River Terrace Memory Care

Based on interview and record review, conducted during a site visit on 07/15/24 and 07/16/24, it was confirmed the facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records. Findings include, but are not limited to:Documentation of residents showers dated 07/13/24 through 07/15/24 was obtained and reviewed on 07/16/24. A review of the records revealed residents showers and nail care are documented by care staff.During a phone interview on 07/19/24, Staff 6 (Administrator) stated the CGs fill out shower sheets and nail care daily and give them to the MT to review and sign. They are then given to RCC and RN for review and shredded. Staff 6 stated they do not document what was indicated on the shower sheets anywhere in the residents records prior to shredding.The findings were reviewed with and acknowledged by Staff 6 on 07/19/24.The facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records. Verbal plan of correction: Administrator will maintain shower documentation.

Based on interview and record review, conducted during a site visit on 07/15/24 and 07/16/24, it was confirmed the facility failed to promptly investigate all reports of abuse and suspected abuse and take measure to protect residents and prevent reoccurrence of abuse for 1 of 1 sampled resident (#1). Findings include, but are not limited to:A review of Resident 1's signed physican orders dated 06/20/23 revealed an order for Levetiracetam (generic for Keppra, a seizure medication) 100MG/ML SOLN 5 ML (60MG) by mouth two times daily. A review of an incident report dated 01/08/24 noted "Since 12/04/23 there have been up to 16 times/doses where [Resident 1] received less than the prescribed dose of Keppra."During an interview on 07/16/24, Staff 6 (Administrator) stated the entirety of the investigation was included in the Incident Report dated 01/08/24.There was no documented evidence of the following required elements of the investigation:*Time, date, place and individuals present;*Description of events as reported;*Response of staff at the time; and*Follow-up action.The findings were reviewed with and acknowledged by Staff 6 on 07/19/24.The facility failed to promptly investigate all reports of abuse and suspected abuse.Verbal Plan of correction: Regional nurse will provide education on investigations to Administrator and facility RN by end of day 07/26/24.Based on interview and record review, conducted during a site visit on 07/16/24 and 07/17/24, it was confirmed the facility failed to report any suspected abuse to the local APS office for 1 of 1 sampled resident (#1). Findings include, but are not limited to:A review of Resident 1's signed physican orders dated 06/20/23 revealed an order for Levetiracetam (generic for Keppra, a seizure medication) 100MG/ML SOLN 5 ML (60MG) by mouth two times daily. A review of an incident report dated 01/08/24 noted "Since 12/4 there have been up to 16 times/doses where [Resident 1] received less than the prescribed dose of Keppra."A review of an email from Staff 6 (Administrator) to APS on 01/10/24 did not include the information that this error occured multiple times. The email stated, "It was discovered yesterday that [Resident 1] received .5 ML rather than 5 ML of Keppra."The compliance Specialist referred the incident to Adult Protective Services on 07/17/24.The facility failed to report any suspected abuse to the local APS office.The findings were reviewed with and acknowledged by Staff 6 on 07/19/24.Verbal Plan of correction: Administrator to report any abuse or neglect that he can not be definitively ruled out within 24 hours.

Based on observation, interview and record review, conducted during a site visit on 07/16/24 and 07/17/24, it was confirmed the facility failed to ensure the implementation of services for 2 of 2 sampled residents (#s 1 and 3). Findings include, but are not limited to:During the site visit, Resident 1 and Resident 3 were not observed to be left in their pajamas or be left in soiled briefs or on soiled chucks. Discrepancies between observations, resident and staff interviews, and Resident 1's service plan dated 04/11/24 were identified in the following areas:*Toileting;*Oral hygiene; and*The use of a fall mat at Resident 1's bedside.Resident 1's service plan indicated Resident 1 was to be toileted before and after meals. Resident 1 was observed to not be toileted before or after the morning meal and did not receive oral care on 07/16/24. A fall mat was observed at Resident 1's bedside on 07/16/24 and 07/17/24 but the service plan lacked direction for its use.During an interview on 07/16/24, Staff 3 (MT/CG) stated Resident 1 was not toileted before the meal or provided oral care assistance due to "running out of time." S/he further stated that Resident 1 had falls out of bed so it was decided to place a fall mat at his/her bedside while s/he was sleeping for his/her safety.Discrepancies between resident and staff interviews and Resident 3's service plan dated 05/10/24 were identified in the following areas:*ToiletingResident 3's service plan indicated Resident 3 was to be toileted before and after meals. Resident 3 was observed to not be toileted on 07/16/24 before or after the morning meal.The findings were reviewed with and acknowledged by Staff 6 (Administrator) on 07/19/24.The facility failed to ensure the implementation of services.Verbal plan of correction: Administrator will re-educate team members on service plans and will have lead MT audit the particular ADL needs with each resident.

Based on interview and record review, conducted during a site visit on 07/15/24 and 07/16/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:A review of Resident 1's signed physican orders dated 06/20/23 revealed an order for Levetiracetam (generic for Keppra, a seizure medication) 100MG/ML SOLN 5 ML (60MG) by mouth two times daily. A review of an incident report dated 01/08/24 noted "Since 12/4 there have been up to 16 times/doses where [Resident 1] received less than the prescribed dose of Keppra."During an interview on 07/15/24, Staff 8 (RN) confirmed the errors occurred.The findings were reviewed with and acknowledged by Staff 6 (Administrator) on 07/19/24.The facility failed to carry out medication orders as prescribed.Verbal plan of Correction: Nurse to audit physician orders, MAR and carts weekly. MT meeting scheduled by end of day 07/26/24 and will provide education on adherence to five rights of medication administration.

Based on observation, interview and record review, conducted during a site visit on 07/16/24 and 07/17/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:During the site visit the facility's posted staffing plan was observed and reviewed which indicated the need for the following staff:Day: 4 CG, 2 MTEvening: 4 CG, 1 MTNight: 2 CG, 1 MTOnly 1 CG and 1 MT were noted to be working between the hours of 2:00 am and 5:00 am on 07/16/24.During an interview on 07/16/24, Staff 2 (MT) stated there were four residents who required the assistance of two people for transfers and/or cares.The following inconsistencies between resident ABST profiles and resident needs were identified during the site visit:*Resident 1 required the assistance of two people for transfers and care, but his/her ABST profiled did not reflect this.*Resident 2 could become agitated and staff were to provide redirection but zero minutes were reflected in ABST for cueing and redirection due to cognitive impairment and/or interventions for behaviors.*Resident 3 had behaviors but zero minutes were reflected in ABST for cueing and redirection due to cognitive impairment and/or interventions for behaviors.Resident 1's service plan dated 04/11/24 indicated Resident 1 was to be toileted before and after meals. Resident dent 1 was observed to not be toileted before or after the morning meal and did not receive oral care on 07/16/24. During an interview on 07/16/24, Staff 3 (MT/CG) stated Resident 1 was not toileted before the meal or provided oral care assistance due to "running out of time." Resident 3's service plan dated 05/10/24 indicated Resident 3 was to be toileted before and after meals. Resident 3 was observed to not be toileted on 07/16/24 before or after the morning meal.Additionally, the facility's shower documentation for 07/13/24 through 07/15/24 were reviewed which revealed an unsampled resident did not receive a shower on 07/14/24 due to " no time, to much going on."The findings were reviewed with and acknowledged by Staff 6 (Administrator) on 07/19/24.The facility failed to fully implement and update an acuity-based staffing tool.

Based on interview and record review, conducted during a site visit on 12/18/23 and 12/19/23, it was determined the facility failed to ensure a resident monitoring and reporting systems is implemented for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but are not limited to: In separate interviews, Staff 1 (Medication Technican), 2 (Caregiver/MT), 3 (CG), 5 (CG/Activities), 6 (CG), 7 (MT), 8 (Resident Care Nurse), 9 (CG), 10 (CG), 11 (CG), 12 (MT), 13 (CG), and 14 (Agency CNA) stated if a resident falls with or without injury, CG will notify the MT who will respond to the scene and take the residents' vitals, ask questions as to what happened and if the resident is experiencing any pain that cannot be seen, then document the incident, put the resident on alert, and if new interventions are necessary, they are developed by the nurse and administrator then implemented. A review of the facility's "Resident Alert Protocol" (undated) indicated that resident alerts will be initiated for reasons including but not limited to "injury and non-injury falls". The protocol directs staff to record observations every shift for 3 days for injury falls and record observations every shift for 24-hours and to continue for another 48-hours if the resident is observed to be unstable. A review of Resident 2's records including progress notes, dated 11/20/23 through 12/15/23, Resident Alert Notes, dated 11/18/23 through 12/11/23, and incident reports, dated 11/29/23, indicated the following: * Non-injury falls occurred on 11/20/23, 11/21/23, and 11/29/23. * There was no evidence Resident 2's fall on 11/29/23 was monitored for injury until 12/11/23.* An incident report, dated 12/06/23, indicated Resident 2 had a fall on 11/29/23 at 3:38 am and Resident 2 was found when the care giver was preforming safety checks. There was no injuries and abuse/neglect had been ruled out. * Progress note, entered on 12/06/23, notated a fall occurred on 11/29/23. There was no evidence to indicate that the resident was monitored per shift after each new event. In an interview on 12/19/23, Staff 4 (Administrator) stated it was brought to his/her attention that Resident 2 had a fall on the night shift on 11/29/23 and it wasn't documented. An investigation was initiated as well as monitoring, and the staff member involved was disciplined. The facility failed to ensure a resident monitoring and reporting system is implmented for a resident who had fell. On 12/19/23, these findings were reviewed and acknowledged by Staff 4.Verbal Plan of Correction: The resident was immediately put on alert and staff member involved was coached and trained.

The findings of the re-licensure survey, conducted 10/24/23 through 10/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the relicensure survey of 10/27/23, conducted 03/19/24 through 03/21/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

b. On 10/25/23 at 2:52 pm, Resident 4's apartment door was open. The resident was observed sitting on the toilet with his/her briefs pulled down. A caregiver was sitting in a wheelchair next to the resident in the bathroom. This was all observed from the hallway outside of the resident's apartment.The need to ensure residents were treated with dignity and respect and received services in a manner that protected privacy and dignity was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/27/23. They acknowledged the findings.2. During an environmental tour on 10/26/23 at 2:58 pm with Staff 1 (Administrator), a white board was observed in Apartment 29. The board was facing the entrance to the resident's apartment and contained personal health information which was easily readable from the hall. The need to ensure residents were treated with dignity and respect and received services in a manner that protected privacy and dignity was discussed with Staff 1 (Administrator) during the environmental tour. He acknowledged the findings.
3. Resident 1 moved into the facility in 06/2021 with diagnoses including vascular dementia. During the survey the resident was observed to be dependent on staff for all transfers and ambulation, unable to verbally make his/her needs known, and was unable to use the call light. During the survey from 10/24/23 through 10/27/23 the resident's door remained opened when the resident was not in his/her apartment and when the resident was laying in bed. Review of Resident 1's evaluation and service plan dated 07/25/23, identified there was no documented evidence the resident had been evaluated for the ability to manage a key to his/her room. Additionally there was no documentation the resident's representative or designee had been offered a key or requested the resident's door to remain opened in lieu of security and privacy. The need to ensure residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/26/23. They acknowledged the findings. 4. On 10/27/23, an unsampled resident in apartment 5 was observed receiving toileting assistance with three staff members present. The resident's apartment door was opened to the hallway and the bathroom was in line of sight of the individuals walking through the hallway. The need to ensure residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/27/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure the residents' rights to be treated with dignity and respect and to receive services in a manner that protects privacy and dignity for 2 of 4 sampled residents (#s 1 and 4) and 2 of 2 unsampled residents. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 08/2021 with diagnoses including dementia. a. Observations of the resident's room on 10/26/23 revealed s/he shared the room with another resident, and there was no observable barrier between the two sides of the room to protect privacy and dignity during ADL cares. During an interview at 8:30 am on 10/26/23, Staff 15 (CG) stated staff "turn [their] backs to the other resident so they can't see anything" when providing ADL care in shared rooms.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia and Type II diabetes.The resident's alert charting notes, dated 09/14/23 through 10/24/23 and investigations for the same time period were reviewed during the survey.On 10/13/23, staff identified a "blister on [his/her] tail bone and a cut on the inside of [his/her] cheeks close to the blister" while assisting Resident 2 in the restroom. On 10/26/23 at 11:50 am, Resident 2 confirmed s/he had a skin issue on his/her lower back area. The resident put his/her thumb nail to the inside of his/her pinky between the top joint and tip of the finger and said, "It's about this big." When asked what happened, the resident stated, "I don't know." This represented an injury of unknown cause and required an immediate investigation to rule out abuse.There was no documented evidence the facility immediately investigated the injury of unknown cause or that it was reported to the local SPD office.The need to immediately investigate injuries of unknown cause and if the facility was not able to reasonably conclude and document the physical injury was not the result of abuse, report the incident to the local SPD office was discussed with Staff 3 (Health Services Director) on 10/26/23 and Staff 1 (Administrator) on 10/27/23. They acknowledged the findings. The facility was asked to report the injury of unknown cause to the local SPD office.
Based on interview and record review, it was determined the facility failed to immediately investigate incidents to rule-out abuse, and report incidents to the local Seniors and People with Disabilities (SPD) office if abuse could not be ruled out, for 3 of 3 sampled residents (#s 1, 2 and 4) with injuries of unknown cause and resident to resident altercations. Findings include, but are not limited to:1. Resident 1 was admitted to the MCC in 06/2021 with diagnoses including vascular dementia. Resident 1's alert charting notes dated 08/10/23 through 10/24/23, and investigations for the same time period were reviewed during the survey. a. On 10/18/23 an altercation with another resident in which Resident 1 was hit in the face.The facility completed an investigation however, there was no documented evidence the facility reported the altercation to the local SPD office.The facility was asked to report the altercation to the local SPD office. Verification was received during the survey. b. The following incident lacked an immediate investigation:On 07/31/23 the resident had a "mark on [his/her] belly that looked like potential fingers [finger marks]". The care staff notified the Administrator on 08/02/23 and the RN on 08/03/23. The facility staff completed an investigation on 08/10/23 and reported the injury to the local SPD office. This represented an injury of unknown cause that required an immediate facility investigation that the physical injury was not the result of abuse. The need to immediately investigate injuries of unknown cause and altercations and report the incidents to the local SPD office if abuse could not be ruled out was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/26/23. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 08/2021 with diagnoses including dementia. The resident's progress notes and investigations dated 07/24/23 to 10/24/23 were reviewed. The following was identified:* On 07/25/23: bruises under left arm, left bicep, right hip, and middle of back that "may be finger bruises from changing resident"; and* On 08/10/23: a "red scrape" on his/her right hip. Progress notes documented, "unclear when or what caused scrape/abrasion to hip."The above constituted injuries of unknown cause and required immediate investigations to rule out abuse. During an interview on 10/25/23, Staff 3 (Health Services Director) stated no investigation had been completed for either injury. Survey requested the above injuries of unknown cause be reported to the local SPD.The need to ensure the facility reported physical injuries of unknown cause to the local SPD office, unless an immediate investigation reasonably concluded and documented the physical injury was not the result of abuse, was discussed with Staff 1 (Administrator) and Staff 3 on 10/26/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia. The Pre-Admission Evaluation was reviewed and the following elements were not addressed: * Customary routines relating to eating; * Personality including how the person copes with change or challenging situations; * Transportation; * Non-pharmaceutical pain interventions; * Emergency evacuation ability; * Complex medication regimen; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting and room temperature.The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator) on 10/27/23. He acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia and insomnia. The resident's service plan, dated 09/14/23, and facility notes dated 09/14/23 through 10/23/23, were reviewed. The resident, his/her family member, and facility staff were interviewed. The service plan was not reflective of the resident's care needs and lacked a clear description of who would provide the services and what, when, how, and how often the services would be provided in the following areas:* Interventions for when the resident did not want to eat breakfast; * Resident preference on bed time versus what time MTs were administering a medication for insomnia; * Interventions relating to a past resident to resident altercation were not being followed; * Preference of wearing slippers; * "Bathing" in the sink of the resident's bathroom; * Occasional incontinence with bowels; * Frequency of the resident taking self to the restroom; * Interventions when Resident 2 was without his/her four wheeled walker; * Behavior interventions; * Call light use; * Skin issues; and * Use of gait belt for transfers. The need to ensure service plans were reflective of residents' current needs and provided a clear description of services for staff was discussed with Staff 3 (Health Services Director) on 10/26/23 and Staff 1 (Administrator) on 10/27/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of the resident's needs, included a written description of who would provide the services and what, when, how, and how often the services would be provided and ensured the service plans were implemented for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 06/2021 with diagnoses including vascular dementia.Observations of the resident, interviews with staff, and review of the current service plan dated 07/25/23 were conducted during the survey.The service plan was not reflective of the resident's care needs and lacked a clear description of who would provide the services and what, when, how, and how often the services would be provided in the following areas:* Two person care for dressing and toileting;* One to two person bathing;* Use of a tilt in space wheelchair and one person escort; * Grooming including brushing his/her hair and applying cologne;* Recent fall and fall intervention;* Preference to have his/her apartment door open;* Activities preferences; and* Behavior interventions. The need to ensure service plans were reflective of residents' current needs and provided a clear description of services for staff was discussed with Staff 1 (Administrator) on 10/26/23. He acknowledged the findings.
3. Resident 3 was admitted to the facility in 02/2020 with diagnoses including dementia. The resident's current service plan dated 07/31/23 and progress notes dated 07/25/23 to 10/24/23 were reviewed, interviews were conducted, and observations were made. Resident 3's service plan was not reflective of his/her needs and/or did not provide clear direction regarding the delivery of services in the following areas: * Sleeping habits;* Elopement risk;* Evacuation assistance;* Fingernail care; and* Activities.The need to ensure the resident's service plan reflected his/her needs and provided clear direction was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/26/23. They acknowledged the findings.4. Resident 4 was admitted to the facility in 08/2021 with diagnoses including dementia and dysphagia (difficulty swallowing). The resident's current service plan dated 10/19/23 and alert charting notes dated 07/24/23 to 10/24/23 were reviewed, interviews were conducted, and observations were made. Resident 4's service plan was not reflective of his/her needs, did not provide clear direction, and/or was not implemented by staff in the following areas:Eating, including diet texture, liquid consistency, cueing, and use of clothing protector.The need to ensure service plans were reflective, provided clear direction, and were implemented was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/26/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to monitor and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift and made part of the resident's record with weekly progress noted through resolution for 3 of 4 sampled residents (#s 1, 2, and 4) who were reviewed for changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia, Type II diabetes, and hypertension.Resident 2's 09/14/23 through 10/23/23 progress notes, alert charting notes, incident reports, and MARs were reviewed. The following changes of condition were identified: * On 09/17/23 - "small abrasion left of tail bone" that resulted from a fall;* On 10/10/23 - fall with a skin tear to the left elbow;* On 10/13/23 - staff identified a blister on the resident's tail bone and "cut on inside of cheek";* On 10/13/23 - fall resulting in scratches on right foot, right toe, and left side of back;* On 10/18/23 - possible resident to resident altercation; * On 10/19/23 - medications not administered for stroke prevention, diabetes, and cholesterol; and* On 10/21/23 - a blood pressure medication was not administered. On 10/26/23 at 1:43 pm, Staff 3 (Health Services Director) confirmed Resident 2's skin conditions had not been monitored with progress noted at least weekly through resolution. There was no documented evidence the resident was evaluated, actions or interventions were determined and communicated to staff on each shift, and monitored at least weekly through resolution for the possible resident to resident altercation or missing medications.The need to ensure residents who experienced short term changes of condition were evaluated, actions or interventions were determined, the actions or interventions were communicated to staff on each shift, and weekly progress was noted was discussed with Staff 3 on 10/26/23 and Staff 1 (Administrator) on 10/27/23. They acknowledged the findings.
2. Resident 1 moved into the facility in 06/2021 with diagnoses including vascular dementia. During the survey the resident was observed to be unable to verbally communicate his/her needs. Resident 1's progress notes and alert charting notes, dated 08/10/23 through 10/23/23, and incident reports for the same time period were reviewed and identified the following changes of condition lacked monitoring, at least weekly, until resolved and/or lacked monitoring of interventions for effectiveness:* On 07/31/23, Resident 1 had "finger point marks on [his/her] belly". The facility RN resolved the residents skin injury on 09/26/23 however, there was no documented evidence the facility monitored the skin injury at least weekly until resolved. * On 09/24/23, the resident experienced a catatonic event. There was no documented evidence the facility monitored the resident's condition, at least weekly, through resolution.* On 10/18/23, the resident had an altercation with another resident. On 10/23/23 an intervention was communicated to staff to keep the two residents separated in the dining room. On 10/25/23 and 10/26/23 staff were observed seating the two residents next to each other in the dining room. The facility failed to monitor the intervention for effectiveness.The need to ensure the facility had a system for monitoring changes of condition through resolution was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/26/23 and 10/27/23. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 08/2021 with diagnoses including dementia. The resident's 07/24/23 to 10/24/23 progress notes and alert charting and current service plan dated 10/19/23 were reviewed and the following was identified:The resident was placed on alert on 07/25/23 for multiple areas of bruising. Staff monitored the bruising until 08/09/23. The alert was ended by Staff 3 (Health Services Director) on 10/24/23. During an interview on 10/27/23, Staff 3 confirmed the condition had not been monitored from 08/09/23 to 10/24/23.The need to ensure short term changes of condition were monitored with progress noted at least weekly until resolution was discussed with Staff 1 (Administrator) and Staff 3 on 10/27/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a timely RN assessment for a significant change of condition for 1 of 1 resident (#3) who experienced a significant change of condition. Findings include, but are not limited to:Resident 3 was admitted to the facility in 02/2020 with diagnoses including dementia. The resident was identified during the acuity interview as recently having a significant weight loss. The resident's 07/24/23 to 10/24/23 progress notes and alert charting, and service plan dated 07/30/23 were reviewed, interviews were conducted, and observations were made. The following significant weight loss was identified:* On 04/01/23: 125.4 pounds;* On 05/03/23: 129.2 pounds;* On 06/01/23: 125.2 pounds;* On 07/08/23: 127.6 pounds;* On 08/06/23: 124.6 pounds;* On 09/01/23: 120.4 pounds;* On 10/06/23: 114.2 pounds; and* On 10/25/23: 116.4 pounds (observed).From 09/01/23 to 10/06/23, the resident experienced a 6.2 pound or five percent weight loss which constituted a significant change of condition and required an RN assessment. During an interview at 10:45 am on 10/25/23, Staff 3 (Health Services Director) stated she had implemented interventions for the weight loss on 10/23/23 but had not completed an RN assessment.The need to ensure a timely RN assessment for significant changes of condition was discussed with Staff 1 (Administrator) on 10/26/23. He acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication and treatment administration system for 1 of 1 sampled resident (# 4) whose orders were reviewed. Findings include, but are not limited to:Resident 4 was admitted to the facility in 08/2021 with diagnoses including dementia and dysphagia (difficulty swallowing). The resident's 10/01/23 to 10/24/23 MAR, physician orders, service plan dated 10/19/23, and alert charting dated 07/24/23 to 10/24/23 were reviewed, observations were made, and interviews were conducted. The following was identified:The resident was identified during the acuity interview as requiring a modified diet and cueing during meals. Review of the service plan indicated the resident was on "mechanical soft, cut up, finger food" textures and "thick" liquid consistencies. Interviews with kitchen staff indicated they were following the instructions on the can of liquid thickener for "nectar-thick" consistency. Meal observations made during the survey from 10/24/23 to 10/26/23 revealed Resident 4 was sometimes served regular texture foods like bacon strips, liquids thickened to a natural nectar consistency, and staff cued the resident for two of four meals. Snack observations made during 10/24/23 to 10/26/23 revealed activities staff were providing the resident with thin liquids.There were no diet orders in the resident's medical record and during an interview at 12:45 pm on 10/26/23, Staff 3 (Health Service Director) confirmed there were no diet orders for the resident.The need to ensure a safe medication and treatment administration system was discussed with Staff 1 (Administrator) on 10/26/23. He acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including Type II diabetes and hypertension. The resident's 09/01/23 through 10/24/23 MARs and physician's orders were reviewed. The following medications were not administered per physician's orders as they were not in the facility:* Clopidogrel (for stroke prevention) on 10/19/23;* Glipizide (for diabetes) on 10/19/23; * Rosuvastatin (for cholesterol) on 10/19/23; and* Losartan (for blood pressure) on 10/21/23.There was a note relating to Resident 2 refusing "am meds" and receiving a 9:00 am dose of divalproex (for seizures and bipolar disorder) "late. Holding this [dosage]." There was no documented evidence the unlicensed staff contacted the facility RN or the resident's physician to find out if she needed to hold the resident's 1:00 pm dose of divalproex.The need to ensure medication orders were carried out as prescribed was discussed with Staff 3 (Health Services Director) on 10/26/23 and Staff 1 (Administrator) on 10/27/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 4 residents (#s 2 and 3) whose medication orders were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 02/2020 with diagnoses including dementia. The resident's 09/01/23 to 10/24/23 MARs and progress notes, current physician orders, current service plan dated 07/31/23 and shower logs dated 09/01/23 to 09/09/23 were reviewed and the following was identified:The resident had an order for olanzapine, 2.5 mg, give 1 tablet by mouth daily "as needed for agitation. May give prior to shower if needed." Facility staff documented the resident was administered the medication on 09/09/23 at 5:36 am for "refusal of cares." Review of the resident's service plan indicated s/he showered on Monday and Thursday evenings. Review of the shower logs indicated the resident did not have a shower on 09/09/23. There was no documentation in the resident record of agitation or refusing a shower on 09/09/23.The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/26/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner if a resident refused to consent to an order for 1 of 2 residents (#3) who had medication refusals. Findings include, but are not limited to:Resident 3 was admitted to the facility in 02/2020 with diagnoses including dementia. The resident's 10/01/23 to 10/24/23 MAR and progress notes dated 07/24/23 to 10/24/23 were reviewed, and interviews with staff were conducted. The following was identified:Staff documented on the MAR the resident refused to consent to the following orders:* Potassium chloride (for low potassium) on 10/07/23;* Furosemide (for edema) on 10/07/23; and* Acetaminophen (for pain) on 10/19/23. During an interview at 1:00 pm on 10/26/23, Staff 3 (Health Services Director) confirmed the physician had not been notified when the resident refused the above medications.The need to ensure the facility notified the physician or other practitioner if a resident refused to consent to an order was discussed with Staff 1 (Administrator) and Staff 3 on 10/26/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behaviors had written, resident-specific parameters and non-pharmacological interventions for staff to attempt prior to administering a PRN psychotropic medication for 2 of 3 sampled residents (#s 2 and 3) who were prescribed a PRN psychotropic medication. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 09/2023 with diagnoses including dementia, behaviors related to anxiety, and insomnia. The resident's 09/01/23 through 10/24/23 MARs and physician's orders were reviewed. The following PRN psychotropics were administered:* Trazadone (for insomnia) on 09/23/23 through 09/28/23, 09/30/23, 10/01/23, and 10/02/23; and* Olanzapine (for behaviors related to anxiety) on 10/18/23 and 10/19/23. On 10/26/23 at 11:25 am, Staff 18 (MT) confirmed there were no non-drug interventions listed in Resident 2's MAR. There was no documented evidence non-pharmacological interventions had been tried with ineffective results prior to administering the medications.The need to ensure residents' MARs included resident specific non-pharmacological interventions for staff to try prior to the administration of a PRN psychotropic which included documentation of the interventions tried with ineffective results was discussed with Staff 3 (Health Services Director) on 10/26/23 and Staff 1 (Administrator) on 10/27/23. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 02/2020 with diagnoses including dementia. The resident's 09/01/23 to 10/24/23 MARs and progress notes, and physician orders were reviewed and the following was identified:The resident had an order for PRN olanzapine for agitation. Facility staff documented the resident was administered the medication on 09/09/23 at 5:36 am for "refusal of cares." The MAR lacked resident-specific parameters for the behavior. There was no documentation in the resident record of agitation on 09/09/23. There was no documentation staff tried non-drug interventions prior to administering the medication.The need to ensure written, resident-specific parameters and documented, non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (Administrator) on 10/26/23. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST), based on the evaluated care needs for 4 of 4 residents (#s 1, 2, 3, and 4), and the ABST failed to convert the evaluated care needs of the residents into staff hours that was used to generate a facility staffing plan that met the 24-hour scheduled and unscheduled needs of all residents. Findings include, but are not limited to:On 10/26/23, the ABST and the facility staffing plan was reviewed with Staff 1 (Administrator). The following was identified: * The facility had not updated the ABST to reflect all evaluated care needs for four sampled residents; and* The staffing hours generated by the ABST failed to meet the 24-hour scheduled and unscheduled care needs for Resident's 1 and 4 and four other non-sampled residents who required one to two person care for transfers and emergency evacuation. The need to ensure the facility updated the ABST to convert evaluated care needs of residents into staff hours needed to generate a facility staffing plan that included meeting the 24-hour scheduled and unscheduled needs of all residents was discussed with Staff 1 on 10/26/23. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a written record of resident fire safety training which included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building within 24 hours of admission and an annual written record of re-instruction for residents was kept. Findings include, but are not limited to:Fire Safety training records for residents was requested on 10/25/23 at 3:30 pm. During an interview on 10/26/23 at 8:45 am, Staff 1 (Administrator) confirmed the facility did not currently have a process for providing residents fire safety training upon admission and re-instruction at least annually.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair, grounds were kept orderly and free of refuse, and garbage was stored in a covered refuse container. Findings include, but are not limited to:The facility grounds were toured on 10/24/23. The secured courtyard was observed with drop-offs up to approximately two and a half inches from the sidewalk to the middle planting bed which created tripping hazards.Garden refuse was observed throughout the survey which was not stored in a covered refuse container.The building exterior was toured with Staff 1 (Administrator) on 10/26/23. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the design of the Residential Care Facility (RCF) supported the installation of handrails at one or both sides of resident-use corridors. Findings include, but are not limited to:The interior of the building was toured on 10/24/23. There were no handrails observed on one or both sides in the corridor located through the double doors to the right, back corner of the main dining room. The need to ensure handrails were installed along resident-use corridors was discussed with Staff 1 (Administrator) on 10/26/23. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:Observations of the facility on 10/24/23 revealed the following:* Apartment 23 had gouges in the wall to the left of the resident's bed; * Carpets throughout the facility were in need of deep cleaning;* The threshold, located by apartments 3 and 4, was covered in duct tape; and * Air vents throughout the facility had built up dust and cobwebs present. The surveyor toured the environment with Staff 1 (Administrator) on 10/26/23 at 2:58 pm. He acknowledged findings.

Based on observation and interview, it was determined the facility failed to ensure soiled linens and soiled clothing were kept in closed containers to ensure the separate storage and handling of the soiled items, and that staff were following the facility's procedures relating to a one way flow of soiled items from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing. Findings include, but are not limited to:During a tour of the facility on 10/24/23 at 12:23 pm, there were observations of an uncovered plastic basket containing clothing, and a pile of clothing located on the floor next to the basket in front of the left door located in the soiled laundry area. Also, there was an uncovered large bin full of re-usable "chucks," used for bed and chair protection, located to the left in the soiled laundry area. Staff 12 (CG) confirmed she entered and exited the laundry room with soiled linens and clothing through the right door, which led directly into the laundry room where unsoiled linens and clothing were washed and dried. There was a separate door, the left door, intended for staff to enter the soiled laundry area.On 10/26/23 at 2:58 pm, Staff 1 (Administrator) confirmed staff were to enter the laundry room with soiled linens and soiled clothing through the left door and all clean laundry was to be taken out through the right door. The need to ensure soiled items were stored in a closed container and the one way flow of soiled laundry was utilized by staff was discussed with Staff 1. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:Observations on 10/24/23 through 10/26/23, identified exit doors to the interior courtyard did not have an operable alarm or other acceptable system to alert staff when residents exited the building. On 10/26/23, Staff 10 (CG), stated she had not been aware of an alarm sounding when the doors to the courtyard were opened. The failure to ensure exit doors were equipped with an alarming device or other acceptable system and were operable was discussed with Staff 1 (Administrator) on 10/26/23. 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 200, C 231, C 361, C 422, C 510, C 511, C 513, C 530, and C 555.

Based on interview and record review, it was determined the facility failed to ensure direct care staff completed 16 hours of in-service training annually for 2 of 2 direct care staff whose records were reviewed. Findings include, but are not limited to:Staff training records were reviewed with Staff 2 (Business Office Manager) on 10/25/23 and the following was identified:Staff 19 (MT) and Staff 14 (CG), hired 09/16/21 and 10/12/21, respectively, did not have documented evidence of completing the required 16 hours of training annually, including six hours of dementia care topics.The need to ensure direct care staff complete 16 hours of training annually, including six hours of dementia care topics, was discussed with Staff 1 (Administrator) on 10/26/23. He acknowledged the findings, and no additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 260, C 270, C 280, C 300, C 303, C 305, and C 330.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the residents' service plans for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:Residents 1, 2, 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.* Residents 1, 3 and 4 were observed to require meal assistance which included cueing and physical assistance;* Resident 3 experienced significant weight loss; and* The facility failed to provide Resident 1 snacks and hydration between breakfast and lunch meals on 10/24/23 and 10/25/23. The need to develop individualized service plans that addressed residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/25/23 at 4:45 pm. They acknowledged the findings and provided a nutrition and hydration plan for Resident 1 on 10/26/23 at 8:45 am.

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations were completed which included an individualized activity plan for each resident based on their activity evaluation and was reflective of the resident's activity preferences and needs for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:Although Residents 1, 2, 3, and 4's service plans offered some information about the residents' interests, the facility had not fully evaluated the residents' activity needs in one or more of the following areas:* Current abilities and skills;* Emotional and social needs and patterns;* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Activities which could be used as behavioral interventions, if necessary.There were no resident-specific activity plans developed from activity evaluations.Observations between 10/24/23 and 10/26/23 showed multiple small group activities being led by facility staff. Residents 1 and 3 were not observed to be invited to activities or provided adaptations to participate in the activities. The need to ensure activity evaluations were completed for all residents and individualized activity plans that reflected the residents' preferences and needs and were developed based on their activity evaluation was discussed with Staff 1 (Administrator) on 10/26/23. He acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2023 with diagnoses including behaviors relating to dementia.The resident's 09/14/23 through 10/23/23 progress notes, alert charting notes for the same date range, and the service plan dated 09/14/23, were reviewed. The following behaviors were identified: * On 09/24/23 - observed by staff sleeping with another resident that was not located in Resident 2's apartment; * On 09/25/23, 09/28/23, and 10/04/23 - being nude in shared spaces in the facility;* On 10/04/23 and 10/19/23 - attempting inappropriate urination or defecation in shared spaces in the facility; * On 10/13/23 - being aggressive with staff and trying to get the scissors located on a nearby table;* On 10/18/23 - being agitated with staff while trying to assist another resident in a wheelchair; and* Multiple dates when the resident was identified as either being agitated or aggressive with staff.The service plan available to staff lacked individualized interventions for them to try when responding to the behaviors. The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 3 (Health Services Director) on 10/26/23 and Staff 1 (Administrator) on 10/27/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident or others in the community were evaluated and included in the service plan for 2 of 4 sampled residents (#s 1 and 2) who had behaviors that negatively impacted others in the facility. Findings include, but are not limited to:1. Resident 1 moved into the facility in 06/2021 with diagnoses including vascular dementia. During the survey, Resident 1 was observed to be unable to verbally communicate his/her needs. The service plan dated 07/25/23 noted under the section titled "Eating: Seat [the resident] away from the TV as the sounds tend to bother [him/her] and cause distress or keep the volume down during meals. Monitor that resident is in a calm area for eating." Additionally, the service plan noted under the section titled "Behaviors: when [the resident] gets frustrated [s/he] may start yelling, staff to just take a step back and give him a few minutes to calm down and collect [him/herself]."On 10/24/23, Resident 1 was escorted to the dining room at 11:55 am. The resident was seated at a table with three other residents located at a table closest to a large television that was turned on and the volume up. There was a total of 36 residents in the dining room. At the conclusion of the lunch service, the resident began yelling while in the dining room.A staff member approached the resident and immediately used a radio device to contact another staff member to escort Resident 1 back to his/her apartment at 12:48 pm.During an interview on 10/24/23, with Staff 10 (CG) and Staff 12 (CG), it was reported "we were told to bring [him/her] back to [his/her] room because s/he yells a lot, and it disturbs and riles up other [same gender] residents. [S/he] won't get up again until around 5:00 pm [for dinner]." The current service plan, dated 07/25/23, lacked individualized interventions for staff to try when responding to the behavior.The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 1 (Administrator) and Staff 3 (Health Services Director) on 10/25/23. They acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 02/14/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on record review and interview it was confirmed that the facility failed to implement the resident's right to be given informed choice and opportunity to select or refuse service. Findings include but not limited to:A review of Resident #1 (R1) progress notes for December 2022 and service plan dated 11/7/2022 revealed than on 12/27/2022 R1's service plan was altered to adjust incontinence care practices. Progress notes do not reflect that the resident, family or their Power of Attorney (POA) were notified of this change.During a phone interview on 02/14/2023 Witness #1 (W1) stated that the facility changed R1's service plan without notifying them.These findings were reviewed with and acknowlegded by Staff #1 by phone on 02/16/2023.Facility Plan of Correction: Facility to document conversations with family in progress notes and notify of any changes as soon as possible within 72 hours or less.

Based on record review and interview it was confirmed that the facility failed to report any suspected abuse to the local Adult Protectice Services (APS) office. Findings include but not limited to:A review of Resident #1 (R1)'s incident reports and progress notes for August 2021 revealed: *On 08/20/2021 R1 had an unwitnessed fall with injury. Q 2 hour checks noted to be initiated. Abuse ruled out because "No staff member went into the room before the incident"*On 08/21/2021 R1 had an unwitnessed fall with injury. There is no documentation on whether two hour checks had been provided. Abuse and neglect ruled out by "cameras were reviewed and no staff member went into apartment prior to incident." Resident was very agitated after.*On 8/22/2021 given double dose of psychotropic. R1 experienced a decreased level of consciousness. PCP was not notified of error until 9/1/2021.*On 8/30/2021 unwitnessed fall. encourage resident to stay in bed. 2 hour checks are mentioned again, but there is no documentation if they occurred.None of these events were self-reported to APS.These findings were reviewed with and acknowledged by Staff #1 by phone on 02/16/2023 who was in agreement. S1 stated they now review all incidents Monday-Friday with administrator, Resident Care Coordinator (RCC) and nurse.Plan of correction: CS emailed copy of ODHS abuse/neglect reporting guide for review.

Based on record review and interview, it was confirmed that the facility failed to provide a service plan with written description of who shall provide the services and what, when, how, and how often the services shall be provide and date and initial changes and entries made to the service plan.A review of the Resident #1 (R1)'s service plan dated 11/07/2022 and 02/08/2023, Resident #2 (R2)'s serices plans dated 5/4/2021 and 8/12/2021and Resident #3 (R3)'s service plan dated 1/30/2022 fail to identify who shall perform what services and when. R1's service plan dated 11/07/2022 contatains handwritten additions that are not dated or inititaled.These findings were reviewed with and acknowledged by Staff #1 by phone on 02/16/2023.The facility was unwilling to provide a Plan of Correction though stated they woud follow up.

Based on record review and interview, it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:Compliance Specialist (CS) reviewed Resident #1 (R1)'s Medication Administration Record (MAR) for January 2023 which revealed that R1 did not receive a medication for nine days straight due to "waiting on delivery". R1's MAR for August 2021 revealed at least two more instances when medications were not given for the same reason. A review of R1's progress notes for these time periods did indicate any steps that were taken by staff to obtain these medications. An incident report dated 8/22/2021 revealed that R1 was given double dose of a psychotropic medication which resulted in a decreased level of consciousness.These findings were reviewed and acknowledged by with Staff #1 (S1) by phone on 02/16/2023 who was in agreement with findings.Plan of Correction: Facility to audit MARs and progress notes Monday-Friday for exceptions and ensure that appropriate actions taken beginning 2/17/2023.

Based on oservation, record review and interview, it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:During an unannounced site visit on 02/14/2023, Compliance Specialist (CS) observed five caregivers (CGs) and one medication technician (MT) working the floor, which would total 42 hours. There was one additional medication technician in training on the floor.A review of the facility's ABST updated on 2/11/2023 revealed the need for 46.79 hours on day shift. A review of the facility's posted staffing plan stated the facility needed:Three CGs and one MT on day shift.Three CGs and one MT on evening shiftTwo CGs and one MT on noc shift.A review of the facility's staff schedule for February 2023 and time cards for 02/13/2023 revealed only 30 hours of care on day shift on 02/13/2023, and several days in February 2023 when only three CGs were scheduled during the day. There were five noc shifts when only one CG and one MT were scheduled.A review of Resident #1 (R1)'s service plan dated 11/07/2022 revealed that R1 sometimes requires assistance of three people for transfers and incontinence care. a review of R1's progress notes revealed that R1 had a fall on 2/4/2023 when two staff members were assisting with incontinence care.During interview, Staff #3 (S3) and Staff #4 (S4) stated:*Day and swing shift are short-staffed.*Swing shift and weekends have the worst staffing.*There are sometimes only two CGs and one MT on day shift.*There is only one CG sometimes on swing shift.In an email on 02/15/2023, Staff #1 (S1) stated that the facility's "call light system is not set up to track call light usage."These findings were reviewed with and acknowledged by Staff #1 by phone on 02/16/2023.Plan of Correction: S1 stated that they disagreed with findings and that R1 can be changed in bed with only two people. Facility will update service plan to be reflective of need for only two people on noc shift.

Based on observation, interview and record review, it was confirmed that the facility failed to fully implement an Acuity Based Staffing Tool. Findings include but not limited to:During an unannounced site visit on 02/14/2023, Compliance Specialist (CS) observed five caregivers and one medication technician working the floor, which would total 42 hours. There was one additional medication technician in training on the floor.A review of the facility's ABST updated on 2/11/2023 revealed the need for 46.79 hours on day shift. The facility's ABST does not include all 22 Activities of Daily Living (ADLs). A review of the facility's posted staffing plan stated the facility needs three CGs and one MT on day shift. A review of the facility's staff schedule for February 2022 and time cards for 02/13/2023 revealed only 30 hours of care on day shift and several days when only 3 CGs were scheduled during the day.During interview, Staff #1 (S1) stated: *Two of the caregivers working were on light duty and unable to lift more than two pounds and would not be responsible for taking a section of residents.*Their background is in skilled nursing so they believe they need less staff than required by skilled nursing ratios.These findings were reviewed with and acknowledged by S1 by phone on 02/16/2023.Plan of Correction: S1 stated that data is entered incorrectly and says that tasks are distributed incorrectly to disproportionately effect day shift. They will review and revise within two weeks. They will speak with company management to address 22 ADLs.

Based on observation, interview and record review, it was confirmed that the facility failed to have a training program that includes methods to determine the competency of direct care staff. Findings include but not limited to:During an unannounced site visit on 02/14/2023, Compliance Specialist (CS) observed Staff #2 (S2) passing medications unsupervised throughout the day.During interview, S2 and Staff #3 (S3) stated:*S2 is still in training*A Medication Technician (MT) in training can pass medications unsupervised when the employee in training feels confident.*S3 has been working as a MT for many months.CS requested all training documents for S2 and S3. S2's training materials included a single page "Medication Assistant Training Check Off List" which was not signed by the trainee, and had several missing initials. There was no indication any of these skills were verified. S3's "Medication Assistant Training Check Off List" was complete and dated 1/5/2023. No other training documentation was available.These findings were reviewed with and acknowledged by S1 by phone on 2/16/2023 who was in agreement.Plan of Correction: Facility will have office manager complete audit of training material for existing staff within two weeks.