Stephanie Gardens Residential Care

Based on interview and record review, conducted during a site visit on 07/09/25, the facility's failure to complete quarterly service plans was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to: A review of service plans for Resident 5 indicated there was a service plan completed on 10/02/23 and the next service plan available was dated 07/10/24. In an interview on 07/09/25, Staff 1 (Executive Director) stated s/he was unable to locate the service plans with signature pages or any indication that there were service planning teams present. S/He also confirmed there were no service plans completed between 10/02/23 and 07/10/24. The facility failed to complete quarterly service plans. The findings were reviewed and acknowledged by Staff 1.

Based on observation, interview, and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local SPD office or the local AAA as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse, and promptly investigate reports of abuse and suspected abuse related to unwitnessed falls for 1 of 3 sampled residents (# 2) whose incidents were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the memory care facility in 12/2022 with diagnoses including dementia. The resident's service plan, last updated on 07/10/24, incident reports, progress notes from 05/10/24 through 08/05/24, observations of the resident, and interviews with care staff identified the following: * 07/25/24: Unwitnessed fall; * 07/27/24: Unwitnessed skin tear; and * 07/28/24: Unwitnessed fall in the secured courtyard. The unwitnessed skin tear represented an injury of unknown cause which required reporting to the local SPD office or the local AAA as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the injury was not the result of abuse. The facility investigation for both unwitnessed falls failed to effectively rule out suspected abuse and include if the service planned fall interventions were being implemented at the time of the falls and there was no evidence the injury of unknown cause had been reported to the local SPD office as required. In an interview with Staff 1 (ED) on 08/06/24 at 10:20 am, the facility was requested to self report the above incidents. Verification was received on 08/06/24 at 11:49 am. The need to ensure all injuries of unknown cause were reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN) and Staff 7 (RCC) on 08/08/24 at 1:37 pm. They acknowledged the findings.

Incident reports will be closed out within 5 days and ruled out for abuse within 24 hours during investigation by RCC/Nurse/ED. Daily review during Clinical meeting M-F at 10am to investigate and document with RN/LN/RCC/ED Summary of the incident will be done by RCC/LN/RN/RD after reviewing cameras if possible, talking to med techs and caregivers that were involved and reviewing service plan. An overview of previous interventions will be reviewed and gone over if they are accurately working to prevent the incidents. A new TSP/intervention will be placed (looked over by RCC/LN/RN/ED in clinical meetings). ED to report all incidents that can not rule out abuse or neglect including injuries of unknown cause, unwitnessed falls, and any incidents that cannot be ruled out for abuse or neglect to APS within 24 hours. Regional health services or operations will be reviewing all IR's to make sure anything that is reportable is sent on a weekly basis All former incident reports were gone over and investigated for ruling out of abuse and neglect and reported if needed with the RCC/Nurse/ED. Resident 2 incident reports gone over, a safety plan put in place with interventions specific for resident.

2. Resident 4 was admitted to the facility in 03/2024 with diagnoses including hypertension and chronic kidney disease stage 3. Observations of the resident, interviews with staff and review of the most current service plan, dated 03/20/24 with revisions dated 08/05/24, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Customary routine; * Pain including PRN pain medications; * Supportive devices and use of side rails; * Eating meals/nutrition including where resident prefers to dine; and * Toileting routine. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN) and Staff 7 (RCC) on 08/08/24 at 1:20 pm. 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 and provided clear directions to staff regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2024 with diagnoses including type 2 diabetes mellitus, Alzheimer's disease and disorder of right external ear. Observations were made of the resident's care from 08/05/24 through 08/07/24. Interviews with facility staff and Witness 1 (family member) were conducted. Witness 1 sat with the resident three times a week for approximately two hours to assist with ADLs, including grooming. Resident 1 was unable to communicate clearly with facility staff but used gestures and short sentences to answer simple questions. The current service plan dated 07/29/24 was reviewed. Resident 1's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Number of staff needed to assist with activities of daily living; * Number of staff needed to assist with emergency evacuations; * Instructions on signs and symptoms of depression to report while on anti-depressant therapy; * Instructions to staff on blood glucose monitoring protocol when resident skipped meals; * Instructions on edema management; * Blood sugar monitor on left upper extremity, instructions for proper maintenance, and how to monitor malfunctions; * Instructions on specific changes of condition and complications to report to the outside provider; * Skin integrity and instructions on whom to report skin impairments; * Personality, including how the person copes with change or challenging situations; * Hearing and use of assistive devices; * Non-pharmaceutical interventions for pain, including how a person expresses pain or discomfort; * Behavioral problems; and * Instructions on fall prevention. The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN), and Staff 7 (RCC) on 08/08/24 at 12:30 pm. They acknowledged the findings. No further information was provided.

IDT- team to assist on service plan writing. Service Plan General-The need to ensure service plans are updated and are reflective of current care needs and provide clear instruction to staff. 1. ED/RCC/RN/LN/Regional team will be completing all service plans by 10/7/24. The service plans will consist of information relayed by care staff, residents, residents family or POA, RN/LN, RCC, and ED. ED will provide inservice to re-educate on 8/30/24 Nurse/RCC on creating a comprehensive and accurate care plan for admission, 30 day and quarterly after move in. HSD and RCC have completed an online training entitled Person Centered Care Planning for People Living with Dementia on Relias by 8/29/24. ED, HSD, and RCC have completed a webinar training on the Integrated Evaluations and Service Plans by 8/29/24. 2. ED, HSD and RCC will all participate in a check system for creation of all service/care plans. When the Level of Care evaluation is done by ED/HSD/RCC, then the other 2 staff will proof read them for thoroughness, individualized information and that all aspects of the care plan have specific instructions for staff. All signitures will be assisgned for each department of activities, resident care, nursing, ED and then service plans will be placed out in TSP book for review by care staff TSP book will be evaluated M-F during clinical meeting to ensure signitures of care staff is on service plans and information is being read. The dates for reevaluation will be entered correctly within Point click care (PCC) and the dashboard will be monitored triggering when the next service plan is due. 3. All service plans will be reviewed as due- initial, 30 day, 90 day and when a change of condition occurs. Otherwise, all care plans will be reviewed on-going every 90 days. For change of condition- tracking will be done through clinical white board in teams and gone over during clinical meetings.   4. Results will be reported to High Risk Meeting committee at next scheduled meeting (2nd Tuesday of each month). The ED/Designee all have responsibility in ensuring corrections are made and the system is maintained as outlined 5. Regional Director of Education or Regional RN will review all completed service plans for missing components once a month. For resident 4  service plan will be updated  for individualized ADL needs and current care needs by 9/15/24. Resident one has passed away since survey. ED completed a service plan 8/22/24

2. Resident 4 moved into the facility in 03/2024 with diagnoses including hypertension and chronic kidney disease stage 3. The resident's clinical record, including progress notes, temporary service plans, and incident reports, were reviewed and interviews were conducted. The following was identified: a. Resident 4's weight records reviewed from 04/2024 through 06/2024 noted a severe weight gain of 15.2 pounds, or 6.72% of his/her total body weight which constituted a significant change of condition. There was no documented evidence the facility evaluated the residents severe weight gain, documented the change and updated the service plan as needed. Refer to C 280. b. "Weekly Skin Assessment" documentation reviewed dated 06/05/24 through 06/25/24 noted the following short term change of condition: * 06/05/24 - Resident 4 reported to Staff 5 (RN) swelling of his/her ankles as documented in "Weekly Skin Assessment" which noted, "swollen ankle, pitting edema" for the right ankle and "swollen ankle, edema" for the left ankle. Resident 4 was observed during the survey with minimal swelling to the lower extremities with compression stockings on. In an interview with Resident 4 on 08/06/24 at 9:35 am s/he stated that compression stockings were being put on every morning and taken off every evening by staff. During an interview with Staff 5 (RN) on 08/07/24 at 2:45 pm they verified Resident 4's swelling was a change in condition and acknowledged there was no documented evidence actions or interventions had been developed, communicated to staff and monitored weekly through resolution. The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5, and Staff 7 (RCC) on 08/08/24 at 1:20 pm. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes mellitus, Alzheimer's disease and disorder of right external ear. Clinical records, including the current service plan, dated 07/29/24, temporary service plans, progress notes from 05/01/24 through 08/05/24, and outside provider notes were reviewed, and interviews with facility staff were conducted. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved: 05/04/24 - "New order for Acetaminophen 500 mg."; 05/08/24 - "Resident is now taking Cephalexin 500 mg ...due to Non-Purulent Skin and Soft tissue infection."; 05/10/24 - "Resident has been refusing to eat meals and claims s/he just wants to go to heaven."; 05/17/24 - "Resident is now to have 2 cartons of Boost Glucose Control Liquid Supplement drinks daily.."; 05/21/24 - "Resident is on alert for new medication order oxycodone and senna."; 05/22/24 - "new treatment orders for lower legs received."; 05/30/24 - " new antibiotic order clindamycin 300 mg cap."; 06/07/24 - "Resident expressed new behaviors of aggression."; 06/26/24 - "May crush tablets/open capsules as needed.."; and From 06/2024 - 07/2024 there were six occasions the resident's blood glucose level was below 70 mg/dl which constituted low CBG. The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN), and Staff 7 (RCC) on 08/08/24 at 12:30 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate, document the change and update the service plan as needed for a significant change of condition, and determine and document what actions or interventions were needed for short term changes of condition, communicated resident-specific instructions and interventions to staff on each shift, and monitored the change of condition at least weekly until resolved for 3 of 4 sampled residents (#s 1, 2, and 4) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including dementia and Alzheimer's disease. Resident 2's clinical records, including progress notes, incident reports, service plan and temporary service plans (TSP's) were reviewed, observations of the resident and interviews with staff were conducted during the survey. Resident 2's service plan with updates made on 05/05/24 indicated the resident was at risk for falls and had the following fall interventions: * At risk for falls due to inability to identify hazards in the environment; * Ensure floor is dry if [Resident] turns on water without staff assist; and * Staff to check on [him/her] often and encourage [him/her] to stay in common areas for increased supervision. a. The resident experienced the following non-injury and injury falls that lacked determined action or intervention communicated to staff, interventions reviewed for effectiveness and/or monitoring through resolution: * 05/16/24 - Unwitnessed injury fall in the common area dining room resulting in a bruise on the right shin; * 05/17/24 - Unwitnessed injury fall in another resident's room resulting  in a bruise to the right lower leg; and * 06/19/24 - Unwitnessed fall in the secured courtyard with injuries (skin tears, elbows, knees, top of head). There was no evidence the facility reviewed the previous service planned interventions to ensure their was increased supervision in the common area and developed new interventions to reduce the potential for future injury falls. * On 06/28/24 - Witnessed fall with skin tear to the right elbow. On 06/29/24 a TSP was written that included the following fall intervention: * Make sure dining room was safe to walk around and that resident was not picking up or dragging chairs, or tripping over other resident walkers/belongings. * On 07/16/24 - Witnessed resident tripped and fell over a small "kitty" pool in the secured courtyard and sustained bruising; and * On 07/21/24 - Unwitnessed fall in the dining room resulting in a skin tear to the right elbow. There was no evidence the facility reviewed the previous service planned intervention to ensure hazards were removed from the environment and to make sure the dining room was safe to walk around to reduce the potential for future injury falls.   b. Resident 2 had the following changes of condition that lacked determined action or intervention communicated to staff on each shift and/or monitoring at least weekly through resolution: * On 07/27/24 - Skin tear on the right arm; and * On 08/02/24 - On alert for possible pain in left hip; and * From June 2024 to July 2024 the resident lost 4.8 % of total body weight within one month. The need to ensure interventions were developed in response to changes of condition, the interventions were communicated to staff on all shifts, and were monitored for effectiveness and monitored at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN) and Staff 7 (RCC) on 08/08/24 at 1:37 pm. They acknowledged the findings.

Regional RN will be hosting a weekly training on Mondays and review alert close out notes with community RN. RCC will audit Alerts charting for daily completion and  follow up with med techs who are not completing alert charting. The need to ensure actions or interventions are determined, documented, and communicated to staff following a short/long term change of condition, that the resident is monitored following the change of condition and potential significant changes of condition are evaluated and referred to the facility nurse. 1. ED, HSD and RCC will evaluate and document all necessary interventions for Res 2 related to falls and any skin issues by 8/30/24.            Going forward process will be           A. Nurse will assisgn skin assessment weekly to those with skin issues and follow up with a form/note           B. RCC/HSD/ED to review interventions and document if successful or not and place new TSP with changes on weekly COC notes.           C. RCC/HSD/ED to make sure interventions are placed into service plan during High Risk meetings. Also looking over former interventions to discontinue if not improving.           D. Community RN to chart on COC resident weekly and complete form.           D. During Clinical meeting weekly will go over residents placed in clinical white board for COC monitoring               E. Incidents and 24 hour report gone over during clinical meeting daily with clinical team with intervention overview. RCC to make sure signitures from staff are being obtained on each TSP in clinical meeting 2. ED/Designee will reeducate the HSD/RCC's on company guidleines for Change of Condition and the need to ensure all actions/interventions regarding a change of condition are documented,TSP's are completed, RN assessement is completed, and staff notified by 8/30/24.           A. RN/RCC/Designee will reeducate all clinical staff on company guidelines for Change of Condition and the need to ensure all actions/interventions regarding a change of condition are documented and TSP created. Occurring on Thursday 9/5/24 during med tech meeting and ongoing. 3. The ED/Regional RN will also monitor the clinical white board spreadsheet at minimum twice a month to ensure it is up to date and accurate. 4. Results will be reported at high risk meeting monthly on the second tuesday. The ED/Designee all have responsibility in ensuring corrections are made and the system is maintained as outlined. Resident 2 is currently being monitored for COC weekly with nurse and interventions being monitored. Resident 4 has a new basline established, daily weights monitoring to continue due to diagnosis. Resident 1: Has passed away since survey

Based on observation, interview, and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status and interventions, for 1 of 2 sampled residents (#4) who experienced a significant change of condition.  Resident 4 experienced severe weight gain followed by a hospital stay. Findings include, but are not limited to: Resident 4 was admitted to the facility in 03/2024 with diagnoses including hypertension and a recent diagnosis of congestive heart failure. Resident 4 was observed during the survey with minimal swelling to the lower extremities with compression stockings on. In an interview with Resident 4 on 08/06/24 at 9:35 am, s/he stated that compression stockings were being put on every morning and taken off every evening by staff. Resident 4's clinical record, including, but not limited to, the current service plan, revised on 08/05/24, progress notes dated 05/31/24 through 08/05/24 and weight records from 04/2024 through 08/08/24 were reviewed. Resident 4's weight records noted the following: * 04/2024 - 221.2 pounds; * 05/2024 - 226.2 pounds; and * 06/2024 - 241.4 pounds. Between 05/2024 and 06/2024, Resident 4 gained 15.2 pounds, or 6.72% of his/her total body weight in one month, which was considered severe and triggered a significant change of condition. In an interview with Staff 5 (RN) on 08/08/24 at 10:45 am, he stated he became aware of the swollen ankles on 06/05/24 when Resident 4 reported s/he noticed swelling in her/his ankles. Staff 5 completed weekly skin assessments and noted the following: * 06/05/24 - "swollen ankle, pitting edema" for the right and "swollen ankle, edema" for the left; * 06/12/24 - "swollen ankle, pitting edema" for the right and "swollen ankle, edema" for the left. Note continued "will continue to assess weekly, [provider] notified today and she will assess legs as well."; * 06/19/24 - Progress note stated, "This RN called [provider] to inform them that this resident has been complaining of swollen legs." * 06/25/24 - "swollen ankle, pitting edema" for the right and "swollen ankle, edema" for the left. Note continued "Residents new baseline, PCP called...This RN will take off weekly skin assessments due to baseline unless [provider] advises differently." A progress note dated 06/27/24 stated "Resident was sent out around 8:00 am to [the hospital]. [Provider] was called first but by the time the [provider] called, resident was unresponsive. Resident was out of breath, lips and whole face were purple. BP (77/34 P 120 Ox2 69)." There was no documented evidence an RN assessment had been completed which included findings, resident status, and interventions, when the resident had a severe weight gain. The resident became unresponsive, required a hospital stay and returned to the facility on 06/28/24 with new diagnoses including congestive heart failure and pulmonary hypertension. Resident 4's weight during the time of the survey was noted to be 230.5 pounds and the resident's weight has been taken daily since the hospital stay. In an interview on 08/07/24 at 2:45 pm, Staff 5 confirmed he was aware of the severe weight gain and confirmed an assessment had not been completed. The need to ensure all significant changes of condition were assessed by an RN, with documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5, and Staff 7 (RCC) on 08/08/24 at 1:20 pm. They acknowledged the findings.

Weights will be reviewed by clinical team during high risk meeting on the second Tuesday of every month with regional nurse.  Community nurse will now oversee that all residents with a weight loss/ gain within 1 month, 5% Greater than 5%, 3 months, 7.5% Greater than 7.5%, 6 months, 10% Greater than 10%.  Any weights triggered will go on alert monitoring for weight loss, have intervention of weekly weights added and meal monitoring for 72 hours. 1. Weights will be obtained at the beginning of the month by care staff, Med techs, RCC, and RN (1st-5th). Tracking to be placed into weight chart that will prompt any weight loss/gain betweeen 1/3/6 months and percentages of loss within state guidelines.               A. weights will be completed for high risk meeting second Tuesday of each month with Regional RN/RN/RCC/ED. 2. If weight loss/gain is seen, resident will be placed by RN on alert monitoring for weight loss, have interventions placed, weekly weight and 72 hour monitor of meal intake. 3. Refer to C270 for change of condition requirements 4.  Notification to the PCP by Medtech/RCC/RN for further evaluation and recommendation. Monitored each month during High Risk meeting with ED and RN Resident 4 is being monitored daily for weights and will be notified by med tech to nurse of significant changes.

3. Resident 2 moved into the memory care community with diagnoses including Alzheimer's disease and unspecified dementia. The resident's 07/01/24 through 08/05/24 MARs and physician's orders were reviewed and identified the following: Resident 2 had physician orders to administer morphine oral solution, take 0.25 ml by mouth every hour as needed for pain. Call hospice before first dose. The facility administered the morphine PRN on 07/25/24, 07/29/24 and 08/02/24. There was no documented evidence hospice was notified prior to administering the PRN morphine on 07/25/24 and 07/29/24. The need to ensure the facility followed physician orders was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN) and Staff 7 (RCC) on 08/08/24 at 1:37 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 03/2024 with diagnoses including hypertension and chronic kidney disease stage 3. The resident's 07/01/24 through 08/05/24 MARs and physician's orders were reviewed and revealed the following: Resident 4 had physician orders for blood pressure readings to be done twice daily prior to administering Lisinopril 20 mg (for hypertension). The physician's orders gave unlicensed staff parameters to hold the medication for systolic blood pressure below 110. Review of the MAR revealed staff administered the medication when the systolic blood pressure was below 110 on four occasions during the month of 07/2024. The 07/2024 MAR was reviewed with Staff 16 (MT) and she stated it "looks to have been administered based on the MAR" and provided no further information. The need to ensure the facility followed physician orders was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN) and Staff 7 (RCC) on 08/08/24 at 1:20 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 2 and 4) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2024 with diagnoses including Type 2 diabetes mellitus, Alzheimer's disease and disorder of right external ear. Review of Resident 1's current physician orders and MARs from 06/01/24 through 08/05/24 revealed the following: * Lispro 100 U/ml insulin was ordered for injection six units subcutaneously after breakfast and dinner to control blood glucose level with instructions to hold if blood glucose level was less than 150. There was no documented evidence insulin was held based on these instructions on two occasions; and * Glargine Solostar 100 U/ml insulin was ordered for injection 25 units subcutaneously once nightly to control blood glucose with instructions to hold if blood glucose level was less than 100. There was no documented evidence insulin was held based on these instructions on three occasions. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN), and Staff 7 (RCC) on 08/08/24 at 12:30 pm. They acknowledged the findings.

Facility failed to ensure physician orders were carried out as prescribed. 1. RN will review MARs and ensure meds will have appropriate parameters and interventions. 5 MAR's per week will be audited after completion of all residents, going forward MARs will be audited during quarterly service plan. 2.ED performed inservice on 8/30/24 with RN/RCC on Medication Management, following physician orders, and medication availabilty guidelines per company policy. 3. RCC/RN/ED will review the medication variance report on PCC 3X weekly to determine if any medications were held, why they were held and if the MD was notified as required. 4. A med tech training will be held monthly to review on-going issues and provide skills training. The first meeting will be held on 9/5/24. Training will include appropriately following medication parameters and when to notify the MD. For the next 60 days, weekly meetings with specific med techs will be completed with RN/RCC/Regional RN to review orders that were processed the previous week to check for errors. 5. ED/Regional RN will audit variance reports bi-weekly to provide additional oversight for parameters and MAR's. 6. EMAR audits/ reconcilation will be completed by RN/RCC/Designee every month. 7. MAR's will be audited during service plan updates and quarterly PO send out by community RN. 8. ED and RN have responsibility in completing corrections and ensuring the systems are maintianed and remain in compliance. Residents 2 and 4 MAR/TAR's will be reviewed and audited by 9/25/24 Resident 1 has passed away since survey

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 2 sampled residents (#6) who chose to self-administer their medications. Findings include, but are not limited to: Resident 6 moved into the facility in 03/2024 with diagnoses including Type 2 diabetes. During the acuity interview on 08/05/24, staff reported the resident self-administered their medications. During an interview with Staff 1 (ED) on 08/06/24 at 8:28 am, surveyor requested a self-administration of medications evaluation and a signed physician order. The facility provided an evaluation that was completed on 08/05/24. There was no documented evidence the facility evaluated the resident's ability to safely administer his/her own medications upon move in and quarterly thereafter. The facility failed to have signed physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications. The need to ensure the facility updated the self-administration of medications evaluation quarterly and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN) and Staff 7 (RCC) on 08/08/24 at 1:37 pm. They acknowledged the findings.

Community Nurse has completed all self med assessments and they are now up to date as of 8/20/24. ED/RCC/Nurse  reviewed forms to be accurate quarterly with Service plan review. Self med assessments to be done quarterly by Nurse or as needs change. A order in MAR will be placed fo self medication administration. Physician orders for self med administration will be requested and received upon move in. Going forward will be placed on MAR so that 90 day physician orders will be signed with self medication order. Nurse  to ensure all physican orders are received for self med administration with assessment Self med assessment for residents 6 has been completed and order from physician for self med admistration has been received.

Based on interview and record review, it was determined the facility failed to ensure medications that were given to treat a resident's behavior had written, resident-specific parameters, included when to contact a health professional regarding side effects, and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#2) who was prescribed and administered a PRN psychotropic medication. Findings include, but are not limited to: Resident 2 was admitted to the facility in 12/2022 with diagnoses including Alzheimer's disease, unspecified dementia and generalized anxiety disorder. A review of the resident's 07/01/24 through 08/05/24 MARs and 05/05/24 through 08/05/24 progress notes identified the following: Resident 2 had an order for Lorazepam 0.5 mg every day four hours as needed for anxiety. The Lorazepam PRN dose was administered on 07/18/24, 07/23/24, 07/27/24, and 07/29/24. On 07/23/24 and 07/29/24 direct care staff documented on the MAR that the PRN was ineffective. During an interview with Staff 11 (MT) on 08/07/24 at 1:20 pm it was confirmed there was no documented evidence non-pharmacological interventions had been tried first with ineffective results prior to giving the PRN medications, there were no instructions for when to contact a health professional regarding side effects and there were no resident-specific parameters instructing staff what to do when the PRN dose was ineffective. The need to ensure PRN medications given to treat a resident's behaviors had written non-pharmacological interventions which had been tried with ineffective results prior to administration and included instructions for when staff were to contact a health professional with side effects was discussed with Staff 1 (ED), Staff 2 (Regional Director of Operations), Staff 3 (Regional RN), Staff 4 (Regional Director of Training), Staff 5 (RN) and Staff 7 (RCC) on 08/08/24 at 1:37 pm. They acknowledged the findings.

The need to attempt non-pharm interventions prior to administering PRN psychotropic medications. 1. All residents on PRN Psychotropics will receive an audit for resident centered interventions and instructions added for steps to follow if the medication is ineffective or with side-effects.  This audit will be complete within 14 days by RN 2. Facility will continue process of requiring MT to make an observation note after giving a PRN psychotropic medication to document interventions used and if they were effective or not.   3.RN/Designee will reeducate all med techs meeting the regulation to ensure prn interventions are used and documented, prior to the admnistration of any psychotropic medications, training to be completed by 10/7/24 . 2. All PRN psychotropic medications will be processed through triple check system. RN on third check will assure that individualized interventions are added to the order before it is approved. 3. RCC will pull daily medication prn administration reports to review for admnistration of these meds and documentation of effectiveness and interventions. 4. RN will conduct a monthly MAR audit to ensure all medicaitons that require nursing parameters, interventions, order of administration, etc. are placed in MAR Resident 2 MAR will be updated with interventions and parameters by 9/25/24

Based on observation and interview, it was determined the facility failed to ensure interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to: During a tour of the interior of the facility on 08/05/24 at 9:20 am, carpet throughout the common area hallway of the second floor and stairwells were stained throughout. A large tear in the flooring of the medication room on the first floor was observed which created an uncleanable surface. The surveyor toured the environment with Staff 8 (Maintenance Director) on 08/07/24 at 2:00 pm. He acknowledged the findings.

The need to ensure the environment was clean, in good repair. 1. Maintenance Director will inquire with outside vendor about repairing the floor in the med tech room and schedule the repair to be completed. 2. Carpet cleaning company came in and did a commercial cleaning of carpet floors and stairways on the second floor on 8/19/24             A. Going forward Summit carpet cleaning is scheduled every quarter for carpet cleaning and annualy for all flooring in the building. 3. MD will maintain spot cleaning as needed for spots to the second floor carpet. 3. MD and ED will conduct a building walk-through once a month to identify areas that need repaired or replaced, specifically focusing on "uncleanable surfaces. 4.Monthly Safety Committee for maintenece needs will be on the 25th of every month prior to staff meeting. MD and ED will follow up with needs that arise prior to next meeting.

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 231 and C 513.

Please refer to C231 C513 for response

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, C 280, C 303, C 325, and C 330.

Please refer to C: 260, 270, 280, 303, 325, 330 for response

The findings of the change of ownership survey, conducted 08/05/24 through 08/08/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 08/08/24, conducted 12/18/24 through 12/19/24, 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 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 facility main kitchen, food storage areas, food preparation, food service, and the Residential Care kitchenette area on 12/05/23 noted a buildup of splatters, spills, drips, and debris on:   - Interior of reach in refrigerators and freezers; - Exterior and interior of ice machine; - Stand mixer; - Walls in food preparation areas; - Interior of the Residential Care microwave; - Can opener casing and blade; - Exterior, sides, beneath, and behind the gas range and oven; - Open shelving - surfaces, legs, and underneath; and -  Equipment throughout kitchen. * There were undated and unlabeled foods in refrigerators. * Raw eggs were stored on the top shelf above produce. * Packaged foods were not dated when opened. * Scoops were left in bulk bins of foods. * Dented cans were noted in the upstairs dry storage area. * The ice machine had a leak creating a puddle on the floor. * There was not a small diameter probe thermometer to measure thin foods. * Sanitizer buckets were observed with insufficient water to submerge towels. * Staff were unaware of how to use sanitizer strips for the low temp dish sanitizer and the sanitizer buckets. * Staff preparing food did not have hair restrained. * Dish racks were stored directly on the floor. * Staff washing dishes did not remove gloves and wash hands between rinsing and loading dirty dishes and putting away clean dishes. * Caregiving staff, who assisted residents with incontinent care, did not use aprons while serving food. * Staff were observed to not wash hands upon entry to the kitchen. * Garbage cans did not have lids to use when not in use. * The back door to the kitchen was left open allowing for the entry of pests. Staff 1 (Executive Director) and the surveyor toured the kitchens on 12/05/23. Staff 1 acknowledged the food storage issues and the kitchens needed cleaning.

Dietary aide will clean; interior of reach in refrigerators and freezers, exterior and interior of ice machine, stand mixer, walls in food preparation areas, interior of the residential care microwave, can opener casing and blade, exterior, sides, beneath, and behind, the gase range and oven, open shelving- surfaces, legs and underneath, and equipment through the kitchen, if splatters, spills, drips and debri are found. If no spillage or debri is found dietary aide will still document that the area was monitored. Signed documentation on a log will be used to ensure duties are completed. Diatery Manager/ED will monitor logs weekly to ensure duties are being done correctly. Food will be labeled and dated when opened and placed in the refrigerator. Dietary staff will be educated by an inservice training. Dietary Manager/ED will monitor labeling weekly for task completion. Raw eggs have been moved to the bottom shelf of the refrigerator. Dietary taff will be educated on placing eggs on the bottom shelf when putting away deliveries by an inservice training. Packaged foods will be labeled and dated when opened. Dietary staff will be educated by an inservice training. Dietary manager/ED will monitor labeling weekly for task completion. Scoops have been removed in bulk bins of food. Staff will be educated by an inservice training. Dietary manager/ED will monitor labeling weekly for task completion. Dented Cans have been removed and placed in a designated area. Dietary staff will monitor weekly for dented cans at deliveries and move them into designated area. Dietary staff will be educated on procedure by inservice training. Dietary Manager/ED will monitor weekly that cans have been removed. Ice machine leak has been fixed with no observation of further leakage. Dietary Manager/ED will monitor monthly for proper function of the ice machine and sign off on the documention log binder. Community has purchased and received a small diameter probe thermometer to measure thin foods. Dietary staff will be educated on where to locate the small diameter probe thermometer by inservice training. Dietary manager/ED will monitor weekly to ensure thermometer is in working condition. Sanitization buckets have sufficient water to submerge towels. Dietary staff will be educated on how much water to place into the sanitization buckets by an inservice training. Dietary Manager/ED will monitor task compentency monthly and document in log binder. Dietary staff will be educated on how to use sanitizer strips for the low temp dish sanitizer and the sanitizer buckets. Education will be in the form of inservice training. Dietary staff have been privided Hair nets and hats to restrain hair. Dietary manager/ED will monitor and document in log book weekly for proper uniform Dish racks will be placed in designated shelf near dish shelf. Dietary staff will be educated on the proper placement of the dish racks by an inservice training. Dietary Manager/ED will monitor weekly and document completion of task in log book. Staff will be educated when washing dishes that they will remove gloves and wash hads between rinsing and loading dirty dishes and putting away clean dishes by inservice training. Dietary Manager/ED will monitor weekly and document completion of task in log book. Health Services and Dietary staff will be be educated on wearing aprons when staff are handeling food after providing incontinence care by inservice training. Dietary Manager, ED and RCC will monitor Weekley for compliance and document in log book. All staff will be educated to wash hands when entering a food preperation area by inservice training. ED/Dietary Manager/RCC will monitor weekly and document in log book of proper completion of task. Garbage cans have proper lids to use when not in use. Dietary Manager will monitor proper and functional garbage lids weekly and document in log. Magnetic screen door will arrive and be installed in Kitchen to prevent entry of pests when kitchen door to the outside is open 12/22/2023. Dietary Manager will monito the condition of the magnetic screen door Monthly and documnt in log book.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The facility's main kitchen in the MCC, the "Warming Kitchen" in the RCF, and the refrigerator in the MCC dining room were observed on 02/23/24. a. Observation of the facility's reach-in refrigerators revealed the following foods were not dated, and/or labeled appropriately: * Meat and bean mixture; * Individual fruit servings; * Marshmallow and fruit desserts; * Sandwiches; * Coffee cake slices; * Desserts with whipped topping; and * Individual cups of unidentified food items. b. The garbage can near the prep area in the facility's main kitchen remained uncovered when not in use and did not have a lid. c. The back door to the kitchen was left ajar allowing for the entry of pests. The facility had installed a magnetic screen door; however, it did not extend the length of the doorframe and was not closed. d. Staff were unaware of how to test and which sanitizing testing strips to use for the solution in the sanitizing buckets. e. Staff washing dishes were observed to not wash hands between rinsing dirty dishes and shelving clean dishes. f. A moldy cantaloupe was observed in storage, and an open container of a cream based dressing was observed unrefrigerated in the dry storage area. The kitchens were toured with Staff 4 (Dietary Manager) on 02/23/24. Photographs and a discussion of the findings occurred with Staff 1 (ED) and Staff 4 on 02/23/24 at 11:39 am. They acknowledged the findings.

Plan of correction for Stephanie Gardens annual kitchen inspection 1. Concerning foods not labeled and dated appropriately- Plan in place and policy moving forward is as follows a. All snacks scheduled to go out at 10 am, 3pm, and 7 pm, Noc shift are to be labeled and dated by dietary aide preparing them.  The Snacks are to be rotated and used following the FIFO method and tossed after 3 days. Floor aides were instructed to date and label any items placed in warming kitchen refrigerator. The CDM/CFPP will do audits daily for 30 days, Weekly Audits going forward, administrator will do audits weekly, and the corporate director of dining services will do audits monthly to ensure policy is followed. CDM/CFPP has added this to weekly audit and logged in QA binder. Start Date 3/5/24 b. The unlabeled snacks that surveyor took picture of were from the previous day and were thrown out and new snacks made by CDM/ CFPP, dietary aides showed correct procedure for making snacks moving forward. Floor aides were instructed to date and label any items placed in warming kitchen refrigerator.   The correction for the system was demonstrated in a mandatory kitchen meeting held 3/5/24 by both CDM/CFPP and Corporate Director of Dining Services. The new system was in place 3/5/24.   2.  Concerns with garbage can near prep area Plan in place and policy moving forward is as follows   a. Stephanie Gardens purchased three Rubbermaid "hands free" garbage cans that were delivered 3/11/24. These have attached lids that open and close with a footstep on method. The CDM/CFPP will monitor weekly checks on garbage cans to ensure they are working to ensure 24/7 closed lids unless the footstep action is in play.     2. Concerns with door ajar- Plan in place and policy moving forward is as follows a. The hanging screen has been added 3/5/24 to create a top-to floor screen with magnets to close the screen from top to bottom. The Staff will not prop door open without ensuring screen is properly closed.   b. The correction for the system was demonstrated in a mandatory kitchen meeting held 3/5/24 by both CDM/CFPP, Maintenace Director and Corporate Director of Maintenance and Corporate Director of Dining Services. The new system was in place 3/5/24.       Plan of correction for D- F D- The correct use of sanitizing strips- The correction for the system was demonstrated in a mandatory kitchen meeting held 3/5/24 by both CDM/CFPP and Corporate Director of Dining Services. The new system was in place 3/5/24. CDM/CFPP called Chemical company to set up a quarterly training going forward to ensure the sanitizer and strips are correctly used for testing. CDM/CFPP has added this to weekly audit and logged in QA binder. Start date 3/5/24. E- Staff not washing hands between rinsing dirty dishes and shelving clean dishes- The correction for the system was demonstrated in a mandatory kitchen meeting held 3/5/24 by both CDM/CFPP, Maintenace Director and Corporate Director of Maintenance and Corporate Director of Dining Services. Where CDM/CFPP demonstrated the correct way to handwash between clean/ dirty dishes.  The new system was in place 3/5/24. The CDM/CFPP will do audits daily for 30 days, Weekly Audits going forward, administrator will do audits weekly, and the corporate director of dining services will do audits monthly to ensure policy is followed. CDM/CFPP has added this to weekly audit and logged in QA binder. Start Date 3/5/24   F- Moldy Cantaloupe - All "room temperature" produce will be placed in proper bins and dated upon receiving. All food shall be kept in a "temperature controlled" area and monitored daily by cook that is on, the CDM/CFPP will audit as follows. The CDM/CFPP will do audits daily for 30 days, Weekly Audits going forward, administrator will do audits weekly, and the corporate director of dining services will do audits monthly to ensure policy is followed. CDM/CFPP has added this to weekly audit and logged in QA binder. Start Date 3/5/24

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

Dietary aide will clean; interior of reach in refrigerators and freezers, exterior and interior of ice machine, stand mixer, walls in food preparation areas, interior of the residential care microwave, can opener casing and blade, exterior, sides, beneath, and behind, the gase range and oven, open shelving- surfaces, legs and underneath, and equipment through the kitchen, if splatters, spills, drips and debri are found. If no spillage or debri is found dietary aide will still document that the area was monitored. Signed documentation on a log will be used to ensure duties are completed. Diatery Manager/ED will monitor logs weekly to ensure duties are being done correctly. Food will be labeled and dated when opened and placed in the refrigerator. Dietary staff will be educated by an inservice training. Dietary Manager/ED will monitor labeling weekly for task completion. Raw eggs have been moved to the bottom shelf of the refrigerator. Dietary taff will be educated on placing eggs on the bottom shelf when putting away deliveries by an inservice training. Packaged foods will be labeled and dated when opened. Dietary staff will be educated by an inservice training. Dietary manager/ED will monitor labeling weekly for task completion. Scoops have been removed in bulk bins of food. Staff will be educated by an inservice training. Dietary manager/ED will monitor labeling weekly for task completion. Dented Cans have been removed and placed in a designated area. Dietary staff will monitor weekly for dented cans at deliveries and move them into designated area. Dietary staff will be educated on procedure by inservice training. Dietary Manager/ED will monitor weekly that cans have been removed. Ice machine leak has been fixed with no observation of further leakage. Dietary Manager/ED will monitor monthly for proper function of the ice machine and sign off on the documention log binder. Community has purchased and received a small diameter probe thermometer to measure thin foods. Dietary staff will be educated on where to locate the small diameter probe thermometer by inservice training. Dietary manager/ED will monitor weekly to ensure thermometer is in working condition. Sanitization buckets have sufficient water to submerge towels. Dietary staff will be educated on how much water to place into the sanitization buckets by an inservice training. Dietary Manager/ED will monitor task compentency monthly and document in log binder. Dietary staff will be educated on how to use sanitizer strips for the low temp dish sanitizer and the sanitizer buckets. Education will be in the form of inservice training. Dietary staff have been privided Hair nets and hats to restrain hair. Dietary manager/ED will monitor and document in log book weekly for proper uniform Dish racks will be placed in designated shelf near dish shelf. Dietary staff will be educated on the proper placement of the dish racks by an inservice training. Dietary Manager/ED will monitor weekly and document completion of task in log book. Staff will be educated when washing dishes that they will remove gloves and wash hads between rinsing and loading dirty dishes and putting away clean dishes by inservice training. Dietary Manager/ED will monitor weekly and document completion of task in log book. Health Services and Dietary staff will be be educated on wearing aprons when staff are handeling food after providing incontinence care by inservice training. Dietary Manager, ED and RCC will monitor Weekley for compliance and document in log book. All staff will be educated to wash hands when entering a food preperation area by inservice training. ED/Dietary Manager/RCC will monitor weekly and document in log book of proper completion of task. Garbage cans have proper lids to use when not in use. Dietary Manager will monitor proper and functional garbage lids weekly and document in log. Magnetic screen door will arrive and be installed in Kitchen to prevent entry of pests when kitchen door to the outside is open 12/22/2023. Dietary Manager will monito the condition of the magnetic screen door Monthly and documnt in log book.

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

Based on observation, interview, and record review, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

The findings of the kitchen inspection, conducted 12/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection survey of 12/05/23, conducted 02/23/24, 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 second revisit to the kitchen inspection of 12/05/23, conducted 04/29/24, 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 interview and record review, it was determined the facility failed to thoroughly investigate incidents to rule out suspected abuse or neglect for 1 of  2 sampled residents (# 2) who experienced falls. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia. Progress notes dated 06/01/22 through 06/27/22, an Incident Reporting Form dated 06/15/22 and 05/27/22 move-in evaluation and service plan were reviewed and revealed the resident experienced a fall on 06/15/22. The resident's move-in evaluation and service plan noted s/he should be checked for safety and location in an attempt to prevent falls and unmet needs. On 06/15/22 facility staff charted "At around 6:00 this MT found resident lying on the ground" and "...this MT observed resident and noticed an open gash on resident's left side elbow..." The facility lacked documented evidence of a thorough investigation to rule out abuse and neglect as a cause of the resident's injury. The need to thoroughly investigate Resident 2's injuries to rule about abuse and neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 06/29/22. They acknowledged the findings.

1.  The RN added additional information to the sample resident's chart to clarify that she had no reason to suspect abuse and her rationale for that opinion.   2.  The RN, Administrator, or designee will investigate all injuries of unknown cause in a timely fashion.  Documentation of the investigation will include: time, date, place, individuals present, description of the event as reported, response of staff at the time of the event, follow up actions, if and how abuse is ruled out, and Adminstrator's follow-up.  If abuse is not ruled out, the incident will be reported to SPD, AAA, or law enforcement agency.    3.  The Administrator will ensure compliance to the POC as he/she processes and reviews incident reports in each resident's records.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required components for 1 of 2 sampled residents (#1) who were recently admitted to the facility. Findings include, but are not limited to: Resident 1 was admitted to the facility in 05/2022. The move in evaluation was reviewed and failed to address the following components: * Spiritual preferences; * Cognition including confusion; * Personality including how the person copes with change or challenging situations; * Complex medication regimen; and * Recent losses. The need to ensure move in evaluations included all required components was discussed with Staff 1 (ED) on 06/29/22. She acknowledged the findings.

1.  The community has added spiritual preferences, cognition including confusion, personality including how the person copes with change or challenging situations, complex medication regimen, and recent losses to the sampled resident's evaluation. 2.  The community has updated the Resident Evaluation tool to prompt the person documenting the evaluation to include all elements required in the rule.   3.  Upon consideration for admission, all potential residents will be evaluated, the required information will be added to the evaluation software which will generate the Individualized Service Plan 4.  Existing residents' evaluation tools will be converted to the updated version, with their quarterly Service Plan, and as needed in the case of changes.   5.  The Administrator will ensure compliance with each Service Plan Review.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when necessary, for 1 of 3 sampled residents (#2), who experienced a change of condition. Resident 2 experienced a fall which resulted in fracture of the left elbow. The resident continued to experience pain and loss of function for several days before being sent to the emergency room. Findings include, but are not limited to: Resident 2 was admitted to the MCC in 06/2022 with diagnoses including dementia. The resident's progress notes, incident reports and interim service plans (ISP's) were reviewed and revealed the following: * A 06/15/22 progress note and Incident Reporting Form indicated the resident experienced an unwitnessed fall on the same date resulting in a "open gash on resident's left elbow." * 06/15/22 The resident was placed on alert for the fall and injury to the left elbow, staff were informed via ISP to notify the RN and Med Tech if the resident was not using the left arm and had increased pain or swelling; * Daily documentation between 06/15/22 and 06/20/22, the resident was noted to experience pain or discomfort while completing ADL's; * 06/20/22 An RN assessment was completed and the resident was removed from alert for the injury to the left elbow; * 06/22/22 An RN assessment was completed and the resident was placed on alert due to increased edema and swelling in the left hand; * 06/23/20 A progress note transcription from the resident's Physical Therapist noted " ...unable to use the left arm to assist due to pain and swelling of this arm after fall ..." after consultation with the residents PCP, the resident was referred to be seen at an urgent care facility; and * 06/24/22 The resident was seen at the emergency department and diagnosed with a fracture to the left elbow.  The facility failed to evaluate and refer the resident's increased pain during ADL's to the RN for assessment. As a result, the resident continued to experience pain. The need to ensure Resident 2's change of condition was evaluated and referred to the RN was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 06/29/22. They acknowledged the findings.

1.  The RN added documentation to the sampled resident's record to confirm that she had evaluated the resident several times and did not suspect a fracture. The resident was sent to urgent care when his/her condition changed.    2.  All changes of condition will be referred to the RN for review, documentation, and any necessary directions to staff for management. 3.  The RN, Administrator, and RCC will review compliance with change of condition monitoring with Service Plan Reviews.

Based on observation and interview, it was determined the facility failed to ensure all materials and surfaces were clean and in good repair. Findings include, but are not limited to: The first and second floors were toured on 06/27/22. There were multiple dark stains on the carpet throughout the first floor. On 06/29/22, the need to ensure all materials and surfaces were clean and in good repair was discussed with Staff 1 (ED). She acknowledged the findings.

1.  The carpet will be cleaned in the common areas. 2.  The carpet has been added to a routine cleaning schedule for ongoing maintenance. 3.  Stains will be reported to houskeeping for remedy as noted in between routine carpet cleaning appointments.   4.  The Administrator will monitor.

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 alert staff when residents exited the building. Findings include, but are not limited to: Observations during the survey revealed exit doors, including the doors to the enclosed courtyard, had no alarm or other acceptable system to alert staff when residents entered or exited. The failure to ensure doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) on 06/29/22. She acknowledged the findings.

1.  The facility has ordered chimes that will alert the staff through the call system if residents should use a courtyard door. 2.  Once received, the chimes will be added to the call system 3.  The Administrator will check the chimes, at least, annually for continued efficacy.

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 513 and C 555.

Please refer to C231, C512, and C55

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 252, and C 270.

Please refer to C231, C512, and C55

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and included in the service plan for 1 of 3 sampled residents (#2) whose service plans was reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia. The resident's 05/27/22 move-in evaluation and service plan were reviewed.  The evaluation noted the resident was at risk for dehydration and fluids should be offered with and between meals to promote good hydration. The service plan lacked staff instructions related to the resident's individual nutritional and hydration status and needs. The facility failed to create an individualized nutrition and hydration plan based on the resident's preferences and needs and failed to document the plan in the resident's service plan. The need to ensure individualized nutrition and hydration plans were developed, followed and included in the service plan was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 06/29/22. They acknowledged the findings.

1.  The sampled resident's nutrition and hydration status and needs were evaluated and made accessible to staff 2.  The facility evaluation software has been updated to include the required elements so that the person entering the informatin will be prompted to consider each item. Upon admission, as needed, and with each Service Plan Review, nutrition and hydration status and preferences will be reviewed and updated. 3.  Compliance will be reviewed by the Administrator with each Service Plan Review.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2 and 3's service plans offered some information about the residents' interests, however, the facility had not fully evaluated the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. There were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities. Observations and interviews indicated the residents were dependent on staff to initiate activities. On 06/29/22 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED), who acknowledged the findings.

1.  The sampled residents' Service Plan were updated to include specific activity plans.   2.  The facility evaluation software has been updated to include the required elements so that the person entering it will be prompted to consider each item.  Each resident will be evaluated upon admission and quarterly with Service Plan Reviews for updates and modifications to that Service Plan to reflect the individualized activity plan for each resident. 3.  Compliance will be reviewed quarterly by the Administrator with Service Plan Reviews.

The findings of the initial survey conducted 06/27/22 through 06/29/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 06/29/22, conducted 10/04/22 and 10/05/22, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.