indicated the resident had experienced the following changes of condition: a) Resident had been prescribed routine administration of four different medications to treat severe pain and agitation: phenobarbital for severe agitation, morphine for pain, a fentanyl patch for pain, and rivastigmine for "aggressive behaviors."Review of the residents MARs indicated the resident had not been administered the prescribed dose of one or more of these medications 65 times between 03/01/22 - 05/09/22 because the medication was "unavailable." On multiple occasions the resident was not administered one or more of the medications for several days in a row. There was no documented evidence the facility monitored the resident for increased pain or agitation when the medications were not administered or had monitored for potential adverse reactions or effectiveness when the medications were restarted.(Refer to C 300, example 2)b) On 04/29/22 staff identified and documented in progress notes two open pressure areas, one on each elbow, each measuring 0.5 cm x 0.5 cm. Documentation on a "skin charting" log dated the same day described the wounds to the left and right elbows as "pressure sore," measuring 1.0 cm x 1.0 cm. There was no evidence the facility had monitored the wounds, evaluated the potential cause of the pressure areas, or developed resident-specific interventions to help prevent future pressure sores. c) On 02/09/22 resident was prescribed miconazole cream to treat a fungal infection on his/her left hand. There was no documented evidence the facility had monitored the cream for effectiveness or the fungal infection. The need to ensure each resident was monitored consistent with his/her needs, including stopping and starting medications, was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.3. Resident 2 was admitted to the facility in 03/2019 with diagnoses including Alzheimer's dementia. Resident was on hospice at the time of survey, relied on staff for all ADL care and was primarily bedbound. A review of the resident's clinical record and hospice provider notes, indicated the following changes of condition:* 03/09/22: " ...confused about where [s/he] is."* 03/14/22 "PT [patient] appears to be transitioning." * 04/08/22 "Unable to determine last BM. MT educated to administer PRN bowel regimen." * 04/29/22: " ...purple discoloration to feet and cool to touch." There was no documented evidence the facility monitored any of the conditions noted above. The need to ensure each resident was monitored consistent with his/her needs was discussed with Staff 1 (Health Services Director) and Staff 2 on 05/13/22. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 10/2019 with diagnoses including Type II Diabetes and left leg weakness.Review of the resident's progress notes from 02/22/22 to 05/07/22 and skin logs revealed the following:* 04/23/22 - facility identified a pressure sore with a large red mark on the resident's right hip with skin breakdown in the middle;* 04/24/22 - facility LPN documented the size of sore was a quarter red and tender to the touch and dime size was opened within the quarter size; and* 04/29/22 - facility RN documented the size of sore was 3 x 2.5 inches open area to the right hip area. Resident was noted by staff to be scratching it. The area did present with redness and some scratching of it. The resident would not let staff provide positioning and would not turn off the right side. The RN requested HHRN services.The RN assessment for the pressure sore was completed 6 days after the sore was developed. On 05/12/22 and 05/13/22, the need to conduct RN assessments timely for an open pressure ulcer was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN). Staff acknowledged the findings.4. On 05/11/22, survey requested a copy of six months of weight records for all residents in the memory care neighborhoods. On 05/12/22, review of the residents' weight records revealed Residents 3, 14, 15 and 16 experienced a significant weight changes as follows:a. Resident 3 experienced a significant weight gain between 02/02/22 (103.1 lbs.) and 05/04/22 (116.4 lbs.) of 13.3 lbs. or 12.9 % of his/her total body weight in 90 days. b. Resident 14 experienced a significant weight gain between 03/2022 (214. 2 lbs) and 04/2022 (229.2 lbs) of 15 lbs. or 7.0 % of his/her total body weight in 30 days. c. Resident 15 experienced a significant weight gain between 01/05/22 (133.0 lbs.) and 04/05/22 (148.6 lbs.) of 15.6 lbs. or 11.7 % of his/her total body weight in 90 days.d. Resident 16 experienced a significant weight loss between 12/28/21 (147.6 lbs.) and 01/25/22 (136.2 lbs.) of 11.4 lbs. or 7.7 % of his/her total body weight in 30 days. There was no documented evidence the RN had assessed any of the residents for the significant weight changes. On 05/12/22 and 05/13/22, the lack of an RN assessment for multiple residents identified with the significant weight changes was reviewed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN). Staff acknowledged the findings. No further information was provided.
Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and/or updated the service plan for 3 of 7 sampled residents (#s 1, 3 and 7) who experienced a significant change of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility 12/2019 with diagnoses including Alzheimer's disease. On 04/29/22 staff identified and documented in progress notes two open pressure areas, one on each elbow, each measuring 0.5 cm x 0.5 cm. Documentation on a "skin charting" log dated the same day described the wounds to the left and right elbows as "pressure sore", measuring 1.0 cm x 1.0 cm. This represented a significant change of condition. There was no documented 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 05/13/22 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN). They acknowledged the findings.2. Resident 3 was admitted to the facility in 08/2020 with diagnoses including mixed vascular and neurodegenerative dementia.On 03/11/22 staff documented in the resident's progress notes the resident was found on the floor with swelling to the left upper cheek and eyebrow and was unable to bear weight on his/her right knee. The resulting diagnosis was a right knee fracture. This represented a significant change of condition. There was no documented evidence the facility RN had assessed the resident or completed a significant change of condition assessment to include documented findings, resident status, and interventions made as a result of the assessment until 03/19/22. On 05/13/22 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition and the assessment was completed timely was discussed Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and failed to coordinate care with outside providers in order to ensure the continuity of care, for 3 of 7 sampled residents (#s 1, 2 and 8) who received services from an outside provider. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 02/2021 with diagnoses including peripheral venous insufficiency and lower extremity stasis ulcers. Review of the resident's service plan and progress notes from 02/16/22 to 05/11/22 indicated the resident had chronic wounds on both lower legs. The facility provided wound care multiple times per week until it requested home health evaluate the resident and assist with wound care beginning 03/14/22. The following deficiencies were identified:* The home health provider documented it would provide wound care for the resident two times per week. Review of the home health visit notes that were provided by the facility indicated that between 03/14/22 and 05/07/22, the home heath provider only left notes for visits on 03/21/22, 03/23/22, 04/04/22, 04/06/22, 04/25/22, 05/03/22 and 05/05/22.* In a visit note dated 04/25/22, the home health provider documented new wound care instructions. At the time of the survey, the facility had failed to clarify with the provider whether those wound care instructions were to replace current wound care instructions found in the resident's Treatment Administration Record.The need to ensure outside providers left written information for each of their visits, and that the facility reviewed the information and updated the resident's service plan or orders accordingly, was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged providers had not left notes after each of their visits and the facility had not clarified the new wound care instructions.
2. Resident 1 was admitted to the facility in 12/2019 with diagnoses including Alzheimer's disease. During the acuity interview, the resident was identified as having recently been discharged from hospice services. The facility reported on 05/09/22 that the resident had been readmitted to hospice services.Resident 1's clinical record was reviewed during the survey.a. On 03/28/22 the facility RN documented in a nursing note: "RN was informed by Providence hospice case RN that resident is not showing further decline and [his/her] arm circumfrence [sic] is not showing further loss but gain. RN reports resident is going to be discharged from hospice services. RN and SSW will relay this to [his/her] spouse."There was no documented evidence the facility RN or anyone from the facility had reviewed the hospice services Nurse Practitioner note from 03/21/22 stating, "Patient ...cachectic, severe contractures bilateral upper extremities and lower extremities ...will recommend for recertification for continued hospice services."b. On 03/21/21 the hospice Nurse Practitioner documented in the outside provider note: "Pending pain management plan and discussion with spouse/POA [Power of Attorney] & RN Case Manager."There was no documented evidence of a pain management plan, discussions between hospice services and the RN Case Manager regarding a pain management plan, or that this outside provider note had been reviewed by the facility.c. There was no evidence the facility management or licensed nurse had reviewed 11 of the 14 hospice services notes, dated 02/01/22 through 04/05/22. The three notes that were reviewed by the facility were signed 30-36 days after the provision of care by the outside providers.The need to ensure the facility had a system for coordinating on-site health services with outside providers was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
3) Resident 2 was admitted to the facility in 03/2019 with diagnoses including Alzheimer's dementia. A review of resident's hospice provider notes, 03/09/22 through 05/09/22, indicated that on 04/15/22 hospice recommended facility staff encourage the resident to get out of bed, and on 04/18/22 instructed staff to get the resident out of bed to ease his/her coughing. Resident 3 was observed to be in bed on 05/09/22, 05/10/22 and 05/11/22, and there was no documentation in the resident's service plan, in progress notes or on any temporary services plans instructing staff to get the resident out of bed. There was also no documentation on any of the outside provider notes indicating the notes had been reviewed by facility staff. The need to ensure the facility had a system for coordinating on-site health services with outside providers was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 02/2021 with diagnoses including peripheral venous insufficiency and lower extremity stasis ulcers. At the time of the survey, the resident had chronic wounds to both lower legs, both of which were observed by the surveyor to be freshly wrapped/bandaged. The facility received orders on 01/12/22 to provide twice weekly wound care to both legs.a. Progress notes indicated home health began providing twice weekly wound care on 03/14/22. The facility failed to clarify whether the existing wound care orders should be continued or discontinued. The original orders were still included on the resident's 04/2022 and 05/2022 TAR, and staff were initialing as though they were providing the wound care twice weekly.In an interview on 05/11/22, Staff 11 (MT) reported she was not actually providing the wound care anymore but, rather, was signing when home health provided the wound care.b. In a visit note dated 04/25/22, the home health provider documented new wound care instructions. At the time of the survey, the facility had failed to clarify with the provider whether those wound care instructions were to replace the current wound care instructions found in the resident's TAR.The facility's failure to provide adequate oversight and review of orders and treatment records to ensure documentation was accurate and the resident received the proper treatment was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
3. Interviews were conducted throughout the survey and identified the following: In an interview on 05/09/22 at 12:00 pm, Staff 10 (MT) reported the facility ran out of medications regularly; medications were administered late, along with ongoing medication errors. Staff 10 further stated that staff documented in the MARs they had administered the medications; however, she has found medications in residents' rooms that were still in the med cup, including narcotics. During an interview with Staff 12 (MT) on 05/10/22 at 10:24 am, she reported routine medications were often unavailable. According to Staff 12, this occurred at least twice a week. Staff 12 stated she was never trained on how to reorder medications but tried to reorder before medications ran out; however, she has found that the pharmacy will not have a current or active prescription which then causes an even longer delay in getting the medication refilled. On 5/12/22 at 11:00 am, Staff 12 approached this surveyor and reported the medication carts were empty on the 4th, 5th and 6th floors that morning, and nobody knew where the medications were. Staff 12 finally received a call from another MT that residents' medications were on the 2nd floor. Staff 12 had to go through boxes of medications to find all medications for the 6th floor. She had just finished administering the morning medications at 11:00 am, which were supposed to be done at 8 am. Staff 12 further stated the entire medication system was disorganized. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 05/13/22 with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN).
Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication administration system was in place and failed to ensure adequate professional oversight of the medication and treatment administration system, for 2 of 2 sampled residents (#s 1 and 8) and other unsampled residents. Resident 1 was put at risk for increased pain, agitation, and aggressive behaviors because of the facility's failure to ensure prescribed medications were available for administration. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 12/2019 with diagnoses including Alzheimer's disease with behavioral disturbance. During the survey, s/he was observed to be bedbound, non-verbal, fully dependent on staff for all care, contracted, and unable to self-reposition. Resident had been on and off hospice and was readmitted on 05/09/22.Resident 1 had orders for the following scheduled medications, prescribed to treat pain and agitation:* Phenobarbital 100 mg/ml solution 0.25 ml by mouth twice daily for severe agitation;* Fentanyl 25 mcg patch applied topically every 72 hours for pain;* Morphine sulfate 20 mg/1 ml solution 0.4 ml by mouth every 8 hours for pain;* Morphine sulfate IR 15 mg tablet ½ tablet by mouth 3 times a day for pain;* Phenobarbital 32.4 mg tablet 1 tablet by mouth twice daily for severe agitation; and* Rivastigmine 9.5 mg patch for agitation with aggressive behaviors 1 patch daily.Review of Resident 1's MARS from 03/01/22 through 05/09/22 indicated these medications had not been administered per physician's orders. Staff documented on the MARs "medication unavailable" for a total of 65 occurrences, including the following examples of psychotropic and narcotic medications with consecutive days missed:* Phenobarbital 100 mg/ml solution for severe agitation: 4 days (04/08/22 - 04/11/22), and 13 days (04/27/22 - 05/09/22); * Morphine sulfate 20 mg/1 ml for pain: 4 days (03/21/22 - 03/24/22), 5 days (04/07/22 - 04/11/22), and 14 days (04/26/22 - 05/09/22); and* Rivastigmine for agitation with aggressive behaviors: 3 days (03/01/22 - 03/03/22); 3 days (04/05/22 - 04/07/22), and 4 days (05/03/22 - 05/06/22).These consecutive missed days represent the following concurrent missed medications:* 03/07/22 the resident missed all scheduled doses of morphine sulfate 20 mg/ml and rivastagmine; * 03/08/22 through 03/11/22, for 4 days, the resident missed all scheduled doses of phenobarbital 100 mg/ml and morphine sulfate 20 mg/ ml;* 04/27/22 through 05/09/22, for 13 days, the resident missed all scheduled doses of phenobarbital 100 mg/ml and morphine sulfate 20 mg/ ml; and * 05/03/22 through 05/06/22, for 4 days, the resident missed all scheduled doses of phenobarbital 100 mg/ml, morphine sulfate 20 mg/ ml, and rivastagmine. There was no documented evidence of professional oversight during this time of narcotic and psychotropic medications abruptly stopping and starting, which put the resident at risk for significant adverse reactions to the medications, including the potential for increased pain, agitation, and aggressive behaviors.The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 3 of 12 sampled residents (#s 1, 4, and 12) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 12 was admitted in 07/2019 with diagnoses that included Alzheimer's disease, Type II Diabetes, high blood pressure and high cholesterol. Resident 12's 05/01/22 through 05/12/22 MARs revealed the following medications were ordered but not administered on the following dates:* Donepezil for dementia on 05/11/22;* Memantine for dementia on 05/11 and 05/12/22;* Metformin for Type II Diabetes on 05/11 and 05/12/22;* Lisinopril for high blood pressure on 05/12/22; and* Simvastatin for high cholesterol on 05/11/22. The reason listed on the MAR for not administering the medications was "medication unavailable." The need to ensure all medications were administered as prescribed by the physician was reviewed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. No additional information was provided.
Resident 4 was admitted to the facility in 06/2019 with diagnoses including cognitive impairment. The resident's 03/01/22 through 05/09/22 MARs and physician's orders dated 02/22/22 and 05/10/22 were reviewed. The resident had an order for docusate 100 mg one tablet by mouth twice daily for constipation. The facility failed to administer the medication to the resident for the am doses on 03/03/22, 03/11/22 and 03/28/22, and failed to administer the pm doses on 03/05/22 and 03/10/22 with staff noting the medication was unavailable at those times. On 03/11/22, staff noted the medication had been available for administration and its location in the medication cart.The facility failed to administer the medication as prescribed by the resident's provider.The need to ensure all medications and treatments were carried out as prescribed was discussed with Staff 1 (Heath Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
Resident 1 was admitted in 12/2019 with diagnoses that included Alzheimer's disease.Resident 1's 03/2022, 04/2022 and 05/01/22 - 05/0922 MARs were reviewed. The following medications were identified as ordered but not administered on the following dates:* Phenobarbital 100 mg/ml 0.25 ml by mouth twice daily for severe agitation, 19 days between 03/23 and 05/09/22;* Morphine sulfate 20 mg/1 ml 0.4 ml by mouth every 8 hours for pain, 23 days between 03/21 and 05/09;* Rivastigmine 9.5 mg/24 hr patch 1 patch onto the skin daily for agitation with aggressive behaviors, 10 days between 03/01 and 05/06;* Senna 8.6 mg tablet 1 tablet by mouth twice daily for constipation, 10 days between 03/25 and 04/30; and* Morphine sulfate 15 mg tablet 1/2 tablet (7.5 mg) by mouth 3 times a day for pain, 3 days between 05/04 and 05/09/22.The need to ensure all medications were administered as prescribed by the physician was reviewed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. No additional information was provided.

2. Resident 7 was admitted to the facility in 10/2019 with diagnoses including Type II Diabetes.Resident 7's 05/01/22 through 05/09/22 MARs were reviewed during the survey and showed the facility staff documented the resident refused physician-ordered quetiapine (to treat certain mental/mood disorders), Acetaminophen (for pain) and wound treatments on 05/01/22 and 05/02/22.There was no documented evidence the facility notified the physician when the resident refused to consent to the orders.On 05/12/22 and 05/13/22, the refusals were reviewed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN), and Staff 3 (Regional RN). Staff acknowledged the findings. No further information was provided.
Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 2 of 3 sampled residents (#s 4 and 7) who had documented medication refusals. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 06/2019 with diagnoses including cognitive impairment. The resident's 04/01/22 through 05/09/22 MARs and 02/22/22 and 05/10/11 physician's orders were reviewed and revealed the following:The resident had an order for medication refusals to be reported to the physician. On 03/05/22 staff recorded the resident refused the 8:30 pm doses of the following medications:* Divalproex 250 mg (for seizures);* Docusate 100 mg (for constipation);* Melatonin 3 mg (for insomnia); and* Resiperdone (for bipolar depression).There was no documented evidence the facility notified the physician of the resident's refusal to consent to the orders. The need to ensure the facility notified the prescriber when a resident refused to consent to an order was discussed with Staff 1 (Health Services Director), Staff 2 (Clinical Care Manager/RN) and Staff 3 (Regional RN) on 05/13/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure accurate medication and treatment administration records were kept for 5 of 12 sampled residents (#s 1, 2, 8, 9 and 11) whose MARs and TARs were reviewed. Findings include, but are not limited to:Resident 1, 2, 8, 9 and 11's physician orders, MARs and TARs were reviewed during the survey. The following deficiencies were identified:1. Resident 8 was admitted to the facility in 02/2021 with diagnoses including peripheral venous insufficiency and lower extremity stasis ulcers. The facility received orders on 01/12/22 to provide twice weekly wound care to both legs.Progress notes indicated home health began providing twice weekly wound care on 03/14/22. The facility failed to clarify whether the existing wound care orders should be continued or discontinued. The original orders were still included on the resident's 04/2022 and 05/2022 TAR, and staff were initialing as though they were providing the wound care twice weekly.In an interview on 05/11/22, Staff 11 (MT) reported she was not actually providing the wound care anymore but, rather, was signing when home health provided the wound care.The need to ensure the TAR was accurate and only included the initials of the person actually providing the treatment was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the inaccurate documentation.2. Resident 9 was admitted to the facility in 06/2019 with diagnoses including atherosclerosis of aorta, chronic kidney disease and macular degeneration.Resident 9's 04/2022 and 05/2022 MARs contained the following inaccuracies:* An order to apply diclofenac sodium gel topically BID for pain failed to include instructions for where to apply the product;* Instructions for PRN Pepto-Bismol lacked a reason for use; and* The resident was prescribed PRN Tylenol 650 mg and Tylenol 500 mg - both to treat pain. The MAR lacked instructions as to when to administer each of the medications.The need to ensure resident MARs were accurate was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
3. Resident 11 was admitted to the facility in 02/2022 and had recently quit smoking. Resident 11's 04/01/22 - 05/09/22 MARs were reviewed and identified the following: * A nicotine 24-hour patch for quitting smoking lacked specific instructions on where staff should apply the patch and how to dispose of the patch. The need to ensure medication specific instruction was provided to direct non-licensed staff was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
4. Resident 1 was admitted to the facility in 12/2019 with diagnoses including Alzheimer's disease.Review of Resident 1's 03/01/22 through 05/09/22 MARs and signed physician's orders dated 05/06/22 revealed the following inaccuracies:* Two PRN bowel medications to treat constipation, Milk of Magnesia and bisacodyl suppository, lacked parameters for which medication to administer first.* PRN acetaminophen 160 mg/5 ml 20 ml by mouth twice daily as needed for pain or fever greater than 100.3 F provided no information regarding how the resident would exhibit pain.* Phenobarbital 32.4 mg tablet ordered to treat severe agitation. Reason for use was documented on the MAR as "pain."* Monthly vitals on April and May MARS instructed "no weights since hospice discontinued them and will take arm circumference [sic]." Hospice services had been discontinued on 04/06/22.* PRN bisocodyl for constipation and PRN phenobarbital 100 mg/ml for agitation and combative behavior on April and May MARS had parameters that included calling hospice RN. Hospice services had been discontinued on 04/06/22.* PRN morphine sulfate 20 mg/1 ml 0.4 ml by mouth every hour as needed for pain or shortness of breath provided no information regarding how the resident would exhibit pain.The need to ensure resident MARs were accurate and included specific instructions to staff administering medication were discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.
5. Resident 2 was admitted to the facility in 03/2019 with diagnoses including Alzheimer's dementia.Review of residents 05/01/22 through 05/09/22 showed the resident had been prescribed PRN bowel medications, Milk of Magnesia and bisacodyl suppository, both with the instructions to administer the medication if the resident did not have a bowel movement for three days. There were no clear instructions to staff on when to administer one medication versus the other. The need to ensure the resident's MAR contained clear instructions to unlicensed staff on administering PRN medications was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 3 sampled residents (#4) who received psychotropic medications. Findings include but are not limited to:Resident 4 was admitted to the facility in 06/2019 with diagnoses including anxiety.The resident's 04/01/22 through 05/06/22 MARs were reviewed, and the following was noted:Resident 4 was prescribed lorazepam .25 ml every four hours as needed for nausea, agitation and anxiety. Records indicated lorazepam was administered on 04/06/22. The facility lacked documented evidence non-pharmacological interventions were attempted and determined ineffective prior to administration of lorazepam.During an interview on 05/12/22, Staff 2 (Clinical Care Manager/RN) confirmed the facility had not documented when non-pharmacological interventions were attempted and ineffective prior to administering the lorazepam for Resident 4. The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications was discussed with Staff 1 (Health Services Director), Staff 2 and Staff 3 (Regional RN) on 05/13/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide qualified direct care staff, sufficient in number to meet the scheduled and unscheduled needs of each resident, which placed residents at risk for serious harm. Findings include, but are not limited to: Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision and support. During the survey, observations and interviews with staff indicated there were insufficient numbers of qualified staff to provide adequate supervision of residents and ADL assistance. During the entrance conference on 05/09/22, the following information was identified:* The facility had 136 residents at the time of the survey.* The residents resided in separate areas as follows: - Two separate 17-bed locked memory care units on the 2nd floor. There were 28 of 34 beds filled. - Two separate 17-bed unlocked units on the 3rd floor - one housing residents with early symptoms of dementia and the other for residents requiring "heavier" ADL care (bedbound, full assistance with ADLs, etc). There were 33 of 34 beds filled; and - The remaining 75 residents resided on the 4th, 5th and 6th floors.* At least one resident needing two-person transfer assistance resided in each of the memory care neighborhoods and in the heavy ADL neighborhood.* There were multiple residents who exhibited challenging behaviors and/or required feeding assistance who resided in the 2nd and 3rd floor neighborhoods.* There were multiple residents who had a history of falls and were identified as being at risk for future falls who resided in the 2nd and 3rd floor neighborhoods and the 5th and 6th floors.The current budgeted staffing plan was reported by Staff 1 (Health Services Director) to be as follows:* Each memory care neighborhood: 1 MT and 1 CG plus a float staff on day and evening shifts;* Early dementia neighborhood: 1 MT and 1 CG on day and evening shifts;* Heavy ADL neighborhood: 1 MT and 2 CGs on day and evening shifts;* 4th, 5th and 6th floors: 1 MT and 1 CG for each floor on day and evening shifts; and* Overnight shift: a total of 6 staff (to which neighborhoods or floors of the facility they were assigned was not explained).Observations during the survey indicated the facility failed to consistently provide a float for the two MCCs and only one CG was scheduled to cover the 4th, 5th and 6th floors.In an interview on 05/10/22, Staff 1 (Health Services Director) reported that because of the limited number of current staff, he was unable to create a complete weekly schedule and had to, instead, schedule one day at a time and attempt to get staff to work extra shifts to fill vacancies in the schedule. He acknowledged he had to schedule the four Resident Care Coordinators to fill shifts in the neighborhoods as MTs and CGs and used staffing agency staff to fill shifts, also.Based on the examples below, on 05/12/22 at 11:06 am, the survey team requested an immediate plan of correction to address the staffing shortages. On 05/13/22 at 2:01 pm, a final staffing plan was received and accepted by the survey team.1. On 05/11/22, Staff 16 (CG) was observed to come up from the floor below and run to a resident's room. Upon exiting, she shared with the surveyor that she and the MT assigned to the lower floor had just finished helping the resident with toileting after the resident pushed his/her call light requesting assistance. She identified this resident - Resident 13 - as a resident who used the call light system to request assistance from staff for toileting multiple times per day.Resident 13 was admitted to the facility in 11/2019 with diagnoses including peripheral neuropathy. The resident had his/her right leg amputated above the knee.In an interview on 05/11/22, Resident 13 reported concerns that staff response to call lights was often slow. Resident 13 stated s/he usually requested staff assistance twice per day, and it was not unusual to wait 20 minutes for a staff person to respond. The resident further stated that approximately once per quarter, or approximately four times per year since residing at the facility, staff take over 60 minutes to respond to his/her call light. The resident explained that s/he had lost feeling in both hands due to peripheral neuropathy and, because of the amputation, needed assistance with hygiene following a bowel movement. Otherwise, the resident said s/he was able to transfer and ambulate independently using a wheelchair, and was able to complete most of his/her daily ADLs independently.Review of the call light log for Resident 13 from 05/01/22 through 05/11/22 indicated the resident had used the call light 43 times, or approximately four times per day. Of the 43 calls, seven took longer than 15 minutes for staff to respond, the longest wait time being 38 minutes on 05/10/22 at 8:20 am.The need to ensure the facility had a system for reviewing and addressing slow call light response times was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged staff needed to respond to call lights more quickly.2. On 05/11/22, call light logs from 05/01/22 through 05/11/22 were reviewed for two unsampled residents who resided on the 5th and 6th floors of the facility and Resident 4, who resided on the 3rd floor. These residents were identified as needing assistance from staff and using the call light regularly. Findings were as follows:* Resident 4 used the call light 16 times during that time period. Of the 16 calls, four took longer than 15 minutes for staff to respond. The wait times for those four calls were 71, 43, 37 and 119 minutes.* The 5th floor resident used the call light 95 times during that time period, or approximately 8 1/2 calls per day. Sixteen of the 95 calls took staff more than 15 minutes to respond to, with the average wait time of those calls being 25 minutes.* The 6th floor resident used the call light 14 times during that time period. Three of the 14 calls took staff longer than 15 minutes to respond to. The wait times for those calls were 43, 54 and 23 minutes.* The surveyor compared the long wait times to the number of staff present at the time. Except for a few exceptions, the neighborhood or floors were staffed per the current staffing plan.The need to ensure the facility had a system for reviewing and addressing slow call light response times was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged staff needed to respond to call lights more quickly.3. Staff assigned to the 4th, 5th and 6th floors were observed during the survey often socializing at the workstation on the 5th floor.In interviews on 05/09/22 and 05/13/22 respectively, Staff 16 (CG) and Staff 26 (MT) acknowledged it was often difficult to respond timely to call lights. Staff 26 stated she believed the reason call lights were not answered timely was that many MTs who regularly worked on the upper floors did not want to help or did not think it was within their job duties to provide routine personal care for residents. She also explained that MTs often left their call light monitor on the medication cart, which was often parked down the hall, away from where they were congregating.Feedback from the staff interviews was shared with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. No further information was provided.
4. In a 05/13/22 interview with Staff 26 (MT), she relayed she alone cared for the 17 residents of the unit that morning from 6:00 am until 9:00 am when an agency employee arrived. Staff 26 confirmed seven of the 17 residents on the unit had recently tested positive for the COVID-19 disease and her duties that morning consisted of caring for those exhibiting symptoms as well as providing medication administration and ADL assistance including delivering breakfast for each resident on the unit until the caregiver arrived. The staffing concern was discussed with Staff 1 (Health Services Director) on 05/13/22. No further information was provided.
5. The following observations and interviews were conducted during the relicensure survey, 05/09/22 through 05/13/22. a. On 05/09/22 Staff 20 (MT) confirmed she was the only MT working in both Oak and Maple for the day shift. On 05/11/22 Staff 25 (Resident Care Manger) confirmed she had worked as an MT on the swing shift 05/10/22 and was also working the day shift as MT on Maple 05/11/22. Staff 25 confirmed she was behind on updating resident service plans because she had been working several shifts as an MT. b. On 05/11/22 Staff 20 (CG) confirmed staffing in the building had been an "issue", often there was only one caregiver and one MT working in each of the MCC's, when the schedule indicated there should be two caregivers on each "side" and a float that goes between the two memory care neighborhoods. c. During an interview, 05/12/22 at 9:04 am, Staff 1 (Health Services Director) stated the facility used an acuity-based staffing tool to determine staffing levels. The tool determined staffing levels based on the billable hours and acuity points generated from information input into the resident service plans. Staff 1 confirmed if service plans were not updated or were inaccurate the staffing pattern generated from the acuity tool would also be inaccurate. At the conclusion of the relicensure survey, seven out of 11 service plans reviewed were inaccurate. d. During interviews with staff throughout the survey, 05/09/22 - 05/13/22, staff confirmed there were four two-person transfers on the Oak MCC, and two "sometimes" three on the Maple MCC.The failure to ensure adequate staff to meet the scheduled and unscheduled needs of the residents was discussed with Staff 1 and Staff 2 (Clinical Care Manager/RN) on 05/11/22 and 05/13/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 17, 18, 19 and 20) had documentation of training in the use of First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed with Staff 6 (Human Resources Administrator) and Staff 1 (Health Services Director) on 05/11/22. Staff 17 (CG) was hired 03/29/22; Staff 18 (MT) was hired 03/22/22; Staff 19 (CG) was hired 03/15/22; and Staff 20 (MT) was hired 02/22/22.* There was no documented evidence Staff 17, 18, 19 and 20 had training in the use of First Aid and abdominal thrust at the time of the survey.The need to ensure newly-hired direct care staff completed all required training within 30 days of hire was reviewed with Staff 1 and Staff 6 on 05/13/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:Six months of fire and life safety records were requested on 05/09/22. The facility provided the records for 05/2022 and reported that they had not completed fire drills or staff training for the remaining five months requested. The records lacked documentation of the following components:* Fire drills were conducted every other month;* Fire and life safety training was provided to staff on alternate months;* Evacuation and / or relocation of residents during fire drills; and* Documentation was lacking or incomplete regarding: - Date and time of fire drill; - Location of simulated fire origin; - Escape route used; - Problems encountered, comments relating to residents who resisted or failed to participate in the drills; - Evacuation time-period needed; - Staff members on duty and participating; and - Number of occupants evacuated.The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Health Services Director) on 05/10/22. He acknowledged the findings and provided no additional documentation.
Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:Fire and life safety records dated 09/30/22 were reviewed during the survey. The fire drill record did not include documentation of the following required components:* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time period needed; and* Number of occupants evacuated.In an interview on 10/03/22, Staff 31 (Building Services Manager) stated the facility was not relocating or evacuating residents as a part of their fire drill process. The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 29 (Executive Director) on 10/05/22. Staff 29 acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to Z 142, Z 164 and C 420.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the common-use areas, entrance, and exit ways are maintained in good repair and failed to take measures to prevent the entry of insects. Findings include, but are not limited to: The interior and exterior of the facility were toured on 05/09/22 at 11:09 am. The following deficiencies were identified:* There were drop-offs between two to four inches from the pavement to the planting bed at the corners of, and along the edges of, pathways around the entrance to the building and within the secured courtyards of the Maple and Oak memory care neighborhoods. These drop-offs created potential tripping or fall hazards for residents.* There were multiple dead insects on the floor surrounding the bathtub of the Bather room 279.On 05/10/22 at 11:29 am, the surveyor discussed the need for pathways to be free from drop-offs and to take measures to prevent the entry of insects with Staff 1 (Health Services Director). He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident clean and in good repair. Findings include, but are not limited to:The interior of the building was toured on 05/09/22 at 11:09 am. The following areas needed cleaning or repair: Assisted Living (Floors 4 - 6):* Multiple resident room doors throughout the Assisted Living had black scuff marks, gouges in the wood and chipped paint;* Chair in front of the sixth floor elevator near room 608 had an orange stain;* Laminate near the elevator on the sixth floor was peeling which exposed bare wood;* Sixth floor laundry room had detergent drips on both front-loading machines, black stains and white residue on the folding table and lint build-up and linens behind the dryers;* Entrance door frame to the Vintage Room was scuffed and gouged;* Walls near rooms 505 and 507 had brown spills;* Fifth floor elevator lobby, near Exit Door 2, had scuffed walls behind the garbage can, spills under the elevator control buttons and frayed fabric on the couch;* Fifth floor activity room had garbage on the floor and brown spills on the wall;* Room 401 had a crack in the wall above the door frame;* Room 400 had a brown spill to the right of the door;* Fourth floor laundry room had a brown spill in the corner, scuff marks on the wall, lint and garbage build-up behind the washing machines, garbage on the floor, dust and soap build-up on the counter and drips on the wall near the pull cord; and* Sunset Activity Room had orange stains down the wall, debris on tables, hearing aid battery and twigs on the floor, stained chairs, stained sink and garbage overflowing from the trash can.Cedar neighborhood:* Multiple resident room doors throughout the Cedar neighborhood had black scuff marks, gouges in the wood and chipped paint;* Cedar dining room had food residue and black marks on floors, dirt and gouging on windowsills, gouges and spills on walls, food stains on chairs and gouges with exposed bare wood on cabinets;* Cedar TV area had laminate peeling from the TV console which exposed bare wood, food residue stuck to the console and fraying fabric on the couch; and* Cedar laundry room had dirt and garbage on the floor, brown stains on walls, a bag of garbage on the floor, gouge in the floor, a bag of used linens on the ground and trash behind the dryer.Elm neighborhood: * Multiple resident room doors throughout the Elm neighborhood had black scuff marks, gouges in the wood and chipped paint;* Elm dining room had food residue and black marks on floors, dirt and gouging on windowsills, gouges and spills on walls and food stains on chairs;* Elm TV area had brown and gray spills on the wall to the right of the TV, white residue on TV console and food debris on coffee table;* Blue chairs near room 341 had brown stains;* Couch near room 341 had purple stain; and* Handrails between room 333 and 335 had bare wood exposed.Maple neighborhood: * Multiple resident room doors throughout the Maple neighborhood had black scuff marks, gouges in the wood and chipped paint;* Maple dining room had food residue and garbage on floor, gouging on windowsills, gouges and spills on walls, gouging and scuffs below the extended counter of kitchenette and exposed wood on cabinets below the drink station;* Maple TV area had white marks on the TV console with scrapes exposing bare wood and brown staining on chairs;* Maple handrails were gritty and sticky throughout the neighborhood; and* Maple walls had spills near the following rooms, 202, 203, 204, 205, 206, 207, 208, 209, 211 and 216.Oak neighborhood: * Multiple resident room doors throughout the Oak neighborhood had black scuff marks, gouges in the wood and chipped paint;* Oak dining room had food residue, garbage, and black marks on floors, gouging on windowsills, gouges and brown spills on walls and gouging and scuffs below extended counter of kitchenette;* Oak TV area had food stains near TV, paint chipping and gouging on TV console, red stains and frayed fabric on the couch and brown stains on the carpet behind the couch;* Oak handrails were gritty and sticky throughout the neighborhood;* Oak fireplace seating area had couch with stains; and* Oak walls had spills near the following rooms, 228, 230, 232, 233, 234, 235, 236, 241 and 243. The need to keep interior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety, and comfort of the resident clean and in good repair was discussed with Staff 1 (Health Services Director) on 05/10/22 at 11:29 am. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:During a walk-through of the facility on 05/10/22 at 8:49 am, exit doors to the Maple and Oak MCC courtyards were found to have no working audible alarm or system in place to alert staff when a resident exited the building.In an interview with Staff 20 (MT) on 05/10/22 at 9:27 am, she confirmed the lack of alarm or system to alert staff that a resident exited the building.The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited the building was discussed with Staff 1 (Health Services Director) on 05/11/22 at 1:55 pm. He 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 150, C 155, C 160, C 200, C 231, C 240, C 360, C 372, C 420, C 510, C 513 and C 555.
Based on 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 420 and C 455.

Based on interview and record review, it was determined the facility failed to provide residents with dementia trained staff who have received training as required in OAR 411-057-0155 and failed to ensure staffing levels were sufficient to meet the scheduled and unscheduled needs of residents. Findings include, but are not limited to:Refer to Z 155 and C 360.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 17, 18, 19 and 20) had documentation of having completed orientation training prior to completing any job duties, pre-service training prior to independently providing personal care and demonstrated knowledge and performance in all required areas within 30 days of hire. It was also determined 3 of 3 sampled direct care staff (#s 11, 14 and 15) failed to complete a minimum of 16 hours of annual in-service training annually on topics related to the provision of care for persons in a community-based care setting, including 6 hours of annual in-service training on dementia care. Findings include, but are not limited to:Staff training records were reviewed with Staff 6 (Human Resources Administrator) and Staff 1 (Health Services Director) on 05/11/22. Staff 1 reported MTs were expected to provide personal care to residents when necessary. 1. Staff 17 (CG) was hired 03/29/22; Staff 18 (MT) was hired 03/22/22; Staff 19 (CG) was hired 03/15/22; and Staff 20 (MT) was hired 02/22/22. The following deficiencies were identified:a. Staff 17 failed to complete training in "Standard Precautions for Infection Control," and Staff 18, 19 and 20 failed to complete training in "Standard Precautions for Infection Control" and "Abuse Reporting Requirements" prior to performing any job duties.b. Except for all the newly-hired direct care staff having completed training on the topic of "How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment" and Staff 18 having completed training on the topic of "How to provide personal care to a resident with dementia, including an orientation to the resident and the resident's service plan," Staff 17, 18, 19 and 20 failed to complete the required pre-service training prior to providing care and services independently to residents.c. Staff 19 lacked documentation of demonstrated competency on the topic of "Changes associated with normal aging" and "General food safety, serving and sanitation;" Staff 18 and 20 lacked documentation of demonstrated competency in all required topics except for medication administration.2. Staff 11 (MT) was hired 06/20/18; Staff 14 (MT) was hired 10/22/19 and Staff 15 (MT) was hired 08/22/18. Review of annual training, based on their anniversary date of hire, revealed the following deficiencies:a. Staff 11 and 15 lacked documented evidence of having completed at least 16 hours of annual in-service training on topics related to the provision of care for persons in a community-based care setting.b. Staff 11, 14 and 15 lacked documented evidence of having completed at least 6 hours of annual in-service training on dementia care.Staff training requirements were reviewed with Staff 1 and Staff 6 on 05/13/22. They acknowledged the facility had not met the training requirements.

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 243, C 260, C 262, C 270, C 280, C 290, C 300, C 303, C 310 and C 330.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and included in residents' service plans for 3 of 3 sampled MCC residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Residents 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, needs and preferences.The need to develop individualized service plans addressing residents' nutrition and hydration preferences and needs and document them in the service plan was discussed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) on 05/13/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate residents for activities and develop individualized activity plans based on the evaluation for 3 of 3 sampled MCC residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:Though Resident 1, 2 and 3's service plans offered some information about the residents' interests, the facility had not fully evaluated the residents': * 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 for these residents during the survey. The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Health Services Director) and Staff 2 (Clinical Care Manager/RN) and Staff 4 on 05/13/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to provide a daily selection of meaningful activities for all residents and failed to fully evaluate each resident for activities and develop an individualized activity plan based on their activity evaluation, for 1 of 2 sampled residents (#18) and multiple unsampled residents who resided in the Memory Care Community units. This is a repeat citation. Findings include, but are not limited to:1. Resident 18 was admitted to the MCC in 04/2022 with diagnoses including dementia, glaucoma, congenital hearing loss and generalized anxiety.During the survey, the resident was observed spending most of the morning and afternoon in his/her apartment, either sleeping or sitting in one of his/her chairs, often with eyes closed. The resident's television was not on, and no books or music was observed in the room. The resident came to meals and snack times in the unit dining room. The resident could walk independently and sometimes walked around the unit or looked at a newspaper that was provided by the facility before returning to his/her apartment. The resident did not join any of the scheduled activities during the survey.Resident 18's 09/03/22 service plan included information about past and current hobbies and interests. However, the facility had not fully evaluated the resident regarding:* 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 resident with more individualized activities based on information gathered from the evaluation.2. Thirteen residents lived on the Oak MCC neighborhood at the time of the survey. Observations during the survey revealed eight residents were out in the common areas during the morning and afternoon. In an interview on 10/05/22, Staff 32 (CG) confirmed the other five residents preferred to remain in their rooms and did not attend activities in the common areas.Staff 36 (Life Enrichment Coordinator) provided group activities on the Oak unit during the survey. However, only two or three residents who were in the common areas attended and participated; the surveyor did not see staff invite the other residents to the activities. Two residents walked around the unit and several others sat in common areas apart from the activity. The surveyor did not observe staff provide any one-on-one activities for the residents who chose to remain in their rooms during the survey.All thirteen residents' service plans were reviewed. Though they all offered some information about past and current hobbies and interests, the facility had not fully evaluated: * 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. Ten of the thirteen residents' service plans lacked a specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.The need to ensure the facility completed a thorough activity evaluation, developed an individualized activity plan, and provided meaningful daily activities for each resident was discussed with Staff 28 (MCC Administrator), Staff 30 (RCF Administrator), Staff 33 (Life Enrichment Manager), Staff 34 (Resident Services Director), Staff 37 (Executive Vice President) and Staff 38 (Vice President of Clinical Services) on 10/05/22. They acknowledged the facility needed to complete more thorough activity evaluations and use the information to develop individualized activity plans for the residents which would guide staff in providing meaningful activities for all residents.