Battle Creek Memory Care

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main facility kitchen and the four unit kitchenettes on 01/23/25 from 10:00 am thru 12:45 pm and revealed the following deficient practices.

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

* Interior of left oven under grill;
* Industrial mixer;
* Microwaves in Lily and Daisy unit;

b. The following areas needed repair:

* Dishwasher leaking water and pooling on floor;

c. Unit kitchenette refrigerators observed with potentially hazardous foods not consistently dated when opened. Examples include cartons of juice, milk, and salad dressings.

d. Kitchen staff observed to handle raw beef patties with gloves. Staff did not change gloves after handling the raw beef and proceeded to touch multiple surfaces and cooking utensils with the potentially contaminated gloves. When staff removed the gloves and washed hands, staff washed hands for 10 seconds not the full recommended time to ensure hands are cleaned effectively. A different staff member was observed washing dishes who also had gloves on while handling the dirty dishes. Staff did not change gloves when touching/handling the clean/sanitized dishes potentially contaminating the dishes from the dirty task. When gloves were removed and hands washed, staff did not perform handwashing for the recommended 20-30 seconds to effectively wash hands.

e. Staff was observed to check temperature of cooked food products without sanitizing thermometer prior to use. Staff was not observed to sanitize thermometer between food products including once when temping baked chicken products that were not at correct temperature then using that same thermometer to check the product again potentially contaminating the food product. Surveyor asked the staff their process for sanitizing their thermometers and the staff indicated they rinse it with hot water and acknowledging there was not currently a sanitation step/process for food thermometers. Staff 2 (Director of Dining Services) was informed and alcohol towelettes were obtained for proper sanitation before and between use.

f. A utility cart was observed with a box of raw beef products on it. Once the box was removed, a piece of raw meat was observed left on the cart. This piece of raw beef remained on the cart for several minutes. No observations were made of staff cleaning and sanitizing the cart before it was taken by kitchen staff out to the units.

g. Multiple care staff assisting residents to eat did not have proper protective barrier/aprons on to help prevent potential contamination from care tasks to meal/dining tasks.

h. Multiple dishwashing racks were noted stored on the floor.

i. Boxes of single use utensils were observed stored in dry storage open with food contact surfaces exposed to potential contamination. In Lily unit, single service forks were observed stored with food contact surfaces upright and exposed to potential contamination.

Staff 2 toured the kitchen with surveyor and acknowledged areas. At approximately 12:30 pm, items were reviewed with Staff 1 (Executive Director) who acknowledged areas in need of correction.

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 observations and interviews, 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 kitchen inspection, conducted 01/08/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the first revisit to the kitchen inspection of 01/08/24, conducted 02/09/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen and unit kitchenette food storage areas, food preparation, and food service on 01/08/24 revealed splatters, spills, drips, dust and debris noted on: - Can opener casing; - Interior of plate warmer; - Pedestal stand up fan blades and cage; - Shelves and front vent covers in kitchenette refrigerators;- 2 kitchenette ovens;- Interior and exterior of ice machine;- Paper towel dispenser; and- Ceiling vents, light fixtures, fire sprinklers, and pipes.The following areas/items were found needing repair; - Thermometer in neighborhood refrigerator temping at 44 degrees; and - Ware washing machine wash cycle temperature gauge not registering 150 degrees.* During lunch service pureed fish product was observed served to residents at incorrect texture. Item was runny and was not smooth. Surveyor intervened and requested item be prepared again with the correct texture. Staff pureed items again and texture was appropriate to be served. * Cutting boards were found with deep scoring and staining. * Frying pans found with deep scoring and flaking of non-stick surface material. Dome lids for meal service were cracked. Hot pads found with holes. * Mixer and slicer were observed not covered when not in use.* Steam table with large wooden area that was deeply scored/damaged making it a non-cleanable surface.* Multiple items in all neighborhood refrigerators/freezers were not covered, not labeled with resident specific identifier, and/or not dated when prepared or opened.* Multiple items in dry storage observed not securely sealed when opened.* Care staff observed serving food to residents without aprons.* Hairbrush found stored in neighborhood kitchenette cupboard next to single service paper plates.Staff 2 (Dietary Services Director) and the Surveyors toured the kitchen. Staff 2 acknowledged the above findings.At approximately 1:45 pm, above areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). S/he acknowledged the findings.

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

The findings of the relicensure survey, conducted 10/09/23 through 10/12/23, 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 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 re-visit to the re-licensure survey of 10/12/23, conducted 01/22/24 through 01/24/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with 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. Tag numbers beginning with the letter H refer to the Home & Community-Based Services rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 10/12/23, conducted 05/29/24 through 05/30/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.Tag numbers beginning with 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. Tag numbers beginning with the letter H refer to the Home & Community-Based Services 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 third revisit to the re-licensure survey of 10/12/23, conducted 07/24/24, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:During the relicensure survey, conducted 10/09/23 through 10/12/23, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the number of citations.Refer to deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate administrative oversight of facility operations and supervision and training of staff, which posed a risk to the safety of residents. This is a repeat citation. Findings include, but are not limited to:During the re-visit survey, conducted 01/22/24 through 01/24/24, oversight to ensure resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in the report.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:During a tour of the secure courtyard between the Walnut and Ivy neighborhoods on 01/22/24, it was observed the electronic locking device was loose from the fence post, and there were wires coming out of the box.The loose locking device with exposed wires was discussed with Staff 1 (Executive Director) on 01/22/24. She acknowledged the findings.

2. Resident 5 was admitted to the MCC in 04/2022 with a diagnosis of dementia. A review of the resident's record during the survey revealed the following:In an incident report on 08/12/23, Resident 5 was found on the floor in his/her apartment, sitting between the bed and closet. The resident was unable to state what had happened. Staff noted the resident complained of having pain from right side of his/her head. There was no documented evidence the incident had been thoroughly investigated to rule out abuse or neglect, or reported to local SPD office. Staff 1 (Executive Director) stated in an interview on 10/12/23 the unwitnessed incident was not reported to the local SPD office.The need to investigate resident incidents to rule out abuse and neglect and report to the local SPD office as required was discussed with Staff 1 on 10/12/23. She acknowledged the findings. Staff 1 was asked to report the incident to the local SPD office and provided faxed verification on 10/12/23 that the local SPD had been notified.
Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out, and documented for 2 of 3 sampled residents (#s 1 and 5). Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 04/2021 with diagnoses including dementia.Review of Resident 1's record revealed on 07/18/23, Resident 1 was laying down on a couch in the common area when another resident came over and started slapping and throwing a blanket at Resident 1. The facility investigated the incident, however the facility failed to report the incident to the local SPD office.On 10/09/23, survey requested the facility report the incident to the local SPD office. At approximately 2:50pm on 10/09/23, confirmation of the facility reporting the incident to the local SPD office was provided.On 10/11/23, the need to ensure all incidents of possible abuse and neglect were reported to the local SPD office was discussed with Staff 1 (Executive Director). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out for 2 of 2 sampled residents (#s 11 and 13) with incidents of an unwitnessed fall and an incident of resident-to-resident altercation. This is a repeat citation. Findings include, but are not limited to:1. Resident 13 was admitted to the facility in 12/2023 with diagnoses including dementia and failure to thrive.The service plan dated 1/22/24 noted Resident 13 required one person assist for dressing and bathing, and standby assistance during ambulation. The service plan also noted Resident 13 was a high risk of falls, and of suffering severe injury from a fall, care staff were to report to nurse in charge, changes of gait, balance, appetite, mentation and level of consciousness.Review of the resident's 12/15/23 charting notes, incident report, and temporary service plan revealed Resident 13 was found laying down on the floor at the end of her/his bed on 12/15/23. The investigation was completed at the time of the incident; however, based on the investigation, the fall was unwitnessed, and Resident 13 was unable to state what took place. The investigation did not rule out abuse and/or neglect, and the incident was not reported to the local SPD office.On 01/23/24, survey requested the facility report the incident to the local SPD office. At approximately 12:05 PM on 01/24/24, confirmation of the facility reporting the incident to the local SPD office was provided.On 01/24/24, the need to ensure all incidents for which abuse and/or neglect could not be ruled out were reported to the local SPD office was discussed with Staff 1 (Executive Director). She acknowledged the findings.
2. Resident 11 was admitted to the facility in 10/2020 with diagnoses including dementia, diabetes, and chronic kidney disease.During the acuity interview on 01/22/24, the resident was identified as having had a resident-to-resident altercation, as well as a history of past altercations with the same resident.Review of the resident's progress notes, dated 12/14/23 through 01/20/24, incident reports and investigations, and temporary service plans revealed the following:* On 12/22/23 Resident 11 experienced a resident-to-resident altercation in which s/he was the aggressor;* An incident report was completed on 12/22/23 and interventions were implemented; * The facility reported the incident to the local SPD on 12/22/23; and* The investigation of the incident was conducted four days later, on 12/26/23.The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (Executive Director) on 01/24/24. She acknowledged the findings.
C 231- Investigating and Reporting Abuse-Other Action-1. Residents 11 and 13 who were affected by this finding was reviewed and reported. 2. A full review of other incidents in this time frame was completed and ensured all needed reporting was completed. Going forward ED or MOD will be responsible for investigating and reporting.3. Daily review of incidents to be completed in morning clinical meeting to ensure quick action is taken if needed.4. Executive Director or Designee to investigate and report within 24 hours of initial report.

3. Resident 5 was admitted to the MCC in 04/2022 with a diagnosis of dementia. Resident 5's service plan was dated 10/01/23, each service area was updated on 09/13/23, and the evaluation occurred on 08/04/23. Therefore, the evaluation was not the basis of the resident's service plan and contained inaccurate or incomplete information in the following areas:* Physical decline;* Hospitalization and recent diagnoses of diverticulitis, pneumonia and cholelithiasis;* Level of assistance needed for ADLs;* Nutritional habits, fluid preferences and weight monitoring; and* History of dehydration or unexplained weight loss. The need to ensure quarterly evaluations contained sufficient and/or accurate information and were used as the basis of the quarterly service plan was discussed with Staff 1 (Executive Director ) on 10/12/23. She acknowledged the findings.4. Resident 7 was admitted to the MCC in 08/2023 with a diagnosis of dementia.Resident 7's initial evaluation, dated 07/25/23 failed to address the following required elements: * Effective non-drug interventions for mental health issues;* Cognition, including memory, orientation, confusion, and decision-making abilities;* Personality, including how the person copes with change and challenging situations;* Pharmaceutical and non-pharmaceutical interventions for pain, including how the person expresses pain or discomfort; * Nutrition habits, fluid preferences and weight if indicated; * Fall risk or history;* History of dehydration or unexplained weight loss or gain; * Unsuccessful prior placements; and* Environmental factors that impact behavior, including, noise, lighting, and room temperature.There was no documented evidence Resident 7's initial evaluation was updated and modified as needed during the 30 days following the resident's move into the facility.The need to address all required areas in the initial evaluation and to update or modify the evaluation within 30 days after move-in was shared with Staff 2 (RN/ Director of Health Services) on 10/11/23 and Staff 1 (Executive Director) on 10/12/23. They acknowledged the findings.
5. Resident 3 was admitted to the memory care community in 11/2020 with diagnoses including hypertension, acute renal failure, and dementia.Review of Resident 3's most recent quarterly evaluation, dated 08/03/23, indicated the document was not reflective of the following recent change of condition:On 07/06/23 the resident was discharged from the hospital following admission for a left femur fracture. The resident required a hoyer lift for all transfers since returning to the facility;On 10/11/23 the need to ensure quarterly evaluations included documentation of all recent changes of condition was discussed with Staff 1 (Executive Director) and Staff 2 (RN/ Director of Health Services). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure the initial evaluation addressed all required elements and was updated as needed during the 30 days following the resident's move into the facility for 1 of 1 sample resident (#7) whose move-in evaluation was reviewed, and failed to complete evaluations quarterly or ensure quarterly evaluations accurately reflected the residents' status for 3 of 4 sampled residents (#s 3, 4 and 5) whose quarterly evaluations were reviewed. Findings include, but are not limited to:1. Resident 4 moved into the MCC in November 2021 with a diagnosis of dementia.In an interview on 10/10/23, Staff 3 (RCC), reported the most recent quarterly evaluation was completed in June 2022.The need to ensure evaluations were completed quarterly and were thorough and accurate was discussed with Staff 1 (Executive Director), Staff 3 and Staff 4 (RCC) on 10/11/23. They acknowledged the findings.2. Resident 6 moved into the MCC in February 2022 with a diagnosis of dementia.In the acuity interview on 10/09/23, Resident 6 was identified as being in a sexual relationship with another resident.The resident's most recent evaluation, dated 08/04/23, did not include information about Resident's 6's relationship with another resident.The need to ensure evaluations thorough and accurate was discussed with Staff 1 (Executive Director), Staff 3 and Staff 4 (RCC) on 10/11/23. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure the resident evaluation formed the basis of the resident's quarterly service plan for 1 of 4 sampled residents (#11) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 11 was admitted to the facility in 10/2020 with diagnoses including dementia, non-insulin dependent diabetes, and chronic kidney disease.The resident's facility record was reviewed, and the following was identified:*The resident's current service plan was dated 11/04/23; and*His/her most recent "Resident Assessment" (quarterly evaluation) was dated 11/21/23.There was no documented evidence the resident's quarterly evaluation was used as the basis for his/her quarterly service plan.The need to complete a quarterly evaluation of the resident prior to updating their service plan was discussed with Staff 1 (Executive Director) on 01/24/24. She acknowledged the findings.
C252-Resident Move in and Eval: Res Evaluation-1. Residents included in this report have been reviewed and corrected.2. ED and service planning team to review all new admission evaluations and quarterly evaluations due, during morning clinical meeting to ensure all evaluations are completed timely.3.These evaluations will be reviewed prior to all admission dates and quarterly as they are due. 4. ED/WD/Clinical team.

5. Resident 5 was admitted to the MCC in 04/2022 with a diagnosis of dementia.Observations of the resident, interviews with staff, review of the resident's current service plan dated 10/01/23, and Temporary Service Plans (TSP's) from 08/12/23 to 09/12/23 showed the service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:* Recent hospital stay;* Significant weight loss and interventions;* Dietary intake and nutritional supplemental drinks; and* Falls and current interventions. The need to ensure service plans were reflective of residents' current status, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Executive Director) on 10/12/23. She acknowledged the findings.
6. Resident 2 was admitted to the facility in 02/2023 with diagnoses including dementia.Observations, interviews, and review of clinical records including the service plan, dated 09/28/23, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding hoyer lift transfers.On 10/11/23, the need to ensure the service plan was reflective of Resident 2's current care needs and provided clear direction to staff was discussed with Staff 1 (Executive Director). She acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction to staff regarding the delivery of services, and/or were updated quarterly for 6 of 8 sampled residents (#s 2, 4, 5, 6, 8 and 9) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 4 moved into the MCC in November 2021 with a diagnosis of dementia.Interviews with staff and review of the resident's current service plan, dated 08/03/23, and temporary service plans dated 06/29/23 through 10/04/23, revealed the service plan was not reflective of the resident's current status and lacked clear direction to staff in the following areas: * Relationship with another resident; and* Specific resident-to-resident behaviors.The need to ensure service plans were reflective of residents' status and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 3, and Staff 4 (RCC) on 10/11/23. They acknowledged the findings.2. Resident 6 moved into the MCC in February 2022 with a diagnosis of dementia.Interviews with staff and review of the resident's current service plan, dated 09/19/23, revealed the service plan was not reflective of the resident's current status and lacked clear direction to staff in regard to his/her relationship with another resident.The need to ensure service plans were reflective of residents' status and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 3, and Staff 4 (RCC) on 10/11/23. They acknowledged the findings.3. Resident 8 moved into the MCC in November 2022 with a diagnosis of dementia.Staff 3 (RCC) stated in an interview on 10/11/23 the most recent service plan for Resident 8 was dated 04/09/23, and had not been updated quarterly as required.Interviews with staff and review of the resident's most recent service plan, revealed the service plan was not reflective of the resident's current status and lacked clear direction to staff in regard to his/her resident-to-resident behaviors.The need to ensure service plans were updated quarterly based on the most recent evaluation, reflective of residents' status, and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 3, and Staff 4 (RCC) on 10/11/23. They acknowledged the findings.4. Resident 9 moved into the MCC in June 2022 with diagnoses including dementia and anxiety disorder.Observations of the resident, interviews with staff, and review of the resident's current service plan, dated 09/07/23, revealed the service plan was not reflective of the resident's current status and lacked clear direction to staff in the following areas:* Assistance with meals; and* Adaptive cups.The need to ensure service plans were reflective of residents' status and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 3, and Staff 4 (RCC) on 10/11/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, provided clear direction to staff regarding the delivery of services, and/or were updated quarterly for 2 of 2 sampled residents (#s 11 and 13) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 13 was admitted to the MCC in December 2023 with diagnoses including dementia and failure to thrive.The resident's current service plan and resident assessment, dated 01/22/24, and temporary service plan, dated 12/15/23, revealed the service plan was not reflective of the resident's current status and lacked clear direction to staff in the following areas: * Falls and current interventions; and* Weight loss and interventions.In an interview on 01/23/24, Staff 13 (CG) stated she was unaware Resident 13 experienced a weight loss and had not received documentation from the RN for weight loss interventions.The need to ensure service plans were reflective of residents' status and provided clear direction to staff was discussed with Staff 1 (Executive Director) on 01/24/24. She acknowledged the findings.

2. Resident 11 was admitted to the facility in 10/2020 with diagnoses including dementia, non-insulin dependent diabetes, and chronic kidney disease.The resident's current service plan, dated 11/04/23, quarterly evaluation ("Resident Assessment"), dated 11/21/23, progress notes from 12/14/23 through 01/20/24, and temporary service plans were reviewed. Staff interviews were conducted.The resident's service plan was not reflective and/or did not provide clear direction to staff regarding the delivery of services in the following areas:* Diabetic status;* Dialysis treatments three times per week;* Nail care;* History of resident-to-resident altercations;* Nutrition and hydration preferences;* Monitoring resident's physical status when dialysis treatments were missed; and* Monitoring resident's physical status related to diabetes.The need for the service plan to reflect the resident's current status and care needs, as well as provide clear direction to staff, was discussed with Staff 1 (Executive Director) on 01/24/24. She acknowledged the findings.
C260-Service Plan:General-1. All service plans affected by this deficiency have been corrected and updated as follows; Service Plan for Resident # 13 was updated to reflect weight loss history, nutrition/hydration plan and falls interventions and history. Service Plan for Resident # 11 was updated to reflect diabetic status, dialysis treatments, nail care, history with res/res altercations and interventions, nutrition/hydration plan and preferences, monitoring of physical status when dialysis is missed.2. Retraining of clinical team on significant change TSPs was conducted by consultant RN 02/09/2024. Will review new TSPs during shift change prior to working the floor. Will sign off on TSPs after reviewing. 3 WD/RSC or designee to review TSPs and question team members weekly on knowledge of TSPs. 4. ED/WD/RSC or designee.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 9 of 9 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8 and 9) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, 4, 5, 6, 7, 8 and 9's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans.On 10/12/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director) and Staff 2 (RN/ Director of Health Services). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 4 of 4 sampled residents (#s 10, 11, 12, and 13) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 10, 11, 12, and 13's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.On 01/24/24, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director). She acknowledged the findings.

4. Resident 5 was admitted to the MCC in 04/2022 with a diagnosis of dementia. Observations of the resident, interviews with staff, review of the resident's 10/01/23 service plan and 08/14/23 through 09/16/23 progress notes, revealed the following information:a. The following significant change of condition lacked documentation the facility monitored the resident consistent with his/her evaluated needs for severe weight loss.* From 08/07/23 to 08/27/23, Resident 5 sustained a 10.5 pound loss, constituting a 10.5 % loss in less than a month. Refer to C280, example 3.b. The following short-term change of conditions 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 documented weekly progress until the condition resolved:* 08/12/23 fall with injury; and * 08/22/23 hospital stay. On 10/12/23, the need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift, and conditions were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Executive Director). She acknowledged the findings.
5. Resident 3 was admitted to the facility in 11/2020 with diagnoses including hypertension, acute renal failure, and dementia.Review of Resident 3's progress notes, dated 07/05/23 through 10/09/23, weight records, dated 04/04/23 through 10/02/23, and temporary service plans revealed the resident experienced the following change of condition:During the six month period between 04/04/23 and 10/02/23 Resident 3 experienced a weight gain of 46.1 pounds. This represented a gain of 18.2% of the resident's body weight, and constituted a significant change of condition. The recorded weights were as follows:04/04/23 - 252.3 lbs05/08/23 - 264.7 lbs06/10/23 - 261.8 lbs10/02/23 - 298.4 lbsThe facility failed to identify the weight gain as a significant change, and to determine actions or interventions needed in response to the weight gain.In an interview on 10/11/23, Staff 2 (RN/ Director of Health Services) acknowledged Resident 3's weight gain and stated that no service planning or interventions had been implemented in response.On 10/12/23, the need to ensure the facility had a system for documenting changes of condition and developing interventions as needed was discussed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.
6. Resident 1 was admitted to the facility in 04/2021 with diagnoses including dementia.Resident 1's record was reviewed for changes of condition and identified the following:*Clinical records indicated Resident 1 was slapped and had a blanket thrown at him/her on 07/18/23 by an unsampled resident. Resident 1 was placed on alert charting for the resident-to-resident altercation. The last documented evidence of monitoring was on 07/20/23 in a progress note, until a discontinuing alert charting progress note on 08/08/23.There was no documented evidence the resident was monitored weekly until resolution.On 10/11/23, the need to ensure residents who experienced a change of condition were monitored at least weekly until resolution was discussed with Staff 1 (Executive Director). She acknowledged the findings. 7. Resident 2 was admitted to the facility in 02/2023 with diagnoses including dementia.Resident 2's record was reviewed for changes of condition and revealed the following:* On 08/15/23 the resident was placed on alert monitoring for being found on the floor from an unwitnessed non-injury fall; and * On 08/16/23 the resident was placed on alert monitoring for being found on the floor from an unwitnessed non-injury fall.There was no documented evidence the non-injury falls were monitored weekly until resolution. On 10/11/23, the need to ensure residents who experienced a change of condition were monitored at least weekly until resolution was discussed with Staff 1 (Executive Director). She acknowledged the findings.
Based on observations, interview and record review, it was determined the facility failed to identify and evaluate changes of condition, determine resident-specific actions or interventions needed, communicate interventions to staff on each shift, and/or monitor the conditions to resolution for 7 of 8 sampled residents (#s 1, 2, 3, 4, 5, 6 and 8) who experienced changes of condition. Findings include, but are not limited to:1. Resident 4 moved into the MCC in November 2021 with a diagnosis of dementia.It was identified during the acuity interview that Resident 4 was in a sexual relationship with another resident, and that the relationship had been evaluated and included in the service plan.A Consenting Relationship Assessment, dated 03/30/23, progress notes dated 03/31/23 and 04/03/23, a temporary service plan dated 03/31/23, service plans dated 05/02/23 and 08/03/23, and progress notes dated 07/07/23 through 10/07/23 were reviewed. a. There was no evidence following the 03/31/23 temporary service plan that the service plan was updated with the interventions developed for the sexual relationship, or that the resident was being monitored for ongoing evidence of consent.b. A progress note dated 09/11/23 stated Resident 4 was in another resident's room attempting to keep the other resident from going to dinner. In an interview on 10/12/23 Staff 4 (RCC) reported that Resident 4 had been exhibiting behavior toward this other resident for a few days prior to 09/11/23, attempting to prevent the other resident from going to various activities. There was no evidence this change in behavior had been evaluated, that appropriate interventions had been developed, or that the interventions had been communicated to staff on each shift.The need to evaluate changes in behavior, determine appropriate interventions for behaviors, including sexual relationships with other residents, communicate the interventions to staff on each shift, and monitor changes, including continued consent for a sexual relationship, was discussed with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 4 on 10/11/23. They acknowledged the findings.2. Resident 6 moved into the MCC in February 2022 with a diagnosis of dementia.It was identified during the acuity interview that Resident 6 was in a sexual relationship with another resident, and that the relationship had been evaluated and included in the service plan.Progress notes dated 03/31/23 and 04/03/23, and the resident's most recent service plan, dated 10/09/23, were reviewed. There was no evidence appropriate interventions were developed for the relationship, the service plan was updated with the interventions, or the resident monitored for ongoing evidence of consent.The need to determine appropriate interventions for sexual relationships, communicate interventions to staff on all shifts, and monitor changes, including continued consent for a sexual relationship, was discussed with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 4 on 10/11/23. They acknowledged the findings.3. Resident 8 moved into the MCC in November 2022 with diagnoses including dementia and psychotic disturbance.A Resident Incident Report dated 10/01/23 stated Resident 8 was found having sexual intercourse with another resident. There was no evidence the interventions that were developed were communicated to staff on each shift.The need to communicate interventions for behaviors to staff on all shifts was discussed with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 4 on 10/11/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what resident specific actions or interventions were needed following changes of condition, communicate the interventions to staff on all shifts, monitor residents consistent with his or her evaluated needs and service plan, noting weekly progress until the condition resolved for 2 of 3 sampled residents (#s 11 and 13) reviewed with changes of condition. Resident 13 experienced ongoing weight loss. This is a repeat citation. Findings include, but are not limited to:1. Resident 13 moved to the facility in 12/2023 with diagnoses including dementia and failure to thrive. The current service plan dated 01/22/24 noted the resident was on monthly weights, and the resident was ordered a regular texture diet, which s/he received.Review of progress notes and weight records indicated Resident 13's weight on 12/14/23 was 126 pounds, and on 01/05/24 the resident's weight was 121 pounds. This was a loss of five pounds, and represented a significant weight loss of 3.9% body mass in less than one month. A progress note dated 01/05/24 revealed an RN assessment for a significant change of condition - significant weight loss. There was no documented evidence the RN updated Resident 13's service plan related to the change of condition and failed to provide staff with interventions for weight loss.Resident 13 was observed during the noon meal on 01/23/24 and was noted to eat 50% of the meal with cueing from staff.On 01/23/24, the surveyor requested a current weight for Resident 13. Staff 13 (CG) reported the resident's weight at that time was 119.9 pounds. This was an additional loss of 1.1 pounds since 01/05/25, a loss of 5.5% body mass in the last 18 days (since the first weight loss was identified) and a total loss of 6.1 pounds since admission.Resident 13 was noted to experience a significant weight loss and there was no documented evidence the facility determined resident-specific actions or interventions that were needed and the resident continued to lose weight.The facility's failure to monitor Resident 13's weight and provide staff with interventions and training was reviewed with Staff 1 (Executive Director) on 01/23/24. She acknowledged the lack of monitoring and interventions resulted in continued weight loss.


2. Resident 11 was admitted to the facility in 10/2020 with diagnoses including dementia, non-insulin dependent diabetes, and chronic kidney disease.During the acuity interview on 01/22/24, Resident 11 was identified as attending dialysis on Tuesdays, Thursdays, and Saturdays.Resident 11's 12/04/23 through 01/20/23 progress notes, temporary service plans, 01/01/24 through 01/22/24 MAR, and physician orders were reviewed, and staff were interviewed. The following was identified:* A communication to the resident's physician, dated 11/29/23, written by the facility RN, indicated the fistula had "delayed healing" following dialysis, "sometimes oozing for several hours, saturating layers of bandages." The communication also noted the resident's increasing lethargy and his/her frequent refusals to attend dialysis appointments. The facility requested the family have a physician evaluate the resident's fistula to determine whether it could continue to be used and if it could not, or if the resident continued to refuse dialysis treatments, to write a hospice referral.Progress notes on 12/14/23 indicate the RN again communicated with the resident's family about the status of getting an evaluation of his/her fistula. The family reported to the RN the resident's cardiologist declined to do the evaluation and said they should ask the resident's nephrologist to conduct the evaluation.Following the 12/14/23 communication with the family, there was no documented evidence the facility followed up on the concerns about the resident's fistula.In an interview on 01/24/23, Staff 4 (RCC) reported she had spoken with the resident's family on the previous evening (01/23/23) about the resident's situation; however, no resolution was reached about whether the resident should continue dialysis treatments or stop the treatments and be admitted to hospice.* On 12/22/23 the resident had a physical altercation with another resident. Staff noted on an Incident Report form the resident had a skin tear near his/her right ear. There was no documented evidence the skin tear was monitored through resolution.* On 01/02/24 the resident was sent to the ER. There was no documentation related to why s/he was sent out, nor was there documentation the resident was monitored upon return to the facility.* A progress note dated 01/16/24 indicated the resident did not attend his/her appointment for dialysis that day and had missed three treatments. The resident was sent to the hospital for labs and evaluation on 01/16/24, based on a message from a physician on 12/13/23 stating if the resident missed more than three treatments, s/he should go to the emergency room for further evaluation.In an interview on 01/24/24, Staff 18 (CG) reported the resident had not had a dialysis treatment since testing positive for COVID. Progress notes indicated the resident tested positive for COVID on 01/08/24. The resident had missed a total of seven treatments. On 01/24/24, Staff 1 (Executive Director) reported the resident would be going to the emergency room for evaluation on 01/25/24 for evaluation after missing several consecutive dialysis treatments.There was no documented evidence the facility monitored the resident following missed or refused dialysis treatments, or had followed up on the status of the resident's fistula between 12/14/23 and 01/23/24.The facility RN was unavailable for an interview.The need to evaluate all short-term changes of condition, determine and document resident-specific actions or interventions and make them part of the resident's record, communicate the interventions to staff on all shifts, and monitor the resident consistent with his/her evaluated needs and service plan, noting weekly progress until the condition resolves, was discussed with Staff 1 (Executive Director) on 01/24/24. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had changes of condition had resident-specific instructions or interventions determined, documented, and communicated to staff on all shifts, and/or the conditions were monitored at least weekly through resolution for 3 of 4 sampled residents (#s 15, 17, and 18) who experienced short term changes of condition. Findings include, but are not limited to: 1. Resident 15 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.The resident's current service plan dated 04/25/24, progress notes , temporary service plans, and incident reports dated 03/22/24 through 05/29/24 were reviewed. The following short term changes of condition lacked weekly progress noted through resolution and/or resident-specific actions or interventions needed for the resident, communicated to staff on all shifts. * 04/22/24: Fall with abrasion to the left hip;* 04/23/24: Fall without injury;* 04/29/24: Symptoms of respiratory infection (coughing, congestion, nasal drainage);* 05/09/24: Open wound on the spine.The need to ensure resident-specific actions or interventions for short term changes of condition were determined, communicated to staff on all shifts, and the changes of condition were monitored at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 4 (RCC) on 05/30/24. They acknowledged the findings.
3. Resident 17 moved into the facility in 02/2023 with diagnoses including Parkinson's disease and dementia. The resident's progress notes dated 04/05/24 through 05/28/24, temporary service plans (TSP's), and incident reports were reviewed. The following short term change of condition was identified:* 05/23/24 fall with a head injury, and resident sent to the emergency room. The resident returned to the facility on 05/24/24 with five staples on his/her scalp. The resident was placed on alert charting; however, there was no documented evidence the facility determined actions or interventions, provided written communication of the change of condition and any actions or interventions to staff on all shifts.The need to ensure the facility determined and documented actions or interventions for short term changes of condition, provided written communication of a resident's change of condition and any required interventions to staff on all shifts was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 4 (RCC) on 05/30/24. They acknowledged the findings.


2. Resident 18 was admitted to the facility in 01/2024 with diagnoses including dementia.The resident's current service plan dated 04/30/24, progress notes, temporary service plans, and incident reports dated 03/22/24 through 05/29/24 were reviewed. On 05/20/24, Resident 18 was sent out to the hospital for a head laceration. The resident returned the same day with multiple staples to the wound. The facility failed to determine and document what action or interventions were indicated, communicated to staff on all shifts, and lacked documentation of weekly progress noted. On 05/30/24, the need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on all shifts, and the changes of condition were monitored at least weekly was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 4 (RCC). They acknowledged the findings.

C270- Change of condition and monitoring-1. All residents affected by this deficiency have been reviewed and corrected as follows: Resident #15 has a new significant change on condition assessment completed by the RN and updated service plan refecting current skin conditions which have also been added to our weekly skin check documentation until condition is resolved. Communication and instructions for care staff were implemented as well.Resident #18-RN has completed skin notes with updates and instructions for care staff. Also has been added to our weekly skin documentation log until condition is resolved.Resident #17-RN completed skin note, service plan update and clear instructions for staff to monitor for changes. Skin condition also added to our weekly skin check log.2. ED and RN have established weekly skin check and review days to evaluate, assess and document all active skin conditions within the community.3. ED to review all upated skin documentation notes on a weekly basis.4. ED/RN or designee.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled residents (#s 2, 3, and 5) who experienced a significant change of condition were assessed by the RN. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 02/2023 with diagnoses including dementia.A review of clinical records indicated the resident was sent to the emergency room on 09/01/23 after experiencing an unwitnessed fall. S/he returned to the facility with a diagnosis of a fractured right hip on 09/12/23. The new diagnosis of a fractured hip represented a significant change of condition for the resident. There was no documented evidence an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment.Staff 13 (Lead CG), in an interview on 10/11/23, indicated the resident had needed more assistance with transfers and other ADL's since returning from the hospital on 09/12/23 after experiencing the fall with injury.On 10/11/23, the need to conduct an RN assessment following a significant change in condition was discussed with Staff 1 (Executive Director). She acknowledged the findings.
3. Resident 5 was admitted to the MCC in 04/2022 with a diagnosis of dementia. During the survey, the resident was observed to self-ambulate with his/her walker around the community. The resident appeared very thin and frail. The resident was independent with eating and drinking.A review of the weight record from 04/04/23 to 10/04/23 indicated between 08/07/23 and 08/27/23, the resident's weight decreased from 99.5 pounds to 89 pounds. This was a severe loss of 10.5 pounds or 10.5% of body weight in less than a month. This represented a significant change of condition for which an RN assessment was required.Staff 2 (RN/ Director of Health Services) documented the significant change of condition in a progress note dated 08/28/23. The note included the resident had been hospitalized for diverticulosis during this timeframe, which s/he was on a liquid diet, and the resident was physically weak and had a small appetite. Staff 2 noted he had contacted the resident's PCP with a notification of the weight change, and he would be contacting the resident's POA to discuss interventions to increase the resident's weight and consider a hospice consult.While the assessment noted the weight loss and a few issues that could affect the resident's weight, it lacked interventions made as a result of the assessment, nor was the service plan updated following Resident 5's severe weight loss. From 10/09/23 through 10/11/23, the resident was observed to consume 25-30% of meals and snacks offered. The facility provided a nutritional supplement drink three times per day, which was recorded on the resident's MAR.The need to ensure the RN developed interventions related to the resident's significant change of condition and updated the service plan was discussed with Staff 1 (Executive Director) on 10/12/23. She acknowledged the findings.
2. Resident 3 was admitted to the facility in 11/2020, with diagnoses including hypertension, acute renal failure, and dementia.Review of Resident 3's progress notes, dated 07/05/23 through 10/09/23, weight records, dated 04/04/23 through 10/02/23, and temporary service plans revealed the resident experienced the following:During the six month period between 04/04/23 and 10/02/23, Resident 3 experienced a weight gain of 46.1 pounds. This represented a gain of 18.2% of the resident's body weight, and constituted a significant change of condition. The recorded weights were as follows:04/04/23 - 252.3 lbs05/08/23 - 264.7 lbs06/10/23 - 261.8 lbs10/02/23 - 298.4 lbsThere was no documented evidence the facility RN completed an assessment of the weight gain which included findings, resident status, and interventions made as a result of the assessment.In an interview on 10/11/23, Staff 2 (RN/ Director of Health Services) acknowledged Resident 3's weight gain, and stated no RN assessment for significant change of condition had been completed.On 10/12/23, the need to ensure an RN assessment was completed following all significant changes of condition was discussed with Staff 1 (Executive Director) and Staff 2. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2023 with diagnoses including dementia. Resident 2 had signed physician's orders for PRN oxycodone 5 mg as needed for pain. Resident 2's Controlled Substance Disposition logs and MARS were reviewed from 09/01/23 through 09/30/23. On the following dates oxycodone was documented as being removed from storage on the disposition log but was not documented as being administered on the MAR:* 09/13/23 at 6:30am;* 09/16/23 at 8:15pm;* 09/18/23 at 12:50am;* 09/19/23 at 5:17am;* 09/20/23 at 6:15pm; and* 09/21/23 at 7:00pm.On 10/11/23, the need to ensure the narcotic disposition log and MAR were maintained and reflective for all controlled substances was discussed with Staff 1 (Executive Director). She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 4 sampled residents (#s 5 and 9) whose orders were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the MCC in 04/2022 with a diagnosis of dementia. The resident's MAR dated 09/01/23 through 10/09/23 and physician orders were reviewed, and identified the following medications did not have signed orders in the record: * Acetaminophen 500 mg for temperature greater than 100;* Escitalopram 5 mg for depression;* Ferrous sulfate 325 mg for iron; and * Multivitamin gummy. During an interview on 10/10/23, Staff 2 (RN/ Director of Health Services), acknowledged the above medications did not have signed physician orders. Staff 2 stated he called and faxed Resident 5's PCP multiple times but has not received a response. The facility obtained Resident 5's signed physician orders prior to survey exit.The need to have signed physician orders for all medications and treatments administered by the facility was discussed with Staff 1 (Executive Director) on 10/12/23. She acknowledged the findings.
2. Resident 9 moved into the MCC in June 2022 with diagnoses including dementia and anxiety disorder.Resident 9's current physician's orders, dated 9/23/23, were reviewed on 10/11/23. The following was identified:Resident 9 had a physician's order for a minced and moist diet texture, and had been observed eating a regular diet texture at three meals during the survey.On 10/11/23 Staff 9 (Director of Dining Services) provided a Dietary Communication Notification from Staff 2 (RN/Director of Health Services) dated 07/26/23, requesting a temporary food texture change from regular to minced and moist, ending 08/07/23. In an interview with Staff 2 on 10/11/23, he reported the resident was placed on this diet texture to promote nutrition after oral surgery, per postoperative recommendations. This surveyor requested that Staff 2 clarify the diet order with the physician. Documentation of clarification request was provided, and Staff 2 reported he would ensure Resident 9 received a minced and moist diet texture until clarification was received.The need to ensure medication and treatment orders were carried out as prescribed was reviewed with Staff 2 on 10/11/23, and with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 4 (RCC) on 10/12/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to follow physician or other legally recognized practitioner orders as prescribed and/or failed to have written, signed orders in the resident's facility record for all medications and treatments the facility was responsible to administer for 1 of 5 sampled residents (#11) whose physician orders were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 11 was admitted to the facility in 10/2020 with diagnoses including dementia, non-insulin dependent diabetes, and chronic kidney disease. During the acuity interview on 01/22/24, the resident was identified as being on dialysis three days a week.The resident's 01/01/24 through 01/20/24 MAR was reviewed, along with physician orders and communications. The following was identified:*On 01/02/24 the resident was prescribed Lokelma (for treating high potassium levels) 10 g oral pack, take 1 packet (10 g total) by mouth daily for 2 days. An "After Visit Summary" from an emergency department visit included instructions to administer the medication starting on 01/03/24. The MAR revealed the "effective date" of the Lokelma was 01/04/24, and it was discontinued on 01/05/24, without having been administered to the resident. The MAR notes the resident was "out of building" on 01/04/23.In an interview on 01/24/24, Staff 1 (Executive Director), Staff 3 (RCC), and Staff 4 (RCC) reported they were unaware if the medication had been delivered from the pharmacy or why it was not administered.*The resident had a prescription for Ventolin HFA (for asthma) 90MCG AER INH 18G as needed for cough/wheezing. An "After Visit Summary" dated 11/01/23, from an appointment with a cardiology clinic, instructed the facility to discontinue the inhaler. There was no documentation the facility attempted to obtain a signed order for discontinuing the medication and the Ventolin was still listed on the 01/01/24 through 01/20/24 MAR. In an interview on 01/23/24, Staff 3 and Staff 4 stated the pharmacy generates the MAR and an RCC or RN "usually" reviews it for accuracy.The RN was unavailable for an interview.The need to have signed orders from a physician or other legally recognized prescriber in the resident's chart and to follow orders as written was discussed with Staff 1, Staff 3, and Staff 4 on 01/24/24. No additional documentation was provided.
C 303- Systems: Treatment Orders-1.Full review of residents orders was completed on 1/24. Pharmacy also completed a full review on 1/22/24. Resident # 11's Physician orders were clarified with the provider for accuracy. 2. Retraining of RCC's and ED on the need for parameters and interventions completed 02/09/2024 by consultant RN. 3. WD/RSC to review any new orders for accuracy and to ensure that parameters and interventions are in place for each medication. Will review minimum of 5 residents per week. 4. ED/WD/RSC or Designee.

2. Resident 5 was admitted to the MCC in 04/2022 with a diagnosis of dementia. Resident 5 was admitted to hospice on 09/08/23. At that time the resident received new medication orders through his/her hospice provider; however, the resident's power of attorney decided to discharge the resident's hospice services on 09/13/23. In an interview on 10/10/23, Staff 2 (RN/ Director of Health Services), confirmed Resident 5 was no longer on hospice. The resident's 09/01/23 through 10/09/23 MAR was reviewed and showed that the hospice orders had not been discontinued or removed from Resident 5's MAR. There was no documented evidence the resident was administered the hospice medications. The need to ensure MARs were accurate was discussed with Staff 1 (Executive Director) on 10/12/23. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for all medications ordered by a legal prescriber and administered by the facility, for 2 of 4 sampled residents (#s 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 3's MAR, dated 09/01/23 through 09/30/23, was reviewed during the survey. The following deficiencies were identified:Resident 3 had orders for the following PRN medications for pain: acetaminophen (325 mg), ibuprofen (400 mg), oxycod/APAP (325 mg), and oxycodone IR (5 mg). The MAR lacked specific instructions for staff regarding the sequential order of use for these PRN medications.On 10/12/23, the need to ensure resident MARs were accurate was discussed with Staff 1 (Executive Director) and Staff 2 (RN/ Director of Health Services), Staff 3 (RCC), and Staff 4 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility, for 3 of 5 sampled residents (#s 10, 12, and 14) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 10 and 14's MARs, dated 01/01/24 through 01/22/24, were reviewed during the survey. The following deficiencies were identified:1. Resident 10's MAR included two scheduled medications which lacked reasons for use. These were:* Cephalexin (an antibiotic); and* Ferrous Sulfate (a hematopoietic agent).On 01/24/24, the need to ensure an accurate and complete MAR was kept for all medications ordered by a legally recognized practitioner and administered by the facility was discussed with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 4 (RCC). They acknowledged the findings.2. Resident 14's MAR included four PRN medications which had been previously discontinued on 04/17/23. These were: * Haloperidol (for nausea, delirium, or hallucinations);* Hyoscyamine (for excessive secretions);* Lorazepam (for anxiety or agitation); and* Morphine (for shortness of breath or pain).On 01/24/24, the need to ensure an accurate MAR was kept for all medications administered by the facility was discussed with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 4 (RCC). They acknowledged the findings.
2. Resident 12 was admitted to the facility in 01/2024 with diagnosis including dementia. Resident 12's signed physician orders and 01/01/24 through 01/22/24 MAR were reviewed during the survey.Resident 12 was prescribed the following PRN medications for pain:* Acetaminophen 325mg;* Morphine 20mg/ml;* Oxycodone 5mg; and* Tramadol 50mg.The MAR failed to include clear parameters and instructions to unlicensed staff for when each medication should be administered.On 01/24/24, the need to ensure PRN medications included resident-specific parameters and instructions for use was discussed with Staff 1 (Executive Director). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed prior to use, including a thorough review by an RN, PT or OT, documentation of less restrictive alternatives, and instruction to caregivers on the correct use and precautions of the device, for 1 of 2 sampled residents (#3) who used potentially restraining devices. Findings include, but are not limited to:Resident 3 was admitted to the facility in 11/2020, with diagnoses including hypertension, acute renal failure, and dementia.On 10/09/23, Resident 3 was observed sitting in his/her "tilt-in-space" wheel chair. The resident stated s/he was comfortable using the chair, but was unable to adjust the position independently, requiring staff assistance for adjustments.In an interview on 10/09/23, Staff 16 (CG) stated Resident 3 used the specialized tilt wheel chair regularly and always required staff assistance for repositioning or adjustment of the device.There was no documented evidence the device with restraining qualities had been assessed prior to use by an RN, PT or OT, including documentation of less restrictive alternatives and specific instructions for staff. On 10/11/23, the need for an assessment of all devices with potentially restraining qualities was discussed with Staff 1 (Executive Director) and Staff 2 (RN/ Director of Health Services). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) was updated with significant changes of condition and the entries were reflective of the resident's current care needs for 1 of 4 sampled residents (#2) whose ABST was reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2023 with diagnoses including dementia.Observations of Resident 2, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas:* Dressing and undressing;* Transferring in or out of bed or chairs;* Personal hygiene including mouth care; * Bowel and bladder management tasks; and* Ambulation.On 10/11/23, the need to ensure the facility ABST was updated with each significant change of condition and the entries were reflective of the resident's care needs was discussed with Staff 1 (Executive Director). She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 150, C 231, C 252, C 260, C 262, C 270, C 303, and C 310.
Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 270.

Based on observation, interview, and record review, it was determined the facility failed to provide non-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 C150, C231, and C361.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 150, C 160, and C 231.

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

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 252, C 260, C 262, C 270, C 303, and C 310.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 270.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 5 of 5 sampled residents (#2, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:Residents 2, 3, 4, 5 and 7's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. On 10/11/23, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Executive Director) and Staff 2 (RN/ Health Services Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms which negatively impacted the resident or others in the community for 1 of 1 sampled resident (#4) with documented behaviors. Findings include, but are not limited to:Resident 4 moved into the facility in November 2021 with a diagnosis of dementia.Resident 4 was identified during the acuity interview as having behaviors which included exit-seeking and elopement, aggression, and inappropriate sexual behaviors toward other residents.A review of the resident's most recent service plan, dated 08/03/23, stated, "Follow responsive behavior plan." Staff 3 (RCC) reported the Behavior Plan document developed by a behavioral consultant and located in the service plan binder was the responsive behavior plan to which the service plan referred. The Behavior Plan, dated 08/03/23, was missing pages 2, 4, 6, 8, 10, and 11. Staff 3 reported the original copy was in the resident's hard chart and must have been copied wrong. The need to ensure behavior plans were included in the service plan for residents with behaviors which negatively impacted themselves and other residents in the community was discussed with Staff 1 (Executive Director), Staff 3 (RCC), and Staff 4 (RCC) on 10/11/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to:During a tour of the secure courtyard between the Walnut and Ivy neighborhoods on 01/22/24, it was observed the door entering and returning from the courtyard was locked. This prevented residents from accessing the secure courtyard without staff assistance, both going outside and returning indoors. Upon further investigation, it was determined the doors from all four neighborhoods to the secure courtyards were locked.On 01/22/24 the need to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (Executive Director). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:On 10/09/23, observations of the two enclosed courtyards revealed multiple pieces of furniture (chairs and side tables) made of polywood, which were easily moveable and not of sufficient weight or design to prevent elopement.During a walkthrough of the two courtyards on 10/10/23, the outdoor furniture was shown to Staff 1 (Executive Director) and Staff 6 (Maintenance Director), and the need to ensure furniture was of sufficient weight and design to not aid in elopement was discussed.

Based on observation and interview, it was determined the facility failed to ensure locking devices used on exit doors were electronic and released were the fire alarm or sprinkler system to be activated or in the event of a power failure to the facility. Findings include, but are not limited to:During a tour of the secure courtyard between the Walnut and Ivy neighborhoods on 01/22/24, it was observed the gate exiting to the perimeter of the property had a steel cable and a keyed padlock holding the door closed. The electronic locking device was loose from the fence post.In an interview on 01/22/24 with Staff 1 (Executive Director), she reported the electronic lock was not working and the facility had been attempting to get it fixed.The need for all exit doors to have electronic locking devices which released automatically in specific situations was discussed with Staff 1 on 01/22/24. She 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 04/12/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on interview and record review, it was confirmed that the facility failed to administer medications and prescribed. Findings include:Review of Residents 1(R1) medication administration records (MARs) and progress notes for March 2023 revealed medication not given medication not available. Review of Medication Management Policy.Interviews on 04/12/2023, Staff 1-3 stated there was concerns in March 2023 around medication being available due to reordering of medications. Plan of Correction:Facility has hired a Nurse Consultant to review MARs, update procedures, and train staff.

Based on interview and record review it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: During an interview on 04/12/2023 with Staff #1(S1) stated have not updated the ABST. Current census is 59. The ABST has 50 residents listed. S1 been working with ODHS to get staff access to the ABST. Review of ABST revealed 50 residents listed. Review of resident census revealed 59 residents.

The findings of the initial survey, conducted 2/8/21 through 2/9/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.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 cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey on 02/09/21, conducted from 05/12/22 through 05/13/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to report a resident-to-resident altercation to the local APS (Adult Protective Services) unit, for 1 of 4 sampled residents (# 1) reviewed with altercations. Findings include, but are not limited to:Resident 1 was admitted to the facility in 1/2020 with diagnoses including dementia and anxiety.Resident 1's records were reviewed during the survey and revealed s/he hit another resident in the stomach on 1/25/21. There was no documented evidence the incident had been reported to the local unit.On 2/9/21, Staff 1 (Executive Director) acknowledged the incident had not been reported to the local APS unit. Staff 1 immediately reported the incident and provided a copy to the survey team.

2. Resident 4 was admitted to the facility in 2021 with diagnoses including Alzheimer's disease.Physician orders initiated on 1/30/21 directed staff to administer Diclofenac Sodium Gel (pain relieving topical medication) four times a day for chronic pain. Between January 30th and February 4th, 2021 the resident received the medication as needed. On 2/5/21 the resident began receiving the medication as ordered.The failure to follow physician orders as directed was discussed with Staff 2 (Director of Wellness/RN) on 2/9/21 at 1:30 pm. Staff acknowledged the finding.
3. Resident 1 was admitted to the facility in 1/2020 with diagnoses including Dementia.Physician orders directed staff to administer Diclofenac Sodium Gel (pain relieving topical medication) four times daily as needed for joint pain. Use first for right knee or shoulder pain and Acetaminophen (oral pain reliever) to be used second if no relief in one hour from Diclofenac.Between 11/1/20 and 2/7/21 there were multiple times when the resident was treated for right knee and/or shoulder pain. However, there were times when either the medications were given at the same time, or only Acetaminophen was administered.The failure to follow physician orders as directed was discussed with Staff 2 (Director of Wellness/RN) on 2/9/21 at 10:35 am. She 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 3 sampled residents (#s 1, 4 and 5) whose orders were reviewed. Findings include, but are not limited to:1. Current physician's orders, the 2/1/21 - 2/8/21 MAR, and the progress notes for Resident 5 were reviewed and identified the following:Resident 5 had a physician's order, dated 1/19/21, for glucerna supplement to be administered twice daily for nutrition and weight stabilization. A review of Resident 5's 1/4/21 - 2/4/21 progress notes stated the order for glucerna had not been filled. Resident 5's February 2021 MAR verified s/he had not received the supplement. In an interview with Staff 2 (Director of Wellness/RN) on 2/9/21 at 12:15 pm, she verified that Resident 5's POA had ordered but there was a backlog on the order. The facility did not attempt to provide the supplement as ordered.The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 2 and Staff 3 (RCC) on 2/9/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner if a resident refused consent to an order for 1 of 1 sampled resident (#1) with refusals. Findings include, but are not limited to:Resident 1 was admitted to the facility in 1/2020 with diagnoses including CHF.Physician orders directed staff to weigh the resident every morning before breakfast and notify if the resident gained one pound a day and/or five pounds in one week.Resident 1's MARs from 1/1/21 through 2/7/21 were reviewed. The resident refused consent to daily weights 28 times during that time period.There was no documented evidence the facility notified the physician/practitioner when the resident refused consent to the orders.The facility's failure to notify the resident's physician of the refusals was discussed with Staff 1 (Executive Director) and Staff 2 (Health and Wellness Director/RN) on 2/9/21. They acknowledged the physician had not been notified of the refusals.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC) and did not provide Fire and Life safety training to staff on an alternating months. Findings include, but are not limited to:Fire drill records were reviewed on 2/8/21 with Staff 5 (Maintenance Director). The records indicated that fire drills conducted every other month lacked documentation of the following information: * Alternating escape routes used;* Evacuation time needed;* Staff member on duty and participating;* Number of occupants evacuated; and* Problems encountered and comments relating to residents' ability to participate.The need to ensure fire drills are completed according to the OFC rules and that Fire and Life safety training was provided to staff on an alternating months was reviewed with Staff 1 (Executive Director) and Staff 5 on 2/8/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:On 2/8/21 at 11:00 am a tour of the facility identified the following deficiencies:The doors to the outside courtyard area had no alarm or other system in place to alert staff when residents exited the building.On 2/9/21 the need to provide exit door alarms or another acceptable system to alert staff when residents exited was discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director). They both acknowledged the findings.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 231, C 420 and C 555

Based on interview and record review, it was determined the facility failed to ensure the required pre-service dementia training was completed prior to providing care and services independently for 3 of 3 memory care staff (#s 12, 18 and 19), failed to ensure direct care staff demonstrated competency within 30 days of hire for 1 of 3 memory care staff (#12) and failed to ensure annual training of 10 hours for the provision of care and 6 hours of dementia related care were completed for 3 of 3 staff (#s 12, 18 and 19). Findings include, but are not limited to:1. Facility's training records were reviewed on 2/9/21.a. Staff 12 (MT) hired 1/20/20, and Staff 18 (CG) hired 1/14/20 and Staff 19 (CG) hired 1/14/20, lacked documented evidence pre-service training was completed prior to providing care and services to residents including:* Resident Rights and values of CBC care;* Abuse reporting requirements;*Standard Precautions for infection control;*Fire safety and emergency procedures;*Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms;* Techniques for understanding, communicating, and responding to distressful behavioral symptoms;* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities;* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to: - Prevent wandering and elopement, and apply the memory care community's policies and procedures in the event a resident elopes; and- Use a person-centered approach for people with dementia.b. Staff 12 and 18 lacked documented evidence of pre-service training of the following:*Use of supportive devices with restraining quality in memory care.c. Staff 18 lacked documented evidence of pre-service training of the following:*How to provide personal care to a resident with dementia including an orientation to resident's service plan.d. Staff 19 lacked documented evidence pre-service training of the following:* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);* Family support and the role the family may have in the care of the resident;* How to evaluate behavior and what behaviors mean by observing, collecting information, and reporting behaviors that require on-going assessment; and lacked evidence of a written job description.2. Staff 12 (MT) hired 1/21/20 lacked documented evidence the following competencies were demonstrated within 30 days of hire: * Medication administration and treatments.3. Staff 12, 18 and 19 lacked documented evidence of the completion of required annual training of 10 hours for the provision of care and 6 hours of dementia related care for a total of 16 hours prior to their annual hire date anniversary.The need to ensure all pre-service dementia training was completed prior to providing care and services, direct care staff demonstrated competency within 30 days of hire and required 16 hours of annual training was completed was discussed with Staff 1 (Executive Director) on 2/9/21. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure health care services were consistently provided. Findings include, but are not limited to:Refer to C303 and C305

Based on interview and record review, it was determined the facility failed to develop and maintain an individualized plan for meaningful activities that promote or help sustain the physical and emotional well-being of residents for 2 of 5 sampled residents (#s 2 and 4) whose records were reviewed. Findings include, but are not limited to:On 2/8/21 review of service plans and evaluations for Resident 2 (move-in 6/17/20) and Resident 4 (move-in 1/30/21) identified the following deficiencies:The activity plans for both residents failed to adequately reflect the resident's preferences and needs in the following areas:*Past and current interests;*Current abilities and skills;*Emotional and social needs and patterns;*Physical abilities and limitations;*Adaptations necessary for the resident to participate; and*Identification of activities for behavioral interventions.On 2/9/21 the need to maintain an individualized plan for meaningful activities that promote or help sustain the physical and emotional well-being of residents was discussed with Staff 1 (Executive Director) and Staff 2 (Health and Wellness Director/RN). They acknowledged the findings.