St Andrews Memory Care Community

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Oregon Food Sanitation Rules. Findings include, but are not limited to:

On 07/24/25, observations of the facility's kitchen at 11:17 am identified the following:

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:

* The exterior and handles of all freezers;
* Walls and ceilings throughout the kitchen;
* Legs and drawers of stainless steel prep counters and shelving;
* Can opener casing;
* Clean dish carts in the dishwashing area;
* Wall behind the dishwasher;
* Dish sprayer nozzle, handle, and cord;
* Stainless steel shelving storing spice bottles; and
* Interior and exterior of the microwave.

b. Leftover food items in the refrigerator were dated but not labeled.

c. The following areas/items needed repair/replacement:

* Several patches of missing/chipped/flaked paint and areas covered in spackle, including above the ice scoop near the ice machine, above/behind/below the dishwasher, and under the food prep sink; and

* Rubber spatulas were worn with pieces of rubber missing.

The above areas were toured and discussed with Staff 1 (ED) at 12:56 pm on 07/24/25. She acknowledged the findings.

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

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

This Rule is not met as evidenced by:

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

Findings include, but are not limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

The findings of the change of ownership survey, conducted 07/15/24 through 07/18/24, are documented in this report. The survey was conducted to determine compliance with 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. Tag numbers beginning with the letter H refer to the Home and 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 first re-visit to the change of ownership survey of 07/18/24, conducted 11/12/24 through 11/15/24, are documented in this report. The survey was conducted to determine compliance with 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. Tag numbers beginning with the letter H refer to the Home and 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 daySituations were identified where there was a failure of the facility to comply with Department's rules that represented an immediate threat to residents' health and safety and required an immediate plan of correction in the following areas:OAR 411-054-0090 - Fire and Life Safety; andOAR 411-054-0020 (8) - Heating and Ventilation Systems. The facility put immediate plans of correction in place during the survey.

Based on interview and record review, it was determined the facility failed to ensure all incidents of abuse or suspected abuse were immediately reported to the local Seniors & People with Disabilities (SPD) office and were promptly investigated for 1 of 1 sampled resident (#10) whose record was reviewed. Findings include, but are not limited to:Resident 10 was admitted to the facility in 04/2019 with diagnoses including unspecified dementia.A review of the resident's facility record, including progress notes dated 10/13/24 through 11/13/24, and temporary service plans was completed, and staff were interviewed. The following was identified:* On 10/28/24, Staff 30 (CG) documented the resident ". . .was found in [his/her] bed with another resident."There was no documented evidence this incident was promptly investigated at the time it occurred to rule out abuse, nor that it was reported to the local SPD office if abuse could not be ruled out. On 11/14/24 at 1:40 pm, Staff 1 (ED) confirmed an investigation was not promptly completed. Survey requested the facility report the incident to the local SPD office. On 11/14/24 at 2:32 pm, verification was received of reporting the incident to the local SPD office. The need to ensure all incidents of abuse or suspected abuse were immediately reported to the local SPD office and were promptly investigated was discussed with Staff 1, Staff 2 (Nurse), Staff 6 (RCC), Staff 26 (Director of Operations), and Staff 27 (Nurse Consultant) on 11/14/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to refer a significant change of condition to the facility nurse for 1 of 3 sampled residents (#5) who experienced severe weight loss. Findings include, but are not limited to:Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.The resident's 07/01/24 service plan, 05/15/24 through 07/15/24 progress notes, 07/01/24 through 07/15/24 MAR, and temporary service plans were reviewed. The following was identified:* The service plan indicated Resident 5 should be offered "finger foods and easy to chew foods." Observations during lunch on 07/16/24 and 07/17/24 revealed the resident required his/her food to be cut up.* The MAR indicated a nutritional shake was ordered twice a day after lunch and dinner.Resident 5's weight records from June 2024 to July 2024 were reviewed and indicated the following:* 06/04/24 - 144.3 pounds;* 07/04/24 - 129.6 pounds; and* 07/11/24 - 133.8 pounds.Between 06/2024 and 07/2024, Resident 5 had a severe weight loss of 14.7 pounds in one month, or 10.2% of his/her total body weight. This represented a significant change of condition.During the survey the following was observed:* On 07/16/24 Resident 5 was served pulled pork (not cut up), cut up roasted potatoes, whole pieces of steamed vegetables, salad, a roll, water, and lemonade. S/he consumed 90% of the meal.* On 7/17/24 Resident 5 was served mashed potatoes, cut up pieces of chicken, steamed carrots and green beans, cut up pieces of salad, a roll, water, apple juice, and an orange drink. During the meal s/he attempted to grab a tablemate's personal dessert, the caregiver intervened and brought Resident 5 four small cookies. S/he ate 40% of his/her meal. Following the lunch meal, Staff 13 (MT) provided Resident 5 a nutritional shake.A progress note, dated 07/05/24, from Staff 8 (RCC) indicated, "Faxed [outside provider] PCP (primary care physician) regarding 5% weight change. Requesting health shakes to encourage intake. Awaiting response." While a temporary service plan was implemented by Staff 8 on 07/10/24, there was no documented evidence Resident 5's significant weight loss was referred to the facility nurse.On 7/17/24 Resident 5 was weighed and was 139 pounds.In an interview on 07/17/24 at 1:45 pm, Staff 2 (RN) acknowledged she had not been notified Resident 5 had a significant weight loss.The need to ensure significant changes of condition were referred to the facility nurse was discussed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed for 1 of 3 sampled residents (# 5) who experienced a significant change of condition. Findings include, but are not limited to:Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.The resident's 11/02/23 through 07/11/24 weight records, 05/15/24 through 07/15/24 progress notes, 07/01/24 service plan, and temporary service plans were reviewed.On 06/04/24, Resident 5 weighed 144.3 pounds. On 07/04/24, the resident weighed 129.6 pounds, which was a 14.7 pound weight loss. This constituted a severe weight loss of 10.2 % in one month, requiring a facility RN assessment.Although progress notes indicated Staff 8 (RCC) notified the physician on 07/05/24 "regarding 5% weight change" and requested "health shakes to encourage intake," there was no documented evidence there was an RN assessment which included findings, resident status, and interventions made as a result of the assessment. No further information was provided.Resident 5's weight during the time of the survey was 139 pounds. No additional significant change had occurred.The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 06/2021 with diagnoses including Alzheimer's Disease.The current service plan, dated 03/07/24, noted the resident was dependent on staff for toileting activities, including changing incontinent products and assistance with perineal care.During an ADL observation on 07/16/24 at 10:00 am, the following was noted:*Staff 9 and Staff 11 (both PCAs) provided incontinence care for Resident 3;*Staff 9 removed Resident 3's soiled incontinence product and placed it in the garbage can;*Staff 9 applied barrier cream to the resident's perineal area and put on a new incontinence product using the same soiled gloves; and*Staff 9 proceeded to open closet doors to retrieve clothing, assist with pants and a shirt, and brushed Resident 3's hair using the same soiled gloves.The observation was discussed with Staff 1 (ED), Staff 6 (RCC), Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations Consultant) on 07/16/24 at 2:47 pm. No additional information was provided.
Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 2 sampled residents (# 3) who received incontinence care from staff and multiple unsampled residents. Findings include, but are not limited to:Observations were made during the survey to determine adherence to universal precautions for infection control.1. On 07/15/24, at 12:03 pm, the surveyor observed Staff 12 (PCA (Personal Care Attendant)) providing lunch meal service to residents on the fourth floor. At 12:38 pm, Staff 12 was observed handling a partially eaten plate of food bare-handed. The thumb of his right hand was visible on the surface of the plate near the partially eaten food. Staff 12 set the plate in a dish bin located on a cart in the dining area. After setting the plate in the dish bin, Staff 12 proceeded to handle a second plate of partially eaten food with his right hand, picking up a used napkin with his left hand, placing the dish in the dish bin and the napkin in the trash can. Staff 12 proceeded to touch the back of a chair occupied by a resident with both hands without performing proper hand hygiene.On 07/15/24 at 12:40 pm, the surveyor spoke with Staff 12 regarding the need to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. He acknowledged the findings.2. On 07/16/24 at 11:22 am, the surveyor entered the fourth floor kitchen through an unlocked door. Upon entry to the kitchen, an unsampled resident was observed to be alone in the kitchen, with one bare hand inside a plastic cereal dispenser. The resident took a handful of cereal from the dispenser and proceeded to eat the cereal.At 11:23 am, the incident was brought to the attention of Staff 24 (PCA) who entered the kitchen and attended to the resident.On 07/18/24, the need to ensure the facility consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC), and Witness 1 (Consultant RN). They 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 for 2 of 4 sampled residents (#s 4 and 5) whose orders were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 06/2024 with diagnoses including psychotic disturbance, mood disturbance, and anxiety.Physician's orders dated 06/24/24, the 07/01/24 through 07/15/24 MAR, 06/27/24 through 07/15/24 progress notes, and an After Visit Summary electronically signed by a physician revealed the following:* Resident 4 had a physician orders for quetiapine (for mood disturbance) 25 mg 1 tablet daily at bedtime.* The resident was hospitalized 07/09/24 through 07/11/24. On 07/12/24, a progress note indicated, "Reviewed discharge medication list ... Changed quetiapine admin time from PM to AM."The signed physician orders listed on the After Visit Summary, dated 07/11/24, included orders to continue quetiapine 25 mg 1 tablet at bedtime. Additionally, Resident 5 was to take quetiapine 25 mg 0.5 tablets once daily in the morning.The MAR revealed Resident 4 stopped receiving the bedtime dose of quetiapine effective 7/11/24 and on 7/12/24 began receiving the morning dose of quetiapine 25 mg 0.5 tablet daily.In an interview on 07/17/24 at 3:40 pm, Staff 8 (RCC) acknowledged the new orders were interpreted incorrectly and the bedtime dose of quetiapine should not have been discontinued. No further documentation was provided. She confirmed that Resident 4 would be receiving the bedtime dose until the physician provided further orders. The need to ensure the facility administered all medications per physician orders was discussed with Staff 1 (ED), Staff 2 (RN), Staff 8 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings. The surveyor confirmed with Staff 1 that Resident 4 received the bedtime dose of quetiapine on 07/17/24.2. Resident 5 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.Resident 5's 07/01/24 through 07/15/24 MAR and physician orders were reviewed and revealed the following:a. Resident 5 had a physician order dated 06/19/24 for Calcitonin (osteoporosis) nasal spray, "1 spray by nasal route daily."The MAR revealed instructions to the staff were to "instill 1 spray in each nostril every day" and additional instructions "alternate nostrils daily." On 7/08/24 and 7/15/24 the MAR indicated staff administered to both the left and right nostril.On 07/17/24 at 1:45 pm, during an interview with Staff 2 (RN), she indicated Resident 5 should not be receiving the medication in both nostrils daily, and the MTs should be alternating the spray into the left and right nostril daily. She acknowledged the conflicting instructions on the MAR and stated she would update them.b. Resident 5 had a physician order for a multivitamin (supplement) daily. On both 07/08/24 and 07/15/24 the medication was recorded as unavailable. Between those same dates the medication was documented as administered on six occasions.During an interview on 07/17/24 with Staff 13 (MT), she confirmed the medication was available during those dates in a bottle located in the third drawer of the medication cart, separate from the medication in bubble packs. She revealed that sometimes the MT's would report a medication as not available when not found among the bubble packs, despite the medication being in another drawer. Staff 13 showed this surveyor the medication bottle, which was marked as opened on 05/28/24.The need to ensure the facility administered all medications per physician orders was discussed with Staff 1 (ED), Staff 2 (RN), Staff 8 (RCC), and Witness 1 (Consultant RN) on 07/18/24 at 1:00 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:At the time of the survey, the MCC had 31 residents. The facility was a four-story building, with residents occupying the first and fourth floors. Each floor was a separate, secured unit. Multiple interviews with staff conducted on 11/12/24 revealed the following:* Staff identified five residents on the first floor who required two-person assistance for transfers and/or ADL care, including the use of a mechanical lift; and* Staff identified eight residents who required 1:1 feeding assistance.The facility's posted staffing plan designated one CG on the first and fourth floors and one MT between the first and fourth floors for the NOC shift. Considering resident acuity, facility structural design, and the number of residents requiring two-person transfers, as listed above, this was not an adequate number of floor staff in case of an actual emergency evacuation. In addition, the NOC shift failed to have a minimum of two direct care staff scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. On 11/12/24 at 3:14 pm, the above findings were discussed with Staff 1 (Executive Director) and Staff 6 (Residential Care Coordinator). The survey team requested the facility schedule an additional direct care staff for NOC shift to ensure the facility meets the evacuation level and the minimum of two direct care staff scheduled and available for residents requiring the assistance of two caregivers. On 11/13/24, the facility provided the survey team with a schedule dated 11/13/24 through 11/30/24 that showed two CGs were scheduled on first floor and one CG on the fourth floor and one MT between the floors for NOC shift. On 11/15/24, the need to ensure the facility provided a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1, Staff 2 (Nurse), Staff 6, and Staff 27 (Nurse Consultant).

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:On 07/18/24, fire and life safety records dated between 01/2024 and 07/2024, were reviewed. Fire drill records lacked documentation of the following required elements:* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;* Evacuation time-period needed; and* The number of occupants evacuated. The facility provided no documented evidence staff were given fire and life safety training on alternate months.On 07/18/24 at 12:00 pm, the need to ensure fire drills were conducted according to the OFC and to provide fire and life safety instruction to staff on alternating months was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code, fire and life safety instruction was provided to staff on alternate months, and that resident evacuation needs were met. The fourth floor had multiple residents who required assistive devices and assistance of staff for mobility, and no plan was in place on how to assist the residents in the event of a fire. This placed the residents at risk and constituted an immediate threat to the residents' health and safety. This is a repeat citation. Findings include, but are not limited to:a. Fire and life safety records dated 09/2024 through 10/2024 were reviewed. The documentation showed no drills were conducted which simulated fires on the fourth floor, and the escape route was not identified. During an interview on 11/13/24 at 9:35 am, Staff 4 (Maintenance Director), confirmed there was not a plan in place to assist the residents on the fourth floor. He stated he had a phone call with the Fire Authority on how to best assist residents who were the least mobile, and the plan was to move them "as far away from the fire behind a fire door and wait on the fire department for rescue." However, there was no documented evidence of approval for this plan by the Fire Marshal. Staff 4 also confirmed he was unaware of any equipment such as transfers blankets in the facility which would assist staff in evacuating residents from the fourth floor if they were unable to ambulate down the stairs. Staff 4 further confirmed he was not sure when the last full evacuation the facility had been completed.Service plans for Resident 7 and Resident 8, who lived on the fourth floor, were reviewed for assistance level needed to evacuate the facility.Resident 7 moved into the facility in 07/2024 and required use of a walker for ambulation. The resident's service plan, dated, 10/12/24, stated Resident 7 was "unable to exit building without total assistance" and "mobile with a walker/cane" in the mobility section. The emergency evacuation ability stated, "provide cues and direction for [Resident 8] during an emergency evacuation." Resident 8 moved into the facility in 05/2020 and required use of walker for ambulation and was on continuous oxygen. The resident's service plan, dated 10/11/24, stated Resident 8 was "unable to exit building without total assistance" and "unable to use stairs without assistance" in the mobility section. The emergency evacuation ability stated Resident 8 "requires assistance with evacuation, she will use her 2WW [two wheeled walker] but needs cueing and direction from staff."Multiple staff were interviewed on day and swing shifts. All staff indicated they did not know how they would get residents who could not ambulate independently down the stairs from the fourth floor to the main level. Staff identified ten residents who lived on the fourth floor that would not be able to ambulate down the stairs independently in case of a fire and who relied on a walker as an assistive device. During interviews on 11/13/24 at 10:40 am, Staff 1 (ED), Staff 2 (Nurse), Staff 6 (RCC), and Staff 27 (Nurse Consultant) stated they were unaware of a current plan for evacuating residents who were unable to ambulate independently from the fourth floor. In the event of a fire, they had instructed staff to evacuate the most mobile residents first, and any residents who could not be evacuated should be moved behind a fire door until the fire department arrived. On 11/13/24, the survey team reviewed with Staff 1, Staff 2, Staff 6, and Staff 27 that staff must provide fire evacuation assistance to residents from the building to a designated point of safety. When asked how many staff were available on each shift to help evacuate residents, Staff 1 and Staff 5 stated they tried to staff a total of three care staff (one MT and two personal care attendants) on night shift. During the acuity interview on 11/12/24 at 9:45 am, Staff 2 had confirmed there were up to five residents who required a mechanical lift or two staff members to assist them for transfers on the first floor. This constituted a significant risk to resident health and safety and required an immediate plan of correction to ensure residents on the fourth floor could be safely and effectively evacuated to the designated point of safety in case of a fire.The facility submitted a plan of correction to the survey team which included:* Evaluating residents for their ability to evacuate and thereby identifying residents who would require assistance;* Updated the residents' service plans to include the ability, time, and level of assistance required from staff to evacuate;* Immediately obtaining a mechanical stair climber and a fire safety blanket/transfer sling which could be used to evacuate non-ambulatory residents down the stairs and educating staff on all shifts on correct usage; and* Ensuring no less than four staff were available on all shifts, including the night shift. An immediate plan of correction was requested on 11/13/24 at 11:20 am. The facility provided a plan of correction on 11/13/24 at 1:01 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system failures associated with the licensing violation.Refer to C 360.b. Fire and life safety records, dated 09/2024 through 10/2024, showed fire drill documentation was lacking in the following areas:* Escape route used;* Problems encountered;* Evidence of alternate routes used;* Evacuation time-period needed; * Staff members on duty and participating; and * The number of occupants evacuated.Additionally, the records reviewed did not show fire and life safety training was provided to staff on alternating months from the fire drills.The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from fire and life safety training was discussed with Staff 1, Staff 2, Staff 6, Staff 26 (Director of Operations), and Staff 27 on 11/13/24 at 1:10 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 420, C 510, C 513, and H 1518.

Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, and other toxic materials were secured in locked storage, and failed to ensure facility grounds were free of litter and refuse and garbage was stored in covered refuse containers. Findings include, but are not limited to:The facility was toured on 07/16/24 at 9:30 am and the following was observed:a. First floor:* Disinfectant cleaner, personal care products, boxes of lancets (containing a blade/needle to puncture skin), and a specimen cup with dark-colored contents located in an unlocked storage room;* Peroxide Multi Surface Cleaner and Disinfectant stored in an unlocked cabinet under the sink in the resident dining room; and* Personal care products stored in an unlocked cabinet above the microwave in the resident dining room.b. Fourth floor kitchenette:* Cleaning chemicals stored in an unlocked cabinet under the sink.On 07/16/24 at 11:50 am, the facility was directed to ensure the identified unsecured toxic materials were stored in a secured location.On 7/17/24 at 8:15 am, the first-floor storage room was again observed to be unlocked with the items listed above unsecured.c. Building Exterior:* Two dumpsters containing large garbage bags were observed to be uncovered; and* Litter and refuse was on the ground near the dumpsters.The need to ensure all poisons, chemicals, and other toxic materials were stored in locked storage, and to ensure the grounds were free of litter and refuse and refuse containers were covered, was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 07/17/24. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, and other toxic materials were secured in locked storage, and failed to ensure facility grounds were free of litter and refuse and garbage was stored in covered refuse containers. This is a repeat citation. Findings include, but are not limited to:The facility was toured on 11/12/24 at 11:10 am and the following was observed:* Personal care products that contained potentially toxic material stored out on shelves and countertops were not in locked cabinets in resident bathrooms on the first and fourth floors.The need to ensure all poisons, chemicals, and other toxic materials were stored in locked storage, and to ensure all exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways were made of hard, smooth material, were accessible, and maintained in good repair, was discussed with Staff 1 (ED), Staff 4 (Maintenance Director), and Staff 26 (Director of Operations) on 11/14/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:The facility's interior was toured on 07/16/24 at 9:35 am and the following was observed to need cleaning and/or repair:a. First-floor interior:* Walls had gouges and exposed drywall/missing paint;* Ceiling vents had a build-up of dust;* Light fixtures had light bulbs out;* Ceiling light covers were missing in the storage room;* Furniture chair legs in the corridor outside the dining room were gouged and had exposed wood;* Ceiling tiles in the storage room, dining room, and near the exit had staining; and* Exit door had damage to the door and door frame.b. Fourth-floor interior:* Walls had gouges and exposed drywall/missing paint;* Ceiling vents had a build-up of dust;* Light fixtures had light bulbs out;* Flooring in the resident corridor had peeling/missing pieces;* Room number outside of room 409 was missing;* Table in the resident corridor had a worn finish/exposed wood; and* Baseboard at the end of the corridor was pulled away from the wall.The facility was toured with Staff 1 (Executive Director) and Staff 4 (Maintenance Director) on 07/17/24 at 10:05 am. They acknowledged the areas needing cleaning and/or repair.

Based on observations and interviews, it was determined the facility failed to keep all interior materials and surfaces and equipment clean and in good repair, including all equipment related to heating elements necessary for the health, safety, and comfort of the resident. This is a repeat citation. Findings include, but are not limited to: The facility's interior was toured on 11/12/24 at 11:10 am and the following was observed to need cleaning and/or repair:a. First-floor interior:* Walls had gouges and exposed drywall/missing paint;* Ceiling vents had a build-up of dust;* Light fixtures had light bulbs out;* Furniture chair legs in the corridor outside the dining room were gouged and had exposed wood;* Ceiling tiles in the storage room, dining room, and near the exit had staining; * Exit door had damage to the door and door frame;* Room 102 had multiple cracks in the ceiling; and* Room 109 was missing flooring near the wardrobe.b. Fourth-floor interior:* Walls had gouges and exposed drywall/missing paint;* Ceiling vents had a build-up of dust;* Light fixtures had light bulbs out;* Flooring in the resident corridor had peeling/missing pieces;* Room number outside of room 409 was missing;* Table in the resident corridor had a worn finish/exposed wood; * Baseboard at the end of the corridor was pulled away from the wall;* Room 413 had a hole in the bathroom ceiling; and* Room 416 had pieces of flooring missing.c. Several baseboard heaters in resident rooms were damaged, separating from the wall, and exposed inner wires and/or pipes on both floors.On 11/15/24 between 9:52 am and 10:17 am, the baseboard heaters in rooms 105 and 409 were observed to be in disrepair with exposed pipes and/or wires. Observations identified base board heaters in multiple resident units were damaged. The heaters were located where residents could come into incidental contact, and combustible materials were placed against the heating elements that posed a risk to the residents. The facility was toured with Staff 1 (Executive Director), Staff 4 (Maintenance Director), and Staff 26 (Director of Operations) on 11/14/24 at 12:10 pm. They acknowledged the areas needing cleaning and/or repair. Refer to C 540.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to:The facility laundry room was observed on 07/16/24. Two commercial washing machines in the laundry room had no indicator of the water temperature. The laundry detergent observed next to the washing machines did not contain a chemical disinfectant.In an interview on 07/17/24 at 8:45 am, Staff 23 (Housekeeper) confirmed the washing machines and laundry detergent were used to wash resident linens and clothing soiled with urine.In an interview on 07/17/24 at 9:00 am, Staff 4 (Maintenance Director) stated the water temperatures of the washing machines were measured at 110 degrees F. Staff 4 acknowledged the water rinse temperature should be at a minimum of 140 degrees F.The need to ensure washing machines had a minimum rinse temperature of 140 degrees or a chemical disinfectant was used when washing soiled linens and soiled clothing was discussed with Staff 4 and Staff 1 (ED) on 07/17/24 and 07/18/24. They acknowledged the findings.

Based on observations and interviews, it was determined the facility failed to keep all equipment in good repair, and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations subject to incidental contact by residents or with combustible material. The facility was using baseboard heaters in resident rooms. Several baseboard heaters were in disrepair and exceeded 120 degrees F, which constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:During an interview with Staff 4 (Maintenance Director) on 11/15/24 at 9:45 am, Staff 4 reported that to keep the temperature in the building between 67-71 degrees F, the boiler pipes had to be heated between 165-200 degrees F. On 11/15/24 between 9:52 am and 10:17 am, the baseboard heaters in rooms 105 and 409 were observed to be in disrepair with exposed pipes and/or wires. Temperatures measured with the surveyor's digital thermometer showed that both baseboard heaters exceeded 120 degrees F. At 1:19 pm, resident room baseboard heaters were measured with Staff 4 (Maintenance Director) using the facility's infrared thermometer. Baseboard heaters in the following resident rooms: 102 B, 103, 111, 123, and 413 exceeded 120 degrees F. Baseboard heaters in the following resident rooms: 402 A/B, 410, 411, 412, 414 and 415 failed to maintain 110 degrees F. Observations identified base board heaters in resident units were damaged. The heaters were located where residents could come into incidental contact, and combustible materials were placed against the heating elements that posed a risk to the residents. An immediate plan of correction was requested on 11/15/24 at 11:48 am. The facility provided a plan of correction on 11/15/24 at 3:47 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. On 11/15/24, the findings were reviewed with Staff 1, Staff 2 (Nurse), Staff 6 (Resident Care Coordinator), and Staff 27 (Nurse Consultant). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure privacy and dignity related to information being accessible in common areas of the facility. Findings include, but are not limited to:During the survey on 07/15/24 and 07/16/24, resident service plans were observed in a binder on a table in the dining room accessible to anyone in the area on the first and fourth floors. In addition, resident meal percentage intake was being documented on a white board in the first floor dining room for public viewing. The accessibility to service plans and meal intake jeopardized residents' rights to privacy and dignity.The observation was reviewed with Staff 1 (ED), Staff 6 (RCC) , Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations, Consultant) on 07/16/24 at 2:47 pm. No additional information was provided.

Based on observation, interview, and record review, it was determined the facility failed to provide each individual privacy in his or her own unit for 3 of 3 sampled residents (#s 1, 3, and 5). Findings include, but are not limited to:During the survey on 07/15/24 and 07/16/24, Residents 1, 3, and 5 were observed in their units with doors open, creating a lack of privacy.Interviews with care staff indicated the residents' doors were left open to conduct frequent safety checks.Review of Residents 1, 3, and 5's service plans did not indicate the residents' preference for their doors to be left open.Resident unit doors being open all the time jeopardized residents' rights to privacy and dignity.The observation was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 6 (RCC) , Witness 1 (Consultant RN), and Witness 2 (Regional Director of Operations, Consultant) on 07/18/24. No additional information was provided.

Based on observation and interview, it was determined the facility failed to ensure the individual and only appropriate staff had a key to access the unit for multiple unsampled residents who resided on the fourth floor. Findings include, but are not limited to:During an interview on 07/17/24 at 12:15 pm with Staff 15 Personal Care Attendant (PCA), she indicated there were a small number of residents who had keys to their rooms but she believed the keys could be used on any of the resident unit doors.An observation on 07/17/24 at 2:15 PM revealed the key to Resident 4's unit could unlock the door to an unoccupied unit on the fourth floor, where Resident 4 resided.In an 07/18/24 interview at 10:21 am, Staff 21 (PCA) indicated at least one resident had a master key that could be used on any of the resident unit doors. The need to ensure the individual and only appropriate staff had a key to access their unit was discussed with Staff 1 (ED), Staff 6 (RCC), and Witness 2 (Regional Director of Operations Consultant) on 07/18/24. No additional information was provided.
Based on observation, record review, and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. This is a repeat citation. Findings include, but are not limited to:Review of records for Residents 6, 7, and 8 revealed no documented evidence the residents had been provided keys to their rooms or had been evaluated for the ability to manage keys to their rooms.During the survey on 11/12/24 through 11/15/24, observations and interviews with residents and staff confirmed residents did not have keys to their units. The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Executive Director) on 11/15/24. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C420, C510, C513, and C530.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 231, C 360, C 420, C 510, C 513, and C 540.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 16, 17, 18, and 19) completed the required dementia training and demonstrated competencies in all required areas within 30 days of hire. Findings include but are not limited to: Training records were reviewed with Staff 3 (Business Office Manager) on 07/17/24.a. There was no documented evidence Staff 16 Personal Care Attendant (PCA), hired 02/26/24, Staff 17 (MT), hired 03/18/24, Staff 18 (PCA), hired 04/02/24, and Staff 19 (PCA), hired 06/13/24, completed the required additional dementia care pre-service training topics, including:* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.);* Family support and the role the family may have in the care of the resident;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.b. There was no documented evidence Staff 16 and Staff 17 demonstrated competency in their job duties within 30 days of hire in the following areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.c. There was no documented evidence Staff 17 (MT) demonstrated competency in their job duties of medication pass and treatments. On 07/17/24 survey requested medication and treatment administration demonstration for Staff 17 be completed prior to survey exit. On 07/17/24 at 2:10 pm, Staff 17 verified he demonstrated competency with medication pass and treatments within 30 days of his hire date and prior to administering medication and treatments. d. There was no documented evidence Staff 18 demonstrated competency in their job duties within 30 days of hire in the following areas:* Role of service plans in providing individualized care; and* General food safety, serving and sanitation.e. There was no documented evidence Staff 19 demonstrated competency in their job duties within 30 days of hire in the following areas:* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition; and* Conditions that require assessment, treatment, observation and reporting.The need to ensure newly hired staff completed the required pre-service dementia care training and demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 07/18/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C270, C280, C295, and C303.

Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to immediately notify the department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation for 1 of 3 sampled residents (# 6). Findings include, but are not limited to:a. A review of Resident 4's progress notes and Unusual Incident/Injury Reports did not indicate an occurrence of a reportable event on or around 08/25/23.b. A review of Resident 5's progress notes and Unusual Incident/Injury Reports did not indicate an occurrence of a reportable event on or around 08/26/23.c. A review of Resident 6's progress notes and Unusual Incident/Injury Reports indicated the following:· On 10/04/23 Resident 6 had an unwitnessed fall, and there were no indications on how abuse or neglect were ruled out. The report indicated resident slid out of bed. There was no indication that the department was notified of the 10/04/23 incident.· On 10/07/23 an injury of unknown cause was then observed on Resident 6. S/he had a 10-inch scratch on his/her back.· On 10/13/23 there was an Unusual Incident/Injury Report completed for Resident 6 regarding a 'found on floor' incident with observed abrasions on both knees. There was no indication that the department was notified of the 10/13/23 incident.In an interview on 06/17/24, Staff 1 (Executive Director) and Staff 2 (RN) did not know why incidents were not reported due to occurring under previous ownership.The facility had a change of ownership on 01/01/24.The facility failed to immediately notify the department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation.The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:A review of Resident 4's service plan dated 08/24/23 indicated Resident 4 returned to facility on 08/19/23 with an update to service plan of a 1:1 sitter due to impulsivity and high fall risk.A review of Resident 4's progress notes dated 08/01/23 - 09/30/23 indicated the following:· On 09/03/23 at 3:43 am resident was placed on alert charting. Resident 4's 1:1 care staff went to lunch. The other care staff on the floor was looking after the resident. Resident was found by the 2nd floor med tech laying on his/her right side with his/her eyes closed. Blood was on the floor and coming from his/her head.In an interview with Staff 1 (Executive Director) and Staff 2 (RN) no additional information was provided regarding Resident 4 ' s care plan not being following under previous ownership.The facility had a change of ownership on 01/01/24.The facility failed to ensure the implementation of services.The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on observation and interview, conducted during a site visit on 06/17/24, it was confirmed the facility failed to coordinate with off-site health services for residents. Findings include, but are not limited to:A call was placed to the facility mainline phone number on 06/21/24 at 8:17 pm. The phone rang, went unanswered for two minutes. At 8:19 pm a Verizon Wireless "Call cannot be completed as dialed please check the number and try again" message played before the phone call was disconnected.On 06/25/24 at 12:11 pm the facility mainline was called. Staff 5 (Reception) answered and stated s/he answers the phone during business hours and at approximately 4:00 pm s/he switched the phones to night mode and the med techs on shift could still answer the phones, but the phone should go to a voice messaging system. The compliance specialist requested Staff 5 turn the phone system to night mode to ensure voice messaging system was enabled.A call was then placed to the facility mainline on 06/25/24 at 12:16 pm after Staff 5 switched the phone system to night mode. The phone rang and went unanswered for two minutes and then the same Verizon Wireless message from 06/21/24 played and the call was disconnected. A call was place to the facility mainline on 06/25/24 at 12:20 pm and spoke to Staff 3 (Business Office Manager). Staff 3 stated s/he had also tried to call facility while phone system was switched to night mode and experienced the same message and call disconnection. The facility failed to coordinate with off-site health services for residents.The findings of the investigation were reviewed with and acknowledged by Staff 3 (Business Office Manager) via phone call on 06/25/24.Verbal Plan of Correction:Business Office Manager was to follow up with Century Link on 06/25/24 to troubleshoot the voicemail system and would have the system operational as soon as possible.

Based on interview and record review, conducted during a site visit on 06/17/24, it was confirmed the facility failed to ensure a safe medication administration system for 1 of 1 sampled resident (# 7). Findings include, but are not limited to:A review of Resident 7's 06/01/23 - 08/31/23 MAR's indicated the following:· 06/01/23 Omeprazole 20mg not available, ordered from pharmacy;· 06/01/23 Polyethylene glycol powder not available, ordered from pharmacy;· 06/01/23 Enoxaparin Sod withheld due to no nurse available to inject medication; and· 07/02/23 - 07/05/23 Lacosamide 150mg seven doses were not administered due to med not received from pharmacy.A review of Resident 7's progress notes from 06/01/23 - 08/31/23 indicated on 07/03/23 Resident 7's PCP was notified the resident was out of Lacosamide and that the pharmacy was faxing an incorrect doctor. In an interview on 06/17/24, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Business office manager) and Staff 4 (RCC) did not have additional information to provide regarding Resident 7's missed medications.The facility had a change of ownership on 01/01/24.The facility failed to failed to ensure a safe medication administration system.The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.

Based on observation and interview, conducted during a site visit on 06/17/24, it was confirmed the facility failed to provide a secure outdoor recreation area. Findings include, but are not limited to:At 11:47 am a large gait from the courtyard exiting to the parking lot was observed to be propped open with a cinderblock and no staff or residents were in sight.In an interview on 06/17/24, Staff 10 (Maintenance Director) stated the gait should be closed and locked at all times.At 11:58 am Staff 1 (Executive Director) was notified of the gate being propped open and a head count of all residents was requested.At 12:07 pm Staff 1 confirmed all residents were accounted for.At 1:45 pm the previously propped open gate was observed to be unsecured. During a walkthrough of the remainder of the courtyard a gate to the facility's HVAC system was unlocked and opened. There was a pair of steel double doors in the unsecured HVAC area that were unlocked and opened to the street north of the facility.Staff 1 was immediately alerted to the unsecured courtyard.The facility failed to provide a secure outdoor recreation area.The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RN) on 06/17/24.A written plan of correction was requested and provided by Staff 1.

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 04/20/2023 and 04/25/2023. 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 observation it was confirmed that the facility failed to be responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. Findings include the following:In separate interviews with Staff #6 and Staff #13 (S6 & S13) and Witness #4 (W4) the following was stated:· There is an endless smell of marijuana in the facility. A resident has complained to staff about how unbearable the smell is, staff have reported to the administrator that marijuana could be smelled on certain staff members and nothing has been done.· Staff smoke weed on their breaks or while they ' re at work.· There are several staff members that smoke marijuana in the building or are high at work.During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) observed Staff #14 (S14) standing in the small copy room by the employee timeclock waiting to clock in from their break. CS observed a pungent skunk like odor emanating from the room upon entering. CS observed odor appeared to be attached to S14 as the odor dissipated after S14 left the copy room.Facility Plan of Correction:The facility will implement random drug testing in alignment with their policy.

Based on interview and record review it was confirmed that the facility failed to develop and implement a policy on smoking. Findings include the following:In separate interviews with Staff #6 and Staff #13 (S6 & S13) and Witness #4 (W4) the following was stated:· There is an endless smell of marijuana in the facility. A resident has complained to staff about how unbearable the smell is, staff have reported to the administrator that marijuana could be smelled on certain staff members and nothing has been done.· Staff smoke weed on their breaks or while they ' re at work.· There are several staff members that smoke marijuana in the building or are high at work.· Multiple staff smoke vape pens on resident floors and blow the smoke down their shirts.A review of facility Separation Form for Staff #11 (S11) indicates that S11 violated facility 5-10 Smoking in the Workplace policy and posted on the social media site Snap Chat images of themselves smoking in the medication room in front of the med cart.Facility Plan of Correction:Facility terminated staff member for violations of facility policies.

Based on record review and interview it was confirmed that the facility failed to develop and implement a written policy that prohibits the falsification of record. Finding include the following:In separate interviews with Witness #4 and Witness #6 (W4 & W6) the following was stated:· The facility has incomplete and falsified training documents. · Several staff received a training document to sign that management had already signed. The document was already signed by an employee and the signature was whited out.Compliance Specialist (CS) requested a copy of the facilities policy that prohibits the falsification of records. No policy was provided. CS reviewed Training documents for Staff #5 - #11 (S5 - S11) which revealed three of seven staff filed reviewed contained a training signature page with what appears to be whited out information and dates removed. CS also reviewed facility incident reports which revealed an Internal Incident Report dated 01/11/2023 for Resident #10 (R10) that was created by staff at the time of the incident, and there are no management signatures or follow-up on the form. CS also reviewed an Unusual Incident/ Injury Report that was created for the same incident and has a time stamp of 03/02/2023 and this document contains management signatures that were back dated for the date of the incident, 01/11/2023.

Based on interview and record review it was confirmed that the facility failed to provide services in a manner that protects privacy and dignity. Findings include the following:During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that Staff #11 (S11) was terminated after they posted a video of themselves smoking in the medication room on Snap Chat and there were resident charts with resident information in the background.CS reviewed facility Separation Form for S11 which indicates that S11 violated facility policy 5-13 Violation on using a Camera Phone on Company property while performing work for Pacifica.Facility Plan of Correction:The facility terminated staff member for violation of company policies.

Based on interview and record review it was confirmed that the facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse. Findings include the following:In an interview with Witness #5 (W5) it was stated that the facility had not sent any facility self-reports to the local Department since August 2022.During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed facility incident binder and found multiple instances of reportable events that do not indicate that the facility reported to APS for Resident #1, #5 and an unsampled resident (R1, R5).The above findings were shared with Staff #2 and Staff #4 (S2 & S4) who were in agreement.Facility Plan of Correction:Staff will review APS reporting and go through their incident binder to report any instances that should have been reported but were not.

Based on interview, observation, and record review it was confirmed that the facility failed to assist with toileting and bladder management. Findings include the following:In separate interview with Staff #13 and Witness #2 (S13 & W2) the following was stated:· Staff leave residents unchanged all night and it causes skin breakdown because they are left in wet briefs for long periods of time.· Residents sit in soiled incontinence supplies for long periods of times causing urinary tract infections and kidney infections when left untreated.During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) observed Resident #7 (R7) appeared to be completely soiled through all layers of their clothing.During unannounced site visit on 04/20/2023 and 04/25/2023 CS observed a prevalent urine odor near the 2nd floor elevator.A review of R7 care plan that was available for care staff was dated 06/13/2022 and it was updated by hand that resident is currently a total assist for toileting and on safety checks. Staff indicated that resident was a 2-hour safety check.

Based on record review and interview it was confirmed that the facility failed to ensure that resident service plans are made readily available to staff as well as failed to ensure changes and entries made to the service plan are dated and initialed. Findings include the following:During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed service plan binders that were available to care staff on the first and second floors and found multiple service plan with changes made and not staff initials or dates for changes, including for Resident #7 (R7). Service plans were out of date and the service plan for Resident #5 (R5) was not available or located in the service plan binder.In separate interviews with Staff #6 and Staff #13 the following was stated:· Resident care needs have changed quite a bit.· R7 is on 2-hour safety checks even if care plan doesn't show it.

Based on interview and record review it was confirmed that the facility failed to have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. Findings include the following:According to Witness #2 (W2) it was stated that Resident #2 (R2) had experienced a UTI and staff were not aware of the residents change of condition. It was also stated that R2 experienced a significant weight gain over six months.Compliance Specialist (CS) reviewed service plan and progress notes from January 2023 to current for Resident #1 (R1) and R2. CS identified in the progress notes for R1 a short-term change of condition with a physician request for monitoring and intervention that was not alert charted and no follow-up was charted regarding the physician request for intervention. CS also discovered in R2 ' s Medication Administration Records for January 2023 to current a severe weight gain of 9.8% over three months. Residents weight gain was not alert charted or monitored.

See findings in C-tags C0301, C0303 and C0330

Based on interview and observation it was confirmed that the facility failed to ensure medications are kept secure between set-up and administration. Findings include the following:During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) observed the medication cart in the dining room on the first floor was unattended, upon further review the medication cart was unlocked in an unsecured area with residents nearby and no staff members present. The above was shared with Staff #2 and Staff #4 (S2 & S4) who acknowledged findings and stated they would work on retraining with the staff working on the med cart that evening.

Based on interview and record review it was confirmed that the facility failed to administer medications as ordered by a physician. Findings include the following:According to Witness #4 (W4) the facility does not have an effective method for receiving new medication orders and that sometimes if new orders are received over the weekend the staff can ' t administer the medication until staff with the proper authorizations come in to review and input the information causing long delays for residents to receive their medications.During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) reviewed Medication Administration Records (MARs) for Resident #1- #3 and Resident #5 (R1- R3 & R5) for January 2023 to current which revealed multiple instances of medications not available, conflicting orders entered and several days passing before error is corrected. CS also found eight instances of the incorrect dosage of a PRN medication being given to R1.

Based on interview, record review, and observation it was confirmed that the facility failed to provide sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include the following:According to Witness #4 (W4) staff consistently no call-no show, come into work late, or leave the floor that they are scheduled to work on leaving the floor unattended or understaffed and no one comes into support. In an interview with Staff #3 (S3) it was stated that the facility was short staffed this evening.During an unannounced site visit on 04/20/2023 Compliance Specialist (CS) reviewed the facility posted staffing plan which was as follows:Day shift - 6 caregivers; 2 medication techniciansEvening shift - 6 caregivers; 2 medication techniciansNight shift - 4 Caregivers; 1 medication technicianCS reviewed posted staff schedule for April 2023 which revealed 38 of the 90 scheduled shifts did not meet the posted staffing plan. CS reviewed the Daily Assignment sheets for 04/19-04/26/2023 which revealed staff are to take staggered lunches and that on the date of the site visit one staff member had called off for swing shift.CS observed two med techs, and three staff identified as caregivers, two of which were on their breaks, upon entering the facility. CS encountered two other staff members working one was identified as the RCC and the other was the facility administrator.

Based on interview and record review it was confirmed that the facility has not fully implemented and updated an Acuity-Based Staffing Tool (ABST). Findings include the following:During an unannounced site visit on 04/20/2023 Staff #1 (S1) provided Compliance Specialist (CS) with a document titled Care Levels and stated that this was their ABST. Document did not address all of the required ABST elements for each resident, nor did it provide an explanation of how the facility determines their staffing plan. CS asked S1 how they get their staffing plan and S1 stated that they use the staffing plan that the State has required them to use.In an interview with Staff #2 (S2) during an unannounced site visit on 04/25/2023 it was stated that they were unsure of what ABST the facility used, but they would do further research and would email what they could find.CS reviewed the ABST that S2 provided via email on 04/26/2023. Last edit date was 12/06/2022, 51 residents were entered into the tool, the current resident census is 46. Newly admitted residents and residents that have experienced a change of condition or an updated service plan were not reflected in the provided ABST.

Based on interview and record review it was confirmed that the facility failed to train direct care staff within the first 30 days. Findings include the following:During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff.Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) which revealed one of seven staff members did not have any training documents. Training documents for S9 appear to have the training dates whited out and are illegible and four of the remaining five staff members training documents were completed more than 30 days after staffs hire date.

Based on interview and record review it was confirmed that the facility failed to have a pre-service orientation and training program for all direct care staff. Findings include the following:During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff.Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) which revealed four of seven staff members had incomplete pre-service training and/or orientation records.

Based on interview and record review it was confirmed that the facility failed to ensure that they have documented that they have observed and evaluated the individual staff members ability to perform safe medication and treatment administration unsupervised. Findings include the following:During an unannounced site visit on 04/25/2023 in an interview with Staff #2 (S2) it was stated that the facility had a staff member that was hired to train new staff and after approximately a week they quit and disposed of the training documents that they had, but they are working on getting all training documents for staff.Compliance Specialist (CS) reviewed training documents for Staff #5 - #11 (S5 - S11) three of which staff members were listed as med techs on the Employee Roster. One of three staff members did not have any demonstrated competencies for passing medications. CS also reviewed Medication Administration Records (MARs) for Resident #1 - #3 and Resident #5 (R1 - R3 & R5) for January 2023 to current and discovered two staff members signing off on medication passes that were not listed as med techs on the Employee Roster. CS reviewed both staff members training records which revealed one of those staff members does not have demonstrated competencies for passing medications.

Based on interview and observation it was confirmed that the facility failed to ensure a copy of the most current inspection report and any conditions placed upon the license is posted with the facility ' s license in public view near the main entrance to the facility. Findings include the following:During unannounced site visits on 04/20/2023 and 04/25/2023 Compliance Specialist (CS) did not observe a copy of the facility ' s condition posted anywhere in the front entrance.In an interview with the facility policy analyst, it was stated that the facility does have a restriction of admissions condition that should be posted. In an interview with Staff #2 (S2) it was stated that they were unaware of the facility condition but would look in to locating it to get it posted.

Based on interview, observation, and record review it was confirmed that the facility failed to keep all interior and exterior materials and surfaces clean and in good repair. Findings include the following: According to Witness #4 (W4) it was stated that resident rooms are not being cleaned either daily or even weekly, toilets and handrails are dirty with brown matter.During an unannounced site visit on 04/25/2023 Compliance Specialist (CS) observed a dark brown substance in the shared restroom for Resident #1 (R1), substance was around the toilet, on the floor and around the doorframe near the restroom light switch. CS also observed a yellowish substance that appeared to run down the wall from approximately waist height and collected and dried at the baseboards in Resident #6 (R6) ' s restroom, the floor was sticky with a strong urine odor while the restroom fan was running.A review of the facility housekeeping schedule revealed that on Tuesdays all floors should have been cleaned as well as a deep clean of the fourth floor. A review of service plans for R1 and R6 revealed staff are to ensure R1 ' s shower and bathroom are clean and dry and R6 ' s states that care staff are to go into room daily on day and swing shift to clean along with housekeeping deep cleans once per week.

See findings in C-tags C0360, C0365, C0370 and C0372

Based on interview and observation it was confirmed that the facility failed to have a secured outdoor recreation area with outdoor furniture sufficient in weight, stability, design, and maintained to prevent resident injury or aid in elopement. Findings include the following:During unannounced site visits on 04/20/2023 and 04/25/2023 Compliance Specialist (CS) observed an unlocked gate, on 04/25/2023 there was a bungee cord holding the gate closed. The gate led to an area that contained the facility ' s dumpsters as well as what appeared to be heating and cooling systems. Within this unsecured area there was a door that was held closed with a screw through the door latch. CS was able to lift screw up and push the door open to gain access to the street. CS also observed on 04/25/2023 a lightweight lawn chair in outdoor recreation area.In an interview with Staff #2 (S2) they identified the lawn chair and stated that they would remove it. S2 also acknowledged photographs of the unsecured doors in the recreation area and stated that they would make sure they got the doors/gate secured as soon as possible.

The findings of the re-licensure survey conducted 05/02/22 through 05/04/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first re-visit to the re-licensure survey of 05/04/22, conducted 12/12/22 through 12/14/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

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 05/02/22 through 05/04/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.Refer to deficiencies in the report.
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. This is a repeat citation. Findings include, but are not limited to:During the first revisit to the re-licensure, conducted 12/12/22 through 12/14/22 administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.Refer to deficiencies in the report.

2. Resident 1 was admitted to the facility in October 2019 with diagnoses including dementia. The clinical record revealed:a. Resident 1 experienced unwitnessed falls on 04/05/22 and 04/19/22. b. Following the fall on 04/05/22, staff observed the resident with "bleeding from forehead and chin" and was sent to the emergency department for evaluation.c. On 04/19/22, Resident 1 was found on the floor in another resident's room with the other resident present. Staff documented observing "redness on forehead and between eyes" and the resident was sent to the emergency department for evaluation. On 05/03/22, incident reports were requested for review. During an interview on 05/04/22, Staff 3 (RCC) stated she was unable to locate the incident reports but recalls reporting both incidents to the local SPD office as the falls were unwitnessed and abuse or neglect could not be ruled out. The need to ensure a timely and thorough investigation of falls and injuries was completed and that those records were maintained was reviewed with Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and falls with injury were promptly and thoroughly investigated to rule out abuse and neglect and reported to the local SPD office as required for 2 of 5 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the MCC in 04/2021 with diagnosis of dementia.A review of Resident 2's incident reports and chart notes from 02/10/22 through 05/02/22 indicated the following injury of unknown cause:* 02/20/22 Skin tear to right wrist.A review of the incident report documented, "Resident has a ST [skin tear] of unknown origin to right wrist, area noticed when giving resident a shower. Zero suspected abuse. Zero neglect." The date of the investigation was 03/28/22 and there was no follow-up action or administrative review of the investigation. There was no documented evidence the facility either reported the injury as suspected abuse to the local APD office or conducted an immediate investigation of the injury which reasonably concluded and documented that the injury was not the result of abuse. The facility's failure to immediately investigate Resident 2's injury and document the investigation to rule out abuse or neglect and report the injury as suspected abuse was reviewed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings. The facility was directed to self-report the incident to the local APD office. Staff 2 provided verification that the incident was self reported to local APS office prior to survey exit.

Based on interview and record review, it was determined the facility failed to report suspected abuse to the local Seniors and People with Disabilities (SPD) office and failed to conduct an investigation of an injury of unknown cause, to rule out possible abuse or report the injury to the local SPD office for 1 of 3 sampled residents (#6) whose record was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease.Review of Resident 6's clinical records during the survey revealed the following:a. 10/21/22 - "Resident on alert charting for [left] skin tear above eyebrow."The investigation of the injury of unknown cause failed to reasonably rule out abuse or neglect as the cause of the injury. The injury was not reported to the local SPD office.b. 11/22/22 - An outside provider reported witnessing another resident push Resident 6.There was no documented evidence the facility notified the local SPD office of the suspected abuse, investigated the suspected abuse or implemented measures necessary to protect residents and prevent the reoccurrence of abuse. The need to investigate injures of unknown cause to rule out abuse and neglect or report the injury to the local SPD office, report suspected abuse to the local SPD office and implement measures to prevent the reoccurrence of abuse was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings. The survey team requested the facility submit the reports. Documentation was provided prior to survey exit.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 05/02/22 at 11:00 am, the central kitchen and kitchenettes on each floor were toured.a. The central kitchen on the first floor was observed to need cleaning and repair in the following areas:* Multiple ceiling tiles had holes that allowed for the potential entrance of insects and rodents into the kitchen;* Ceiling light fixtures or light bulbs near the entrance of the kitchen, above the steam table, and in the dry storage room were broken;* Ceiling light fixtures were missing light covers near the ware wash and in the dry storage room; and * Four ceiling vents were covered in brown or black matter.b. Kitchenette's on each floor had food spills, splatters, debris, dust and black matter that was observed on or underneath the following:* Interior of all cupboards and cabinets;* Exterior cupboards and cabinets were gouged and had a sticky residue buildup;* Multiple cabinet hardware (knobs and hinges) were loose or missing;* Interior and exterior surface doors, bottom and sides of refrigerator shelves and freezers;* Refrigerator handles were loose;* Baseboards and walls; and* Interior and exterior surfaces of the microwaves and toaster ovens.c. The kitchenette on the second floor required the following cleaning and repair:* Interior of the cabinet wall underneath the sink had black matter buildup;d. Kitchenette on the fourth floor required the following repairs:* A broken wall soap dispenser; and* Wall paint near the baseboard wall heater was peeling off. The kitchen was toured with Staff 1 (Executive Director) and Staff 5 (Dining Services Director) on 05/03/22 at 9:38 am and the need to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed. They acknowledged the findings.

3. During the survey, facility staff stated the quarterly evaluation and service plan were combined into the same document.Resident 5's most recent service plan was not dated. When reviewed on 05/03/22, the most recent update was noted as 01/07/22, with no evidence of quarterly evaluation or update in the last 90 days.The need to ensure timely review and updates to the evaluation was reviewed with Staff 27 (Regional Director of Operations) and Staff 3 on 05/04/22. They acknowledged the findings.
2. During the survey, facility staff stated the quarterly evaluation and service plan were combined into the same document. Resident 1's evaluation/service plan was completed on 08/11/21. The next quarterly evaluation would have been due on 11/11/21. There was no documented evidence of any evaluation completed after 08/11/21. During an interview on 05/03/22, Staff 3 (RCC) stated the facility was currently working on some updates for the evaluation/service plan for Resident 1, but it had not been completed.The need to ensure timely review and updates to the evaluation was reviewed with Staff 27 (Regional Director of Operations) and Staff 3 on 05/04/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements or that a quarterly evaluation was completed timely, for 3 of 5 sampled residents (#s 1, 3 and 5). Findings include, but are not limited to:1. Resident 3's move-in evaluation lacked information regarding the following required elements:* The new move-in evaluation was not dated and did not indicate who was involved in the evaluation process.In an interview with Staff 2 (RN) on 05/02/22 at 2:30 pm, he stated that he did not complete the new move-in evaluation for Resident 3 and the previous facility RN was in charge of the new move-in evaluations.The move-in evaluation and the need to complete all required components was reviewed with Staff 1 (Executive Director) on 05/03/22. He acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure evaluations included all required elements, for 2 of 4 sampled residents (#s 6 and 8) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 move into the facility in 11/2022 with diagnoses including dementia.Resident 8's move in evaluation was not dated and did not indicate who was involved in the evaluation process.The move-in evaluation and the need to complete all required components was reviewed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.



2. Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease.The most recent evaluation was dated 10/12/22. The evaluation did not indicate who was involved in the evaluation process. The need to include information on who was involved in the evaluation process was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status and failed to provide clear direction to staff for 3 of 5 sampled residents (#s 1, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia.Observations of the resident, interviews with staff, review of the service plan, temporary service plans and progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas: * Use of a geri-chair;* Directions for catheter care; and* Sitting up 90 degrees to eat meals and remaining at 90 degrees for at least 30 minutes after. The need to ensure resident service plans were reflective and provided clear directions to staff was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. Staff acknowledged the findings.
3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II.The most recent service plan was reviewed and was not reflective or lacked clear instruction for staff in the following areas:* No copy of the service plan was available for staff on the 4th floor where Resident 5 lived;* Not updated after bi-lateral fractures that left Resident 5 non-weight bearing;* Listed wheelchair and walker for mobility, however, Resident 5 was bed bound; and* Failed to list hospice home health services.A service plan update was completed on 3/23/22 instructing staff to place braces on both legs when Resident 5 woke up in the morning, and leave them on until sleep in the evening. Observations on 05/02/22 showed Resident 5 was not wearing the braces, and Staff 16 (Caregiver) stated he was not aware the braces had been added to the service plan.The need to ensure resident service plans were reflective, provided clear directions to staff, and were readily available for staff to review was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. Staff acknowledged the findings.
2. Resident 1 moved into the facility in October 2019 with diagnoses including dementia and depression. The most recent service plan, dated 08/11/21 was reviewed and was not reflective or lacked clear instruction for staff in the following areas:* Walking ability including use of a wheelchair for mobility;* Current, effective fall interventions;* Ability to eat independently and level of meal assistance required;* Interventions to address weight loss;* Sleep pattern and late night waking hours;* Behaviors including agitation and current interventions:* Use of glasses; and* Emergency evacuation needs.The need to ensure service plans were reflective of resident needs, accurate and included clear direction to staff was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.


Based on observation, interview and record review, it was determined the facility failed to ensure service plans included clear direction for staff and were followed for 2 of 4 sampled residents (#s 6 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease. The resident's 10/12/22 service plan was reviewed and revealed the resident was at risk for aspiration and noted the following information:* "[The resident] needs nectar thick liquids. S/he needs to avoid foods that melt into thin liquids (ice cream and popsicles."); and* "[The resident] likes all fluids thin. S/he can manage this if you hand him/her a drink while s/he is sitting." There was no documented evidence Resident 6's service plan provided clear direction to staff related to hydration and liquid consistency. The need to ensure service plans included clear direction to staff was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.
2. Resident 8 moved into the facility on 11/08/22 with diagnoses including dementia. The service plan dated 11/08/22 noted Resident 8 was scheduled for showers twice a week. The shower schedule available to staff at the time of the survey failed to document Resident 8's shower days. During interviews on 12/13/22 and 12/14/22, Staff 28 (Personal Care Assistant), Staff 34 (MT) and Staff 27 (RCC) were unable to verify whether or not Resident 8 was receiving bathing assistance as scheduled in the service plan.During an interview on 12/13/22 at 10:45 am, Witness 1 (Family member)stated s/he was not concerned about the cleanliness of Resident 8. Resident 8 was observed throughout the survey and appeared well groomed. The need to ensure service plans provided clear direction to staff on the delivery of services was reviewed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 11:50 am. 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 included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:Service plans for Resident's 1, 2, 3, 4 and 5 were reviewed and lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) 05/03/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in January of 2022 with a diagnosis of dementia and a Foley catheter.Resident 4's narrative chart notes dated 02/01/22 through 05/01/22 were reviewed and revealed there was no documented evidence the facility monitored changes, resolved monitored changes, notified the facility RN of changes and/or updated the service plan for the following changes of condition:a. The following short term changes were not monitored until resolution: * 01/14/22 New Move-in;* 02/01/22 Blood at catheter insertion site;* 02/02/22 Golf ball size lump on upper left thigh;* 02/03/22 Foot pain; and* 04/19/22 Missed medications.b. The resident experienced that following change of condition related to weight loss:* On 01/14/22 weight upon admission was 194 pounds;* On 02/2022, Resident 4's weight was 188 pounds (six pound loss from previous month);* On 02/23/22, an RN assessment identified Resident 4 ate 100% of meals but had weight loss of 4% since admission;* On 02/24/22, staff documented, "resident has not been eating well in the evenings with an average of 25% of meal intake since RTC [return to community].";* On 04/01/22, progress notes documented intake of dinner was 45% and on 04/04/22 intake was 10%; and* On 04/2022, Resident 4's weight was 181 pounds, which resulted in a total weight loss of 6.7% total body weight within three months.Although the RN identified the change of condition for weight loss in 02/2022, there was no documented evidence weight loss interventions were implemented and the service plan was not updated with direction to caregivers to ensure the resident did not continue to lose weight.c. The resident experienced the following significant changes of conditions that were not monitored to resolution or referred to the RN:* 02/19/22, Return from hospital;* 02/28/22, Pressure ulcers on bilateral heels;* 03/10/22, Pain from catheter insertion site with mucus draining;* 03/17/22, "purulent drainage" from genitalia and "pus coming from catheter";* 03/31/22, Return from hospital for UTI and sepsis;* 04/03/22, Open wound on buttocks; * 04/14/22, Return from the hospital; and* 04/16/22, Starting home health for catheter care, wound care and OT.* 05/02/22, Progress notes documented, Resident 4 continued to experience pain from genitalia and a decline in health condition.There was no documented evidence the facility RN was notified of changes of condition when the resident continued to have pain and decline in health condition and failed to update the service plan following the changes in condition. The need to ensure the facility documented evidence of interventions, monitored changes, resolved changes, notified the facility RN of changes and/or updated the service plan for changes of condition was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
4. Resident 5 was admitted to the facility in 2020 with a diagnosis of dementia and Diabetes Type II.Resident 5's narrative chart notes dated 01/01/22 through 05/01/22 were reviewed and revealed:a. On 01/05/22 Resident 5 was found on the bathroom floor at 4:30 am after an unwitnessed fall. The fall with possible injury constituted a change of condition that required documented evaluation.A med tech note dated 01/05/22 at 9:41 pm stated "facility nurse and nurse consultant assessed during day shift and decided did not need to be sent out". The assessment referenced in the med tech note was not located during the survey and no service plan updates, interventions, monitoring, or instructions to staff were documented or included in the resident record. A progress note dated 01/06/22 at 9:50 am stated "sent out this morning to hospital and admitted for fractures". b. A progress note dated 11/19/21 documented "will receive scabies treatment as a preventative measure C/O exposure to a resident with active rashes and itching". On 12/02/21, 14 days later, a note documented "will notify pharmacy so resident can start his/her medication". There was no documented monitoring or resolution of the scabies, and the service plan was not updated with any instructions for staff.The need to ensure the facility documented evidence of monitored changes, resolved changes, notified the facility RN of changes and/or updated the service plan for changes of condition was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
3. Resident 1 was admitted to the facility in October 2019 with diagnoses including dementia. A review of the clinical record revealed the following:a. In early February 2022, the resident was identified as having a swollen left foot with redness. The facility notified the physician and a video medical appointment was held on 02/04/22. Progress notes documented on 02/04/22 stated "NP [nurse practitioner] will order new medication for leg swelling and redness..." Resident 1 was placed on alert charting. On 02/10/22, Resident 1 went to a scheduled in-person appointment with his/her physician and the provider stated the medication "should have been started". The facility determined the prescription had been sent to another pharmacy.During an interview on 05/04/22, Staff 3 (RCC) acknowledged the facility did not monitor to follow up on the status of the medication order to treat the cellulitis. The order and medication was received and administered starting on 02/12/22 (eight days after the video appointment). In addition, there was no documentation that the facility nurse had been monitoring the swelling at least weekly through resolution.b. Resident 1 experienced two falls in April 2022. There was no documented evidence the facility determined what action or interventions were needed nor was the resident monitored through resolution.The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution and determining what action or interventions were needed was shared with Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, weekly progress notes until the condition resolved and/or the facility failed to refer significant changes of condition to the facility RN for 4 of 5 sampled residents (#s 1, 2, 4 and 5) who had changes of condition. Residents 2 and 4 continued to experience an overall health decline and an increase in ADL care needs. Findings include, but are not limited to:1. Resident 2 was admitted to the memory care facility in 04/2021 with diagnosis of dementia. Resident 2's clinical records, service plans, and temporary service plans were reviewed during the survey and identified the following changes of condition.a. On 04/07/22, Staff 26 (Former RN) documented, Resident 2 was sent to the emergency room for stomach pain and vomiting. The resident returned the same day with hospital orders to monitor bowel movements and after two days, if the resident doesn't have a bowel movement staff were to administer Miralax every 6 hours until the resident had a bowel movement. Additionally, Resident 2 had PRN Miralax orders, from 11/12/21, to give up to four times per day. There was no documented evidence the facility followed the PRN Miralax orders written on 11/12/21 or contacted the health care provider when the resident failed to have a bowel movement prior to being sent to the ER on 04/07/22.During an interview on 05/04/22, Staff 2 (RN) and Staff 3 (RCC) indicated the facility staff were suppose to monitor and track bowel movements on hand written sheets of paper on each shift and give them to the RCC. Staff 2 and 3 were unable to locate documentation that staff monitored Resident 2's bowel movements or administered the Miralax (intervention) as prescribed. On 04/08/22, the resident was sent out to the emergency room for a body temperature of 101.3 degrees F. On 04/11/22, Staff 21 (RCC) documented in chart notes, Resident 2 returned to the facility with a diagnosis of potential UTI, diverticulitis and sepsis. Staff were instructed to administer Cipro (antibiotic) and Culterelle (probiotic) for seven days and hold fortified beverages while on the antibiotic.A review of the April 2022 MAR pass notes indicated the Culturelle was not received and the resident was not administered Culturelle while taking Cipro and the facility failed to hold daily Med Pass 2.0 (fortified beverage). There was no documented evidence the facility monitored the Culturelle (probiotic) and Cipro (antibiotic) medication errors, the effectiveness of the antibiotic, the resident's bowel movements to determine if the intervention (PRN Miralax) was needed and effective, failed to ensure the determined actions or interventions were communicated to staff and failed to refer the change in condition related to multiple ER visits and decline in health status to the facility RN. b. Between 04/12/22 and 04/25/22 multiple facility staff documented the resident continued to decline, won't eat, had nausea, vomiting, stomach pain, won't get up for breakfast, and needed to assist the resident with meals in his/her room. On 04/18/22, Staff 22 (MT) documented in chart notes, unable to obtain BP due to resident had been septic while in the hospital (seven days ago).There was no documented evidence the facility staff referred Resident 2's continued decline in health status and increase in ADL care needs to the facility RN until 04/25/22 (two weeks later) at which time Staff 26 (RN) documented "was notified today that [s/he] is not eating and has not had a bowel movement since [his/her] return from the hospital. There are no bowel tones noted in any quadrant, even after palpation." Resident 2 was sent to the emergency room.c. On 04/26/22, Staff 3 (RCC) documented in chart notes, Resident 2 returned from the emergency room with a diagnosis of dehydration and a referral for hospice services. On 04/28/22 Staff 22 documented in chart notes, Resident 2 was admitted to hospice services. There was no documented evidence the facility determined actions or interventions for the resident, communicated the actions or interventions to staff and failed to refer the change in condition related to return from hospital with admission to hospice services to the facility RN. The need to ensure the facility determined interventions needed for residents with identified changes of condition, monitored the interventions for effectiveness, communicated the interventions and changes to staff and referred changes of condition to the facility RN when appropriate was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.


Based on observation, interview and record review, it was determined the facility failed to ensure a resident who had short-term changes of condition was evaluated, resident-specific instructions or interventions were developed, communicated to staff on each shift, reviewed for effectiveness and the condition was monitored to resolution at least weekly for 1 of 4 sampled residents (# 6), who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease.Review of the resident's 08/04/22 through 12/12/22 progress notes revealed the resident experienced the following changes of condition:* 09/02/22 - Medication change, decrease rivastgmine tablet (dementia) to 1.5 mg twice daily;* 09/19/22 - Admission to hospice, risk for weight loss;* 09/27/22 - Medication change, levothyroxine (hypothyroidism) discontinued; and* 10/22/22 - Resident-to-resident physical altercation.a. The facility failed to show documented evidence interventions were developed and communicated to staff on all shifts for Resident 6's medication changes and the physical altercation. In addition, the resident was not monitored with progress noted at least weekly through resolution regarding the physical altercation.b. The resident was admitted to hospice on 09/19/22 and was noted to be at risk for weight loss. The resident had a 09/20/22 physician's order for a nutritional supplement, (Two Cal) 90 milliliters three times per day. In an interview on 12/14/22, Staff 34 (MT) confirmed the nutritional supplement had not been administered to the resident between 11/01/22 and 12/13/22.There was no documented evidence the facility routinely monitored the resident's weight, reviewed the intervention for effectiveness or implemented new interventions when found to be ineffective.Short-term changes of condition and monitoring was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 1/2022 with diagnoses including chronic kidney disease and had a catheter.Resident 4's record was reviewed including progress notes dated 02/01/22 through 05/01/22. The progress notes revealed the following:* On 02/01/22 care staff reported the resident had blood coming from the catheter insertion site and leaking into his/her brief. S/he was also experiencing pain. The note included the RN was notified, but there was no documented evidence the RN assessed the resident or updated the service plan. * On 02/02/22 the RN was asked to look at a golf ball sized lump on the Resident's upper left thigh, but there was no documented assessment.* Progress notes on 02/18/22 identified the resident had "greenish white discharge coming from insertion point" of the catheter that had been "ongoing for about a week." The notes also documented there was a foul smell present, and Resident 4 had a decrease in range of motion in his/her legs "over the past few days." The Resident was unable to bend his/her legs, was complaining of hip pain, moaning in pain and was less responsive than normal. Resident 4 was sent out to the hospital.* On 02/19/22 the progress notes identified the resident returned to the facility from the hospital and was still having pain. The progress notes included there was blood around the tubing, brief and blankets.There was no RN assessment of the resident until 02/23/22. The assessment included the resident's pants had pulled on the catheter tubing causing issues and the tubing needed to be secured properly to the resident's leg. There was no documented evidence the RN assessed the drainage or the catheter pain. On 03/10/22 a progress note revealed the resident had pain associated with his/her catheter tubing with what appeared to be mucus draining from it. A subsequent note on 03/17/22 included there was "purulent drainage." Resident 4 was sent out to the hospital on 03/27/22 with "stroke like symptoms." Antibiotics were started at the hospital and the resident returned to the facility on 03/31/22 with a diagnosis of UTI with sepsis. There was no further assessment by the RN or documented evidence the service plan was updated with direction to caregivers on catheter care, properly securing the catheter tubing or interventions to ensure the resident did not continue to experience pain.In interview on 05/04/22, Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) the need for a timely RN assessment for a significant change of condition and the service plan to be updated by the RN was discussed. They acknowledged the findings. No additional information was provided.
3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II.Resident 5's clinical record, service plans, and temporary service plans were reviewed during the survey and identified the following:a. On 02/05/22,Resident 5 returned to the facility from a 30 day hospital stay. Resident 5 had not been receiving insulin before the hospitalization, but arrived with orders for insulin. Additionally, Resident 5 had used a walker for mobility before the hospitalization, and then bed bound and non-weight bearing due to fractures of both knees, requiring a Hoyer lift to transfer.There was no evidence Resident 5's significant changes had been assessed by an RN at return to the facility. b. A progress noted dated 02/10/22 documented "Resident was admitted to hospice this morning" and noted there would be medication changes, bath schedule changes, and a new bed. The admission to hospice constituted a significant change of condition. There was no evidence the change was reviewed by an RN until 02/16/22 when an RN note incorrectly stated Resident 5 had returned from the hospital on hospice on 02/05/22. The service plan was not updated to reflect hospice services and no instructions were developed for staff.The significant changes of condition and the need for an RN assessment that included findings, resident status, and interventions developed as a result of the assessment was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to conduct a significant change of condition assessment including findings, resident status and interventions made as a result of the assessment and update the service plan for 3 of 3 sampled residents (#s 2, 4 and 5) who experienced significant changes of condition related to return from hospital, falls, pain and decline in health status. Residents 2 and 4 continued to experience a decline and increased pain. Findings include, but are not limited to: 1. Resident 2 was admitted to the memory care facility in 04/2021 with a diagnosis of dementia. Resident 2's clinical record, service plan, temporary service plans and chart notes reviewed during the survey identified the following:Between 04/07/22 and 04/28/22 the resident was hospitalized on three occasions, had an increase in his/her ADL care needs related to meal assistance, mobility, an overall decline in his/her health condition and an admission to hospice services. These incidents represented a significant change of condition that required an RN assessment and update to the service plan.During an interview on 05/03/22, Staff 8 (CG), reported the resident "used to eat really well and would even try to take other resident's food. Now, s/he will barely eat anything and sometimes won't get up for breakfast. S/he started to decline about three weeks ago and is now on hospice."During an interview on 05/03/22, Staff 2 (RN), reported he was unable to locate an RN assessment for the decline in health status which resulted in multiple ER visits during the month of April 2022 and he was unable to locate an RN assessment for admission to hospice services. There was no documented evidence the facility RN conducted an assessment which documented findings, resident status, and interventions made as a result of this assessment and updated the service plan to reflect hospice admission, meal assistance and ambulation assistance. The lack of an evaluation and RN assessment resulted in the resident experiencing multiple hospitalizations, continued decline in condition and hospice admission. The significant changes of condition and the need for an RN assessment was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.Refer to C 270, example 1.

Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 1 of 1 sampled resident (# 4) reviewed for the delegation of insulin injections by unlicensed staff. Findings include, but are not limited to:Resident 4 was identified as having insulin-dependent diabetes and was administered insulin injections by non-licensed staff. On 05/02/22, the facility's RN delegation records were requested and revealed the following:* The previous facility delegating RN left the position on 04/30/22; and * There was no transfer of delegation documentation completed. In an interview with Staff 2 (RN), he stated the facility RN was no longer there and he would be filling in until they had one. He said the previous RN had not been in the facility since 04/26/22 even though her last day was to be 04/30/22 and did not do a transfer of delegation. He stated he let staff know he was available for questions or concerns, but had not completed any delegations of his own. Due to the facility not having a delegating RN, there were no MT staff with current delegations in place to administer insulin injections in the facility.Staff 1 (Executive Director) and Staff 2 provided an immediate plan for ensuring delegations were completed. Staff 2 completed delegation for a night shift MT and continued delegating staff the next morning to ensure there was a delegated staff member on each shift until all delegations could be completed.On 05/04/22, the need to ensure RN delegation was completed and maintained as required by rule was discussed with Staff 2, Staff 3 (RCC) and Staff 27 (Regional Director of Operations). They confirmed the findings.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers left written information in the facility that addressed the on-site service being provided and any supplemental care needed, for 1 of 3 sampled residents (#4) who received Home Health services. Findings include, but are not limited to:Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia and catheter care.The record indicated Resident 4 received home health services upon admission in 01/2022. Additionally, in 03/2022, weekly home health for wound care was started.The facility was only able to locate seven home heath provider notes since the resident was admitted in 01/2022. The need to ensure the facility had a system for coordinating on-site services with outside providers was discussed with Staff 2 (RN ), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:During the re-licensure survey, conducted 05/02/22 through 05/04/22, the survey team identified the following concerns:* C 282: RN Delegation and Teaching;* C 303: Medication and Treatment Orders;* C 310: Medication Administration; and* C 330: PRN Psychotropic Medications.During the exit meeting on 05/04/22, Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) were informed the overall medication and treatment administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas.
Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. This is a repeat citation. Findings include, but are not limited to:During the first re-visit to the re-licensure survey, conducted 12/12/22 through 12/14/22, the survey team identified the following concerns:* C 303: Medication and Treatment Orders; and* C 310: Medication Administration.During the exit meeting on 12/14/22, Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) were informed the overall medication and treatment administration system was determined to be inadequate based on the deficiencies related to the above medication areas.

2. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia.Resident 4's most recent signed physician's orders, 04/01/22 through 04/30/22 MAR, and 02/01/22 through 05/01/22 progress notes were reviewed, and the following deficiencies were identified:* Humulin was documented as not given because it was not available on 04/03/22 and 04/04/22; and* Humulin lacked documentation if it had been given on 04/16/22 at 8:00 pm, 04/17/22 at 8:00 am, 04/19/22 at 8:00 pm and 04/25/22 at 8:00 pm.There was no written, signed orders for the following:* Progress note dated 02/05/22 and 02/06/22 identified staff started a treatment on Resident 4's feet without orders; and* Progress notes dated 02/19/22 revealed Staff 21 (RCC) directed Staff 9 (MT) to administer PRN Tylenol as a routine medication and Staff 9 followed her direction.The need to ensure physician's order were followed and signed physician's orders were documented in the resident's facility record for all medication and treatments the facility was responsible to administer was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II. Review of Resident 5's hospital discharge orders dated 02/05/22, MARs dated 04/01/22 through 05/01/22, and progress notes dated 01/05/22 through 05/02/22 were reviewed during the survey and the following was identified:On 02/05/22 Resident 5 returned from a hospital stay with physician's discharge orders.A Medication Technician note dated 02/05/22 documented "insulin wasn't given tonight... I wasn't able to administer any PRN pain medications as we had to fax over all documents to the pharmacy".Review of the MAR from 02/05/22 to 02/11/22 documented the following hospital discharge orders were not followed:* Insulin Aspart 100 u/ml flexpen - 24 missed doses;* Insulin Glargine 100 u/ml pen - eight missed doses;* Donepezil 5 mg - four missed doses;* Metformin 500 mg one missed dose; and* Mirtazapine 7.5 mg two missed doses.On 02/11/22 the physician orders were clarified and the insulin was discontinued.On 05/05/22 the need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed or immediately clarified with the prescriber was discussed with Staff 2 (RN) and Staff 27 (Regional Director of Operations). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a legally recognized practitioner were documented in resident records and carried out as prescribed for 3 of 5 sampled residents (#s 2, 4 and 5) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 2021 with a diagnosis of dementia. Resident 2's hospital discharge orders dated 04/07/22, physician orders dated 04/09/22 and 04/28/22 and MARs dated 04/01/22 through 05/01/22 were reviewed during the survey and the following was identified:a. The physician orders dated 04/09/22 were not signed and accessible in the resident's chart;b. PRN Miralax 17 gm pack originally prescribed on 11/12/21 for no bowel movement in three days and instructed staff to contact the health care provider if the resident did not have a bowel movement after two doses; andhospital discharge orders dated 04/07/22 prescribed Miralax every six hours if the resident didn't have a bowel movement within two days of returning to the facility.There was no documented evidence the facility followed the PRN Miralax orders written on 11/12/21 or contacted the health care provider when the resident failed to have a bowel movement prior to being sent to the ER on 04/07/22. Additionally, the facility failed to follow the hospital discharge orders for Miralax every six hours until the resident had a bowel movement.During an interview on 05/04/22, Staff 2 (RN) and Staff 3 (RCC) indicated the facility staff were suppose to monitor and track bowel movements on hand written sheets of paper on each shift and give them to the RCC. Staff 2 and 3 were unable to locate documentation staff monitored Resident 2's bowel movements to ensure the PRN bowel medications were administered as prescribed.c. On 04/11/22, Resident 2 returned to the facility with hospital discharge orders that prescribed Culturelle (probiotic) for seven days while on Cipro. Instructions were given to hold fortified beverages while on the antibiotic. The MAR pass notes indicated the culturelle was not received and the resident was not administered culturelle while taking Cipro and the facility failed to hold daily Med Pass 2.0 (fortified beverage). d. On 04/28/22, Resident 2 was prescribed Tylenol, TID and Senna 1 tablet, daily. The medications were not transcribed on the MARs and Resident 2 had not been administered the medications. On 05/05/22 the need to ensure all written, signed orders from a legally recognized practitioner were documented in resident records and carried out as prescribed was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, for 2 of 4 sampled residents (#s 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 9 was admitted to the facility in 06/2017.A review of the 11/01/22 through 12/12/22 MARs and current physician's orders revealed the following:Resident 9 had a physician order for lispro (insulin for diabetes) 10 units to be given before meals. The MAR indicated on 11/16/22 at 4:30 pm, only 3 units of lispro had been administered instead of 10 units. On 11/17/22 at 7:30 am, there was no documented evidence lispro was administered as ordered. An Administration History entry of the lispro on 11/16/22 indicated that there were only 3 units of medication left and the ordered dose could not be given at 4:30 pm. A second entry dated 11/17/22 revealed the facility was out of the medication and the 7:30 am dose could not be administered. The physician was notified of both incidents and there was not a documented negative outcome to the resident.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 35 (ED) on 12/14/22. He acknowledged the findings.

2. Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia.Resident 8's 11/08/22 through 12/12/22 MARs and current physician orders were reviewed. There was a current order for PRN Carboxymethylcellulose (eye drops) noted on the MAR.During an interview on 12/13/22 with Staff 34 (MT) s/he verified the order however stated the medication was not available for the resident to use if requested. The need to ensure that physician's orders were carried out as prescribed was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure that MARs contained reason for use, resident-specific parameters for PRN medications and clear instruction to staff for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3's 04/01/22 through 04/30/22 MARs were reviewed. Resident 3's physician orders and 04/2022 MARs were reviewed and revealed the following:The following medications did not include a reason for use:* Aspirin (heart health);* Donepezil (Alzheimer's disease);* Lisinopril (hypertension);* Mirtazaoine (depression);* Simvastatin (hyperlipidemia); and* Vitamin B 12 (supplement). In an interview with Staff 2 (RN) at 2:30 pm on 05/03/22, he acknowledged the lack of reasons for use.The need to ensure an accurate MAR was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (RCC) on 5/03/22. They acknowledged the MARs were not accurate.
2. Resident 4 was admitted to the facility in 01/2022 with diagnoses including diabetes. Resident 4's physician orders and 04/2022 MARs were reviewed and revealed the following:The following medications did not include a reason for use:* Plavix (blood thinner);* Vitamin C (supplement);* Zinc Sulphate (supplement);* Zinc oxide (sealant);* Nystatin (antifungal);* Aspirin; and* Ciprofloxacin (antibiotic).The following medication was given by one MT, but documented by another MT:* Humulin (insulin).The following medications had blanks on the MAR:* Ciprofloxacin;* Humulin;* Memantine (for dementia);* Quetiapine (antipsychotic):* Bedtime snack;* Foot treatment;* Nystatin;* Povidone iodine; and* Pressure area treatment to heels.The need to ensure an accurate MARs was reviewed with Staff 2 (RN), Staff 3 (RCC), and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
4. Resident 5's 04/01/22 through 05/02/22 MAR was reviewed during the survey. The following medications lacked a reason for use: * Calcium carbonate (calcium supplement);* Glucerna (sugar free nutrition);* Acetaminophen (analgesic);* Metformin (oral blood sugar;* Mirtazapine (antidepressant);* Polyethylene glycol (laxative);* Senna (laxative); and * Sertraline (antidepressant).The need to ensure MARs were accurate and included reasons for use was discussed with Staff 2 (RN) on 05/04/22. He acknowledged the findings.
3. Resident 2 was admitted to the MCC in 04/2021 with a diagnosis of dementia.Resident 2's 04/01/22 through 05/02/22 MARs were reviewed and identified the following:a. The following PRN medications prescribed to treat the same condition lacked clear instructions for unlicensed staff regarding the sequence of administration (which one to administer first, second, etc.)* PRN Tylenol 325 mg tablet and PRN Tylenol 625 mg suppository; * PRN Miralax 17 gm pack, twice daily and PRN phosphate/saline enema once daily both had instructions to administer after three days without a bowel movement; and* PRN Miralax 17 gm pack twice daily and PRN bisocodyl suppository once daily lacked instructions for which one to use first.b. The following inaccuracies on the MAR were identified:* PRN Miralax Powder and PRN Miralax 17 gm pack were discontinued on 04/28/22, however the medications were still transcribed on the May 2022 MAR. Resident 2 had not been administered either of the medications. The need to ensure MARs were accurate and included parameters for PRN medications was reviewed with Staff 2 (RN), Staff 3 (RCC), and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
2. Resident 9 was admitted to the facility in 06/2017 with diagnoses including diabetes and dementia.Resident 9's 11/01/22 through 12/12/22 MARs were reviewed and identified the following blanks:* 11/07/22 - 8:00 pm atorvastatin (for cholesterol);* 11/07/22 - 8:00 pm Lantus (for diabetes);* 11/07/22 - 8:00 pm metformin (for diabetes); and* 11/17/22 - 8:00 pm Lantus.On 12/14/22, the need to ensure MARs were accurate and included if a medication was administered and by whom was discussed with Staff 35 (ED). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for all medications prescribed by a legally recognized practitioner and administered by the facility for 3 of 4 sampled residents (#s 7, 8 and 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the memory care community in 02/2021 with diagnoses including dementia and insomnia.Review of Resident 7's MAR, dated 11/01/22 through 12/12/22, identified the following:The MAR contained blanks in dosage administration for the following medications: * Benztropine (for muscle control/stiffness) - 11/10/22, 11/11/22 and 11/13/22;* Lorazepam (for anxiety) - 11/11/22; and* Mirtazapine (for unspecified dementia) - 11/10/22, 11/11/22 and 11/13/22.On 12/14/22 the need to ensure accurate MARs were kept for all medications prescribed by a legally recognized practitioner and administrated by the facility was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings. No further information was provided.
3. Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia. Resident 8's MARs dated 11/08/22 through 12/12/22, current physician's orders and interview and observation with Staff 34 (MT) on 12/13/22 at 12:45 pm of Resident 8's available medications were reviewed and revealed the following discrepancies:*Duplicate entries of medications were identified on the MAR for apixaban/Eliquis (blood clots), furosemide (edema), nifedepine (blood pressure) and Carboxymethylcellulose sodium 0.5%/Lubricating Plus 0.5% (dry eyes).*Review of the physician order's for Resident 8 identified the following: nifedepine (for blood pressure) stated one 30 mg tab to be taken by mouth daily and on the MAR it is stated as one 60 mg tab.*Review of the available medications identified there were two medication bottles available for administration for furosemide (for edema). One of the bottles contained 40 mg tabs and the other bottle contained 20 mg tabs. The physician's order and the MAR stated one 20 mg tab was to be taken by mouth every morning. Medication Pass Notes on the reviewed MARs identified dates when 40 mg tab was cut in half prior to administration, but it was uncertain as to which tab was given each time the medication was administered. The need to ensure the accuracy of the MAR was discussed with Staff 35 (ED), Staff 37 (Director of Operations) and Staff 38 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had resident-specific parameters, staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering the medications, direct care staff administering the medications had knowledge of common side effects and when to contact a health professional regarding side effects, and all direct care staff had knowledge of non-pharmacological interventions for 2 of 2 sampled residents (#s 1 and 5) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:1. Resident 5 moved into the facility in 2020 with diagnosis including dementia and Diabetes Type II.Review of the resident's service plan, physician orders, and 04/01/22 through 05/02/22 MAR revealed the following: Resident 4 was prescribed Lorazepam 0.5 mg (anti-anxiety medication) one tablet every hour PRN for anxiety. The facility failed to ensure the resident's MAR and clinical record included the following required information:* Resident-specific parameters regarding how Resident 5 expressed anxiety;* Common side effects; * When to contact a health professional regarding side effects; and * Non-pharmacological interventions to attempt prior to administration of the medication. The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 2 (RN) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided.
2. Resident 1 was admitted to the facility in October 2022 with diagnoses including dementia and depression. The resident was prescribed Risperidone PRN for agitation. The clinical record, including the March 1, 2022 through May 3, 2022 MARs, current service plan and temporary service plans failed to include information on resident-specific symptoms of "agitation".The need to ensure the facility included resident-specific parameters for use of psychotropic medications was discussed with Staff 3 (RCC) on 05/04/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 8, 11 and 14) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 05/04/22 and identified the following:Staff 8 (CG) hired 01/05/22, Staff 11 (CG) hired 02/01/22 and Staff 14 (CG) hired 03/08/22 lacked documentation of demonstrated competency in First Aid/abdominal thrust.The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.
Based on record review and interview, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 21, 25) completed First Aid and Abdominal Thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:Staff training records were reviewed on 12/13/22 and 12/14/22. The following deficiencies were identified:Staff 25 (MT) was hired 11/18/22 and Staff 21 (MT/CG) was hired 10/20/22. There was no documented evidence Staff 25 or Staff 21 completed First Aid and Abdominal Thrust training within 30 days of hire.The need to ensure staff completed all required training as specified in the OARs was reviewed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 12:20 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers, and multiple resident that were bed bound or used wheelchairs for mobility. The MCC housed residents on four floors, with two stairwells and one elevator.On 05/04/22, the facility's fire and life safety records were requested for review.There was no documented evidence of the following general fire and life safety requirements: * Evidence of fire drills completed on alternate months;* Evidence of life safety instruction other months;* Evidence alternative exit routes were used during fire drills; * Residents ability to participate in an evacuation;* Staff interviewed were not aware of the designated point of safety;* Evidence staff and residents participated in fire drills and training to assess ongoing evacuation capabilities of both residents and staff; and* Documentation of interventions and resolution related to resident evacuation concerns identified during fire drills.The need to ensure all general fire and life safety requirements were implemented and followed was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months, and staff interviewed did not know the designated point of safety. This is a repeat citation. Findings include, but are not limited to:* Fire and life safety records, reviewed between 07/2022 and 12/2022, revealed fire and life safety instruction was not provided to staff on alternate months; and* During interviews on 12/13/22, Staff 28 (CG) and Staff 38 (CG) indicated they were unaware of the location of the designated point of safety for evacuating residents.The need to ensure that staff received fire and life safety instruction on alternate months and that all staff were aware of the designated point of safety was discussed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 12:20 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers, and multiple resident that were bed bound or used wheelchairs for mobility. The MCC housed residents on four floors, with two stairwells and one elevator.On 05/04/22, the facility's fire and life safety records were requested for review.There was no documented evidence of the following fire and life safety requirements for residents: * No evidence that each resident was instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and* No written record of fire safety training, including content of the training sessions and the residents attending.There was no documented evidence residents ability to evacuate the building or follow instructions in an emergency had been evaluated or resident training provided and documented.The need to ensure all resident fire and life safety requirements were implemented and documented was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C150, C231, C252, C260, C270, C300, C303, C310, C372, C420, C460, C510, C513, Z155 and Z164.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the condition placed on the facility by the Department of Human Services (DHS). Findings include, but are not limited to:On 07/01/21, the facility was placed under a condition to ensure they had six caregivers and 2 Medication Aides on Day and Evening shifts and four caregivers and 1 Medication Aide on NOC shift. The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers or during care and dementia diagnoses. Review of the MCC schedule from 04/1/22 to 05/02/22, observations, and interviews confirmed the facility failed to have six caregivers on the Day or Evening shifts 54 times and failed to have four caregivers on the overnight shift 19 times.In an interview with Staff 1 (Executive Director), on 05/03/22, he stated they were waiting for additional staffing through a state assistance program. In the interim, current staff were frequently scheduled for double shifts.The need to ensure sufficient staffing to meet the scheduled and unscheduled resident needs based on the condition that was place on the facility, was discussed with Staff 1 on 05/03/22. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the condition placed on the facility by the Department of Human Services (DHS). This is a repeat citation. Findings include, but are not limited to:On 07/01/21, the facility was placed under a condition to ensure they had six caregivers and two Medication Aides on Day and Evening shifts and four caregivers and one Medication Aide on NOC shift. The facility was an endorsed Memory Care Community home to 43 residents at the time of the first re-visit to the relicensure survey. During the acuity interview on 12/12/22 the facility was identified to have residents with high ADL care needs and dementia diagnoses. Review of the MCC schedule from 12/1/22 to 12/14/22, observations, and interviews confirmed the facility failed to have six caregivers on the Day or Evening shifts 16 times and failed to have four caregivers on the overnight shift five times.The need to ensure sufficient staffing to meet the scheduled and unscheduled resident needs based on the condition that was placed on the facility, was discussed with Staff 35, Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit. Findings include, but are not limited to:The interior and exterior of the building was toured on 05/03/22 and 05/04/22. The following issues were noted:On 05/03/22, multiple observations were made of bottles with disinfectant cleaner accessible to the residents on the countertops and in unlocked cabinets of the dining room kitchenettes on the first, second and fourth floors of the facility.The need to ensure all toxic materials were maintained in locked storage to avoid access by residents was discussed with Staff 1 (Executive Director) and Staff 5 (Food Service Director) on 05/03/22 and Staff 6 (Maintenance Director) on 05/04/22. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit. This is a repeat citation. Findings include, but are not limited to:During a tour of the facility on 12/12/22 at 1:15 pm the following was identified:* The door next to Room 102 that opened to a corridor leading to the kitchen on the ground floor was not closed and secured. Cleaning materials were observed to be in the corridor that connected to the kitchen. The kitchen door was also opened allowing residents full access to the kitchen. A walk through with Staff 35 (Executive Director), Staff 32 (Maintenance Director), and Staff 24 (Maintenance Assistant) was conducted on 12/13/22 at 11:00 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:Observations of the facility on 05/02/22 through 05/04/22 showed the following areas were in need of cleaning and/or repair:On the first floor:* A door leading to the back kitchen corridor (near Room 102) could not close completely and latch;* A section of flooring in the hallway in front of the elevator was lifting and uneven, with areas peeling away;* Walls, chair rails and door jambs in the dining room were scuffed, gouged and had some areas of chipped paint; and* Walls on the hallway leading to the medication room had patched but unpainted holes.On the second floor:* An area of the wall was damaged leaving exposed drywall next to the "mechanical room"; and* The trim and door jamb around the elevator was scuffed, gouged and had peeling paint.On the third floor (no residents currently resided on this floor):* A section of exposed wiring on the wall next to the medication room; and* The double doors leading to the balcony area were unsecured, leaving access to a stair way.On the fourth floor:* Room 416 door jambs on the bathroom door and apartment door were gouged, scuffed and had missing paint.The need to ensure the environment was kept clean and in good repair was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained, clean, and in good repair. This is a repeat citation. Findings include, but are not limited to:Observations of the facility on 12/12/22 showed the following areas in need of cleaning and/or repair:a. First floor entrance, hallway, and resident rooms:* Flooring section in front of elevator was damaged and uneven;* Ceiling vent in the main entrance was covered with dust;* The door leading to the back kitchen corridor next to Room 102 was unable to be latched and secured;* Wall corner next to Room 120 was damaged with chipped paint; * Room 120 bathroom was missing a toilet paper holder; and* Room 124 flooring areas in the bathroom and upon entrance had uneven and bulging floor sections.b. Second floor:* Water damage stains and peeling paint on the ceiling arch in the dining room entrance next to the "mechanical room"; and * A section of window was missing and patched with cardboard in the seating area next to Room 219.The areas in need of cleaning and/or repair were shown to and discussed with Staff 35 (Executive Director), Staff 32 (Maintenance Director), and Staff 24 (Maintenance Assistant) on 12/13/22 at 11:00 am. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 150, C 231, C 240, C 372, C 420, C 422, C 460, C 510 and C 513.
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 C150, C231, C372, C420, C460, C510 and C513.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 6, 8, 11 and 14) completed pre-service orientation topics, 1 of 3 newly-hired direct care staff (#11) failed to complete 6 hours of pre-service dementia care training, 3 of 3 newly hired staff failed to complete all required training and demonstration of competency (#s 8, 11 and 14) and 3 of 3 sampled long term direct care staff (#s 7, 12 and 16) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:Training records were reviewed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. The following were identified:a. Staff 6 (Maintenance Director), was hired 02/02/22, Staff 8 (CG) hired 01/05/22, Staff 11 (CG) hired 02/01/22 and Staff 14 (CG) hired 03/08/22. There was no documented evidence the following orientation topics were completed: * Resident rights and values of CBC care; * Abuse reporting requirements;* Standard precautions for infection control; and* Fire safety and emergency procedures. b. There was no documented evidence Staff 11 had completed pre-service dementia care training.c. There was no documented evidence that Staff 8, Staff 11 and Staff 14 completed the required training in:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging; * Changes of condition and changes that require reporting; and* General food safety, serving and sanitation.d. Staff 7 (CG) was hired 01/29/2015, Staff 12 (CG) was hired 03/01/14 and Staff 16 was hired 04/20/15. For the annual period of their respected hire dates, there were no documented hours of the required 16 hours of in-service training on topics related to dementia and provision of care.The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, that newly hired staff demonstrated and documented required 30 day competencies and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 3 and Staff 27 on 05/04/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 25 and 30) completed all required training and demonstrated competency, 3 of 3 sampled long term direct care staff (#s 12, 29 and 31) completed a total of 16 hours of annual in-service training, including six hours of annual dementia care training, and 2 of 3 sampled newly hired direct care staff (#s 25 and 30) completed orientation and pre-service topics. This is a repeat citation. Findings include, but are not limited to:Training records were reviewed on 12/13/22 and 12/14/22. The following were identified:a. Staff 25 (MT) hired 11/18/22 and Staff 30 (MT/CG) was hired on 08/05/22. There was no documented evidence the following orientation topics were completed:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging; * Changes of condition and changes that require reporting; and* General food safety, serving and sanitation.b. There was no documented evidence Staff 30 had completed Med Pass training.c. There was no documented evidence that Staff 25 and Staff 30 completed the required training in: * Resident rights and values of CBC care; * Abuse reporting requirements;* Infectious Disease Prevention; and* Fire safety and emergency procedures. The need to ensure newly hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, that newly hired staff demonstrated and documented required 30 day competencies and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations)on 12/14/22 at 12:20 pm. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 303, C 310 and C 330.
Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C252, C260, C270, C300, C303 and C310.

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 service plans for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:Residents 1, 2, 3, 4 and 5's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. On 05/04/22, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 2 (RN), Staff 3 (RCC), Staff 27 (Regional Director of Operations). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 5 of 5 sampled residents (#s 1, 2 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, 4 and 5'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 and scheduled activities did not happen on each floor of the building.On 05/04/22 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 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations), who acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure individualized activity plans were developed for each resident, based on their activity evaluations, for 1 of 4 sampled memory care residents (#7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 7 was admitted to the MCC in 02/2021 with diagnoses including dementia and insomnia.Residents 7's service plan offered some information about the residents' historical and current interests. However, the facility had not fully evaluated the resident in the following areas:* Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; and* Adaptations necessary for the resident to participate.There was no specific activity plan developed from the evaluation which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.On 12/14/22 the need to ensure the facility developed individualized activity plans for each resident in the MCC was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the community and include information and instructions for staff to follow, for 1 of 1 sampled resident (#1) who exhibited behaviors. Findings include, but are not limited to:Resident 1 resided on the memory care unit since October 2021 and was diagnosed with Alzheimer's dementia. Progress notes indicated the resident became agitated and was involved in a physical altercation with another resident on 02/16/22. Other progress notes, reviewed from 02/01/22 through 04/03/22, indicated the resident would occasionally become agitated and difficult to re-direct, wandered through the unit and occasionally went into other resident's rooms. The resident's current service plan, dated 08/11/21, did not provide any information on agitation, behaviors or interventions for staff to provide when behaviors occurred. The resident had a physician's order for staff to administer a psychotropic medication as needed for agitation.In an interview on 05/02/22, Staff 8 (CG) stated the resident would often require re-direction if s/he got into arguments with other residents or entered other resident's rooms. The facility failed to evaluate Resident 1's behavior, add information about the behavior to the service plan and develop interventions for staff to attempt when the behaviors occurred.The need to evaluate Resident 1's behavior and provide an individualized behavior plan was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Based on interview and observation, it was confirmed the facility failed to ensure reasonable precautions in regard to infection control. Findings include: On 01/05/2021 Compliance Specialist (CS) observed multiple facility staff to either pull down their face mask to talk to each other or wear their face mask leaving their noses exposed. On 1/13/2021 Staff #6 (S6) was observed with his/her eye protection flipped up on their forehead.During separate interviews on 1/13/2021, Staff #2 (S2) and Staff #3 (S3) both stated that the facility had Staff #7 (S7) working when s/he was covid positive. The above findings were discussed with Staff #1, who was in agreement.