Cedar Crest Alzheimer Special Care Center

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 03/27/24 at 11:00 am the kitchen was observed and the following areas of concern were identified: * The interior of the microwave had food splatters; * The sides of stove/grill had food spills/drips; * Ceiling vents (above steam table, dishwashing room and beverage station) were dusty and the ceiling area surrounding the vents had accumulation of dust; * Ceiling vent grate above toaster had a heavy layer of dust; * Ceiling light in dishwashing area was not covered; * Improper glove use: staff were not washing hands between glove changes; used the same gloved hands between dirty and clean tasks; * Staff failed to wash hands when returning to the kitchen; * Staff returned to the kitchen with gloved hands without washing hands and/or changing gloves before beginning another task; and * Non-kitchen employees delivered carts/trays/soiled dishes to the dishwashing area within the kitchen. The areas of concern were observed and discussed with Staff 1 (Culinary Director) and discussed with Staff 2 (Executive Director) on 03/27/24. The findings were acknowledged.

C 240 Resident Service Meals, Food Sanitation Rules 1. Spills/Splatters/Dust-      a. The microwave was cleaned of any splatters.          Completed- 3/27/24 by Culinary Service Director      b. The side of the oven was cleaned of any spills/drips.          Completed- 3/27/24 by Culinary Service Director      c. Ceiling vents were cleaned of any dust.          Completed- 3/27/24 by Maintenance Director      d. Light fixture- will be replaced by a new fixture with            cover. On order ETA 4/8/24, by Maintenance Director      e. Glove usage- staff in-service completed by CSD on            appropriate glove usage and handwashing.          Completed-3/29/24       f. Non-dietary staff in the kitchen- dietary and care staff          in-serviced on leaving dirty dishes and carts outside          the kitchen alleviating entering the kitchen by CSD.          Completed- 4/1/24 2. Cleaning tasks 1a, 1b, and 1c will be included in kitchen staff weekly and monthly deep clean tasks by CSD/designee. Maintenance Director/designee will conduct monthly building walk-thru to identify broken or malfunctioned items and report results to the ED. Culinary Director/designee to do weekly spot checks on glove usage by dietary staff and non-dietary staff coming into the kitchen and report results to ED. 3. All areas of the kitchen will be examined weekly by the CSD/designee for basic cleaning and monthly for deep cleaning. CSD/designee to monitor completion of Daily, Weekly, Monthly cleaning task lists. Maintenance Director will perform monthly walk-thru inspection of kitchen. All staff will be provided with training on food sanitation and glove usage upon hire and at minimum annually through in-services completed by ED and HSD. 4. The Culinary Director, Maintenance Director and Executive Director are responsible for corrections. Results of audit findings will be reviewed monthly at CQI meeting by ED and corrective measures taken as needed.

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

Z 142- Administration Compliance 1. All corrections made under C240 POC. 2. All changes to systems made under C240 POC. 3. All evaluations indicated under C240 POC. 4. Culinary Director, Maintenance Director and Executive Director responsible for corrections and compliance.

The findings of the kitchen inspection, conducted 03/27/24, are documented in this report. The survey was conducted to determine compliance with the OARS 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen inspection of 03/27/24, conducted on 05/28/24 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to ensure the resident evaluation was complete, for 1 of 1 sampled resident (#2) who utilized an assistive device on his/her bed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. During the survey, the resident was observed to have a partial-length side rail on the open side of his/her bed. Throughout the survey, the side rail was observed in the down position. In an interview on 06/08/23, Staff 8 (CG) stated staff did not raise the side rail because the resident did not want the device to interfere with him/her being able to reach items on his/her over-bed table. A HH PT note dated 05/25/23 documented the side rail was recommended but the resident refused its use because it restricted his/her movement. The facility failed to evaluate the use of the device and document how it was being used. The need to ensure the facility evaluated the use of all assistive devices and documented how they were being used was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

The need to ensure the facility evaluated the use of all assistive devices and documented how they were being used. 1.RN completed an assessment of the use of side rail for Res 2 by completing the Sinceri form "Supportive Device Assessment and Re-Assessment on 7/11/23. It was found that the resident does not want the side rail and refuses to use. The side rail has been removed from the bed and is no longer available for use. A observation note was made to document the decision and actions related to removal of the device. HSD/Designee was reeducated on the supportive device guideline on 7/11/23 by ED. HSD/Designee concucted an audit of residents who use supportive devices on 7/11/23 ED/designee will reeducate all staff via in-service on the use of supporive devices and reassessments by 7/13/23. 2. HSD/Designee will audit weekly using a nursing  spreadsheet that has been created for the HSD/Designee which will include all current devices in use and when the next assessment due date is. The HSD/Designee will review all outside provider forms before filing them in resident's chart. 3. The nursing follow-up spreadsheet will be reviewed by the HSD weekly for tasks due. The ED will also have access to this spreadsheet and will review it monthly to ensure compliance. The RCC will review each individual care plan quarterly for accurateness to ensure all devices are listed on the care plan with instruction. Results will be reported to QAPI Director and committee at next scheduled meeting. 4. The ED/Designee and HSD/Designee all have responsibility in ensuring corrections are made and the system is maintained as outlined

3. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. a. The resident's record was reviewed, staff were interviewed and the resident was observed and interviewed during the survey. Resident 2's current service plan, dated 05/11/23, was not reflective of his/her current status and care needs or lacked information in the following areas: * Dressing - resident only wore a top; * Bathing - specifically bed baths were being provided by hospice; * Need to ensure resident's call device was always available and not inadvertently removed from his/her room by other residents; and * Correct use and precautions related to the resident's use of a side rail on the bed. b. In progress notes dated 04/07/23 and 04/16/23 staff identified new interventions to respond to the resident's challenging behavior. There was no documented evidence these interventions were added to the resident's service plan, communicated to staff or implemented. c. Following an incident on 05/19/23 where the resident was found on the floor, the facility added a new intervention to the resident's service plan: "Keep AD [assistive device] in sight to provide visual reminder to utilize." It was unclear as to what assistive device this referred to (wheelchair, call device, etc). The need to ensure Resident 2's service plan was reflective of his/her current needs and was updated as new interventions were developed was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings. 4. Resident 5 was admitted to the facility in 12/2022 with diagnoses including Alzheimer's disease. The resident's 05/17/23 service plan, Change in Plan of Care Communication forms and observation notes dated 01/15/23 through 06/06/23 were reviewed during the survey. The resident was noted to have experienced the following challenging behaviors between 01/2023 and 05/2023: * Verbal aggression; * Resident to resident physical altercations; * Physical aggression towards staff members; * Inability to be redirected; and * Hallucinations, including an incident where the resident broke a window in his/her unit. The facility implemented interventions for the resident's challenging behaviors at the time of occurrence, however, the 05/17/23 service plan failed to include the historical information. The need to ensure Resident 5's service plan included prior historical information was discussed with Staff 1 (ED) and Staff 3 (RCC) on 06/07/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 04/2019 with diagnoses including dementia. Resident 1's 03/22/23 service plan and Change in Plan of Care Communication forms dated 05/18/23 through 06/01/23 were reviewed, the resident was observed, and staff were interviewed. The service plan had not been updated when the resident experienced a significant change of condition on 05/20/23 when s/he transitioned to hospice. Additionally, the service plan was not reflective and did not provide clear caregiving instruction in the following areas: * Meals taken in the south dining room for increased assistance; * Adaptive equipment, including use of a geriatric wheelchair; * Mechanical soft diet; * Physical expressions of pain; * Outside providers; and * Bathing routine, including how to manage the resident's associated behaviors. The need to ensure service plans were updated after a significant change of condition was identified, were reflective of current care needs and provided clear instruction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services and were reviewed and updated following a significant change of condition for 4 of 4 sampled residents (#s 1, 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including dementia. The resident's current service plan dated 03/22/23 was reviewed, observations were made and interviews with the resident and caregivers were conducted between 06/06/23 and 06/08/23. Resident 3's service plan was not reflective or did not provide clear direction to staff following areas: * Behaviors; * Environmental factors impacting resident's behavior; * Grooming, dressing and personal hygiene; * Incontinent care; * Assistive devices, including adaptive utensils and wheelchair; * Evacuation assistance; * Meal assistance; * Beverage preferences; * Activities and assistance required to participate; and * Mobility and transfers. The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

Service Plan General-The need to ensure service plans are updated after a significant change of condition was identified, are reflective of current care needs and provide clear instruction to staff. 1. HSD/Designee audited all resident records with a change of condition, upated service plans and notified staff on condition changes.  Care plans for Res 1, 2, and 4 were updated  with missing information indicated in the SOD on 7/11/23 .Res 3 passed away after completion of this survey. ED will re-educate HSD/RCC on creating a comprehensive and accurate care plan after change of condition on 7/11/23. HSD and RCC will complete an online training entitled Person Centered Care Planning for People Living with Dementia on Relias by 7/17/23. ED, HSD, and RCC will complete a webinar training on the ALIS website entitled Integrated Evaluations and Service Plans by 7/14/23. 2. ED, HSD and RCC will all participate in a triple check system for creation of all service/care plans. When the initial assessment and service plan are created by the ED or HSD then the other 2 staff will proof read them for thoroughness, individualized information and that all aspects of the care plan have specific instructions for staff. This same process will happen at the 30 day and 90 day service plan updates, as well as change of condition updates. All 3 staff will read each service plan to determine they are up to date, accurate and thorough. HSD will maintain a nursing follow-up spreadsheet which will include all residents who have experienced a significant change of condition in the past 90 days. The spreadsheet will include start date and next date to document on monitoring. This will alert the HSD to ensure all monitoring and updating of service plan happens on time. 3. All service plans will be reviewed as due- initial, 30 day, 90 day and when a change of condition occurs. Otherwise, all care plans will be reviewed on-going every 90 days. The nursing follow-up spreadsheet will be reviewed weekly by the HSD to ensure all tasks due are completed. The ED will also monitor the follow-up spreadsheet at minimum twice a month for completion. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. The ED/Designee all have responsibility in ensuring corrections are made and the system is maintained as outlined

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of resident needs as identified in the resident evaluation, provided clear direction to staff regarding the delivery of services and were followed for 5 of 5 sampled residents (#s 6, 7, 8, 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6, 7, 8, 9 and 10's service plans were reviewed during the survey. For each of the residents, there was information in the resident's evaluation related to the his or her needs and services that was not included in the service plan. Some of the areas in the service plans lacking information included cognitive and behavioral functioning and interventions, speech issues, bathing and sleep routines, and eating habits. In interviews on 09/19/23 and 09/20/23, Staff 1 (ED), Staff 3 (Former RCC/Marketing Director) and Staff 21 (Charge Nurse) acknowledged the service plans did not include some information that was included in the resident evaluations. The need to ensure service plans were reflective of all the information contained in the residents' evaluations was reviewed with Staff 2 (Health Services Director - LPN), Staff 3 and Staff 21 on 09/21/23. They acknowledged the findings. 2. Resident 7 was admitted to the facility in 09/2022 with diagnoses including dementia, atopic dermatitis, and history of alcohol dependence. The resident's current evaluation and service plan, both dated 08/23/23, and temporary service plans were reviewed, observations of the resident were made, and care staff were interviewed regarding the resident's care needs and services. The resident's service plan noted the resident often asked to be placed in and out of chairs and required staff assistance to transfer safely. The service plan also noted the resident often slept in common areas and directed staff to redirect the resident into a comfortable recliner or chair to get sleep and to reduce the risk of falling out of his/her wheelchair. On 09/19/23, between 11:30 am and 12:05 pm, the resident was observed seated in his/her wheelchair in the north TV room holding onto and the back of an armchair. At times, the resident appeared to try to get around the chair. On 09/20/23, between 8:45 am and 12:00 pm and between 12:25 pm and 2:45 pm, the resident was positioned at a large round table in the front lobby area seated in his/her wheelchair. During these times, the resident was often observed with his/her head down, eyes closed and motionless. At 2:45 pm, Staff 7 (MT) asked the resident if s/he wanted to lay down in her/his bed at which point she escorted the resident to his/her room for a nap in bed. On 09/21/23, between 8:30 and 12:05 pm, the resident was positioned at the large table in the front lobby seated in his/her wheelchair. Again, during this time, the resident appeared asleep at the table. The facility staff failed to follow the service plan which directed them to offer to transfer Resident 7 to a more comfortable chair to facilitate his/her comfort, desire to sleep and to reduce the risk of a fall out of the wheelchair. The need to ensure services identified in resident service plans were provided by staff was reviewed with Staff 2 (Health Services Director - LPN), Staff 3 (Former RCC/Marketing Director) and Staff 21 (Charge Nurse) on 09/21/23. They acknowledged the findings. 3. Resident 10 was admitted to the facility in 05/2023 with diagnoses including dementia. The resident's current evaluation and service plan, both dated 08/25/23, and temporary service plans were reviewed, observations of the resident were made, and the resident and care staff were interviewed regarding his/her care needs and services. The resident's service plan dated 08/25/23 noted the resident "[w]ears glasses daily... Lead will ensure [s/he] has glasses on daily and will keep glasses in med cart overnight for safe keeping." During an interview at 2:00 pm on 09/19/23, Resident 10 asked for his/her glasses "so I can see things." Observations made from 09/19/23 through 09/21/23, during the interview, while the resident was in common areas and during meals, revealed the resident did not have his/her glasses placed. During an interview at 2:45 pm on 09/19/23, Staff 23 (MT) confirmed the resident's glasses were kept behind the front desk, but she did not know if s/he wore them every day. During an interview at 2:00 pm on 09/19/23, Staff 26 (CG) stated he had not seen the resident wear glasses on swing shift. The need to ensure services were implemented and staff followed the service plan was discussed with Staff 2 (Health Service Director - LPN), Staff 3 (Former RCC/Marketing Director), Staff 19 (RCC) and Staff 21 (Charge Nurse) on 09/21/23. They acknowledged the findings, and no additional information was provided.

C260-Service Plan General 1. HSD/Designee will update all resident care plans named in SOD residents 6,7,8,9, 10 and add specific resident needs to careplan by 10/20/23. HSD/Designee will audit all other resident care plans to ensure care plans are up to date by 11/5/23. ED/Designee will conduct a staff inservice with all lead clinical staff and other care team members on reviewing care plans and ensuring all resident specific interventions are followed by 10/20/23. The HSD/Designee will track compliance with careplans weekly on data tracker sheet on-going until complaint. 2. Regional Health Service Director will reeducate HSD/Designee on creating a comprehensive and individualized careplans by 10/20/23. On-going staff training will be provided to caregivers to follow care-plans by members of nursing dept through daily oversight during rounds to help minimize any lack of services. 3. HSD/Designee will review care plans for accuracy and update them quarterly or when there is a change of condition. 4. The ED and HSD are responsible for providing oversight of resident care plans and implementation.

Based on observation, interview and record review, it was determined the facility failed to ensure actions or interventions needed for a resident following a short-term change of condition were determined, documented and communicated to staff at least weekly until the condition resolved and significant changes of condition were referred to the facility RN for 2 of 3 sampled residents (#s 1 and 2) with documented short-term and significant changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. Review of the resident's record including progress notes, Alert Charting notes, Incident Reports, the current service plan and Change in Plan of Care Communication forms identified the following: a. The resident was found on the floor of his/her room on 04/10/23, 04/18/23, 04/30/23 and 05/19/23. For the first and third incidents, the facility failed to determine, document and communicate to staff what actions or interventions were needed for the resident and failed to monitor whether the resident was demonstrating further behavior related to falling or putting him/herself on the floor. For the second incident, the facility documented "increase observation during waking hours" but failed to update the resident's service plan, ensure staff were informed of and implementing the intervention and failed to monitor the resident. b. Staff documented the resident sustained an abrasion to the left knee when found on the floor on 04/30/23, and documented an abrasion to the right knee on 05/24/23. The facility failed to determine, document and communicate to staff what actions or interventions were needed for the resident. On 05/23/23, Alert Charting instructions were initiated. c. Staff documented the resident had a "small pressure wound to left buttocks" on 05/10/23. The facility failed to determine, document and communicate to staff what actions or interventions were needed for the resident and monitoring of the wound was not initiated until 05/23/23 when the resident was placed on Alert Charting. Further, there was no documented evidence the facility evaluated the resident, including documenting a description of the wound, to determine if it constituted a significant change of condition for which a referral to the facility RN would be required. The need to ensure actions or interventions were determined, documented, and communicated to staff following a change of condition, that the resident was monitored following the change of condition and potential significant changes of condition were evaluated and referred to the facility RN was reviewed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings. 2. Resident 1 was admitted to the MCC in 04/2019 with diagnoses including dementia. Resident 1's progress notes dated 02/26/23 through 06/06/23 were reviewed and revealed multiple changes of condition. a. The following change of condition lacked documented evidence monitoring instructions or interventions were communicated to staff on each shift: * 02/24/23 - Bruise to right upper arm. b. The following changes of condition lacked documented evidence monitoring instructions and or interventions were communicated to staff and made part of the resident's record, with progress noted, at least weekly, through resolution: * 05/20/23 - Admit to hospice; * 05/27/23 - Emesis and fever; and * 06/01/23 - Change to mechanical soft diet. The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff on each shift, made the interventions part of the resident's record and documented progress, at least weekly, until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings, and no additional documents were provided.

The need to ensure actions or interventions are determined, documented, and communicated to staff following a change of condition, that the resident is monitored following the change of condition and potential significant changes of condition are evaluated and referred to the facility RN. 1. ED, HSD and RCC will evaluate and document all necessary interventions for Res 2 related to falls, knee abrasions and pressure wound in a TSP by 7/11/23. HSD will enter the wound on her follow-up spreadsheet and complete weekly monitoring and documentation of the wound. HSD/Designee will update care plan for Res 1 to include missing information regarding hospice and diet by 7/11/23. No TSP's are currently needed as the bruise and emesis mentioned in the SOD are no longer a concern. 2. HSD will create a nursing follow-up sheet which will include start date of a significant change of condition, date of RN assessment completion, a check box that a TSP has been completed with clear instructions to staff and the date of the next nursing oversight note due. ED/Designee will reeducate the HSD/Designee on companyy guidleines for Change of Condition and the need to ensure all actions/interventions regarding a change of condition are documented,TSP's are completed, RN assessement is completed, and staff notified by 8/7/23. HSD/Designee will reeducate all clinical staff on company guidleines for Change of Conditionand  the need to ensure all actions/interventions regarding a change of condition are documented,TSP completed, RN assessment is completed and staff notified by 8/7/23. 3. The HSD will monitor the follow-up spreadsheet weekly to ensure tasks are complete. The ED will also monitor the spreadsheet at minimum twice a month to ensure it is up to date and accurate. The HSD will review all IR's and alert monitoring notes daily on ALIS. This will allow her to identify changes of condition in a timely manner. The care team will meet for every resident quarterly care conference. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. The ED/Designee all have responsibility in ensuring corrections are made and the system is maintained as outlined.

Based on observation, interview, and record review, it was determined the facility failed to determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, document on the progress of the resident at least weekly until the condition resolved and monitor the resident consistent with his or her evaluated needs and service plan, for 3 of 5 sampled residents (#s 6, 7 and 10) who had documented changes of condition or who required monitoring. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 09/2022 with diagnoses including dementia, atopic dermatitis, and history of alcohol dependence. Review of the record identified the following: a. On 08/05/23, the resident was passing a peer in the hallway in his/her wheelchair and touched the peer's blanket. The peer slapped away Resident 7's hand and the two began slapping each other. The conflict ended with the peer pushing Resident 7 out of the wheelchair. The resulting update to the service plan did not identify who was involved in the conflict and only instructed staff to ensure the resident was not seated on a blanket because it slipped easily. No new information or interventions were developed to address the behavior that triggered the conflict or to specifically monitor interactions between the two residents. b. On 08/15/23, progress notes and incident reports noted the resident was slapped or hit by two different peers at two different times during the day without having done anything to provoke the interactions. One peer had been involved in the previous conflict with Resident 7 on 08/05/23. Though the facility intervened by rearranging chairs where Resident 7 typically sat to move him/her out of an area where peers sometimes congregated that could lead to altercations, the update to the service plan failed to identify the peers who had struck Resident 7 and include instructions for staff regarding monitoring interactions between the specific residents. c. On 09/05/23, immediately following an incident where the resident had been upset and pulled down a baby-gate that was used in an office doorway, the resident was found down a hallway, on the floor out of his/her wheelchair, grabbing onto the leg of a peer who was seated on a hallway couch/bench. Resident 7 and the peer had been involved in previous altercations on 08/05/23 and 08/15/23. The facility failed to determine, document and communicate to staff what actions or interventions were needed for the resident, and there was no documented evidence the facility monitored the resident following the physical altercation. The need to ensure actions and interventions were determined, documented and communicated to staff, and residents were monitored consistent with their evaluated needs, was discussed with Staff 2 (Health Services Director - LPN), Staff 3 (Former RCC/Marketing Director) and Staff 21 (Charge Nurse) on 09/21/23. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 06/2021 with diagnoses including dementia. Review of the resident's record including progress notes, outside provider notes, MAR/TAR dated 08/25/23 through 09/18/23, the current service plan and temporary service plans identified the following: a. On 08/15/23, a TSP was placed regarding discontinuing the use of lidocaine patches. The TSP did not include directions to staff regarding symptoms to monitor for or when and who to notify if symptoms presented. There was no documentation of monitoring weekly until resolution. b. On 08/30/23, a TSP was placed regarding being admitted to hospice and starting scheduled morphine. The TSP did not include instructions to staff related to signs or symptoms to monitor related to morphine. Monitoring did not start until 09/02/23, which was two days after the resident began taking the new medication, on 08/31/23. c. On 09/13/23, the resident had an unwitnessed fall which resulted in a head injury. There was no instruction to staff regarding interventions put in place, signs and symptoms to monitor for or when and who to notify if symptoms presented. d. Between 09/19/23 and 09/20/23, through observation and interviews, the resident was shown to have eaten none of the food provided at seven different snack or meal opportunities. Staff reported they offered him/her nutritional shakes that were also not eaten. Multiple staff reported this was not typical for the resident, and in the prior week s/he had often eaten 50-100% of every snack or meal provided. During an interview with Staff 2 (Health Services Director - LPN) and Staff 19 (RCC) on 09/20/23 at 4:30 pm, they reported staff were trained to offer a nutritional shake to anyone who ate less than 50% at a given meal, and then to notify the lead MT on duty. The lead MT should then immediately make a progress note regarding the missed meal. Staff 2 and Staff 19 acknowledged that there had not been progress notes documented on 09/19/23 or 09/20/23, and they were not aware that Resident 6 had a decrease in intake. A TSP was created following the interview above, instructing staff to contact lead MT "when [Resident] is not able to awaken or not eating." There was no additional instruction to staff regarding the resident's decrease in intake. The need to ensure the facility provided written communication of the resident's change of condition and any required interventions for caregivers on each shift for short term changes of condition and were monitored weekly until resolution was discussed on 09/21/23 with Staff 2, Staff 3 (Former RCC/Marketing Director), Staff 19 and Staff 21 (Charge Nurse). They acknowledged the findings. 2. Resident 10 was admitted to the facility in 05/2023 with diagnoses including dementia and type 2 diabetes. Review of the resident's record including progress notes, outside provider notes, MAR/TAR dated 08/25/23 through 09/18/23, the current service plan and temporary service plans identified the following: a. The resident was admitted to hospice services on 08/28/23. An outside provider note dated 08/29/23 noted a Stage I pressure ulcer on the sole of the right foot. The MAR included instructions to staff for care of the pressure injury. During an interview at 01:20 pm on 09/20/23, Staff 2 (Health Service Director - LPN) stated she was not aware of the right foot pressure ulcer. Review of progress notes from 08/29/23 through 09/18/23 revealed a lack of documentation regarding monitoring the right foot pressure ulcer. Observations made of the resident's right foot with Staff 2 revealed a red area on the sole of the resident's right foot. There was no documented evidence the facility monitored the resident consistent with evaluated needs at least weekly until resolution. b. Resident 10 sustained three unwitnessed non-injury falls on 08/14/23, 08/29/23 and 08/30/23. The facility failed to provide written communication of the resident's change of condition and required actions or interventions for caregivers on each shift for the 08/14/23 and 08/30/23 falls. The need to ensure the facility provided written communication of the resident's change of condition and any required interventions for caregivers on each shift for short term changes of condition and were monitored weekly until resolution was discussed on 09/19/23 with Staff 2 (Health Service Director - LPN), Staff 3 (Former RCC/Marketing Director), Staff 19 (RCC) and Staff 21 (Charge Nurse). They acknowledged the findings, and no further information was provided.

C270 Change of Condition Monitoring 1. HSD/Designee will evaluate and document all necessary interventions for residents #6, 7, 10 listed on the SOD to address all areas of concern, document change of condition, update service plans and interventions for each resident. A Lead/MT meeting will be held by 10/20/23. This meeting will include training on the use of TSP's- when to initiate one, what to include and all the details that are required, as well as when to initiate alert monitoring and how often documentation of monitoring is required. The Temporary Service Plan form will be updated to new templates for individual circumstances. Instead of one blanket form, there will be a behavior template, medication change template, skin condition template and others. This will ensure all required information is included in the TSP. An All-staff Meeting wil be held on 10/19. The meeting will include training on reporting- who to report concerns or changes to and how to report the information. 2. Regional Health Service Director will reeducate the HSD/Designee on change documentation per state and company guidelines, reeducate on the creation and documentation of TSP's and staff notification of changes of conditions by 10/20/23. 3. HSD/Designee will monitor change in condition for residents daily to ensure documentation of changes has occurred, staff notification has been completed through TSP's. HSD/Designee will monitor the facility change of condition process weekly through implemented meetings and use of follow-up spreadsheet. 4. ED and HSD will be responsible for providing oversight of the change of condition process and monitoring requirements. Results will be reported at monthly CQI meeting.

2. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. Review of the resident's record including progress notes, Alert Charting notes, Incident Reports, Nursing Assessments, the current service plan and Change in Plan of Care Communication forms identified the following: The resident was hospitalized from 05/13/23 until 05/19/23. Upon return to the facility, the resident was admitted to hospice services. This was considered a significant change of condition for which an RN assessment was required. The facility RN failed to complete a timely assessment of the resident's change of condition. The assessment was not completed until 06/01/23 - 13 days after Resident 2 was admitted to hospice. The need to ensure the facility RN conducted a timely assessment when a resident experienced a significant change of condition was reviewed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed or was completed timely for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2019 with diagnoses including dementia, congestive heart failure, atrial fibrillation and hypertension. a. Review of the clinical record and interviews with staff revealed Resident 1 had a stage two wound on his/her left buttock which was identified by the hospice RN on 05/22/23. The stage two wound constituted a significant change in condition for which an assessment by the facility RN was required. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. During an interview on 06/08/23 at 11:42 am, Staff 16 (RN) acknowledged an RN assessment had not been completed for the wound. b. During the entrance conference on 06/06/23, staff reported the resident had a significant decline in health and was admitted to hospice recently. Review of the clinical record and interviews with staff revealed the resident was admitted to hospice on 05/20/23 for congestive heart failure. The decline in health and admission to hospice constituted a significant change in condition for which an assessment by the facility RN was required. The facility RN failed to complete a timely assessment of the resident's change of condition. The assessment was completed on 06/01/23, or 12 days following the resident's admission to hospice. The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition, and the assessment was completed timely, was reviewed with Staff 1 (ED), Staff 2 (Health Services Director - LPN), Staff 3 (RCC) and Staff 16 on 06/08/23. They acknowledged the findings.

The need to ensure the facility RN conducted a timely assessment when a resident experienced a significant change of condition. 1. Changes of condition assessment were already completed for Res 1 and 2 at the time of this survey. HSD audited all resident records for change of conditon and RN assessments were completed on 7/11/23. 2. Nursing department will follow the Sinceri policy titled Change of Condition when a change of condition is identified.  HSD will review all IR's and alert monitoring notes daily in ALIS. The care team, consisiting of ED, HSD and RCC will hold a weekly At Risk Meeting as outlined in the Sinceri policy Resident At Risk Meeting Guideline. The weekly meeting will give the care team another opportunity to identify significant changes of condition. If a change of condition is identified in any of these processes as significant then care team will follow the Cgange of Condition policy. RN will complete a sig. change of condition assessment within 48 hours of the COC having been identified. HSD audited all resident records for change of conditon and RN assessments were completed on 7/11/23 HSD/Designee will reeducate staff on RN assessments for change of condition by and  company guidelines on change of condtion by 7/13/23. 3. Resident IR's and alert monitoring will be checked daily by HSD. At risk meetings will be held weekly by care team. HSD will monitor her follow-up worksheet weekly. ED will also monitor follow-up worksheet at minimum of twice a month. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. The ED/Designee all have responsibility in ensuring corrections are made and the system is maintained as outlined.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas: C 303: Physician's Orders; C 305: Systems: Resident Right to Refuse; C 310: Systems: Medication Administration; C 315: Systems: Treatment Administration; and C 330: Systems: Psychotropic Medication. On 06/08/23, the requirement to ensure a safe medication system and adequate professional oversight of the medication administration system was discussed with Staff 1 (ED). She acknowledged the findings.

The requirement to ensure a safe medication system and adequate professional oversight of the medication administration system by administrative oversight. 1. Correction plans will be completed for C 303: Physician's Orders; C 305: Systems: Resident Right to Refuse; C 310: Systems: Medication Administration; C 315: Systems: Treatment Administration; and C 330: Systems: Psychotropic Medication. 2. ED will implement a nursing follow-up spreadsheet to be used by HSD by 7/11/23. ED will audit the spreadsheet at minimum twice a month to ensure tasks have been completed. HSD/Designee will audit the EMAR monthly by reviewing ALIS reports for medication refusals, med pass variances and PRN usage. ED will provide continuous training for med techs by holding a training meeting every quarter to review relevent topics. First meeting to be 7/12/23. 3. ED will review systems weekly and monthly. ED will provide training quarterly. 4. Results will be reported to QAPI Director and committee at next scheduled meeting.ED/Designee is responsible for ensuring corrections are completed to bring facility into complaince and maintian a safe medication administration system.

3. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. Resident 2's MAR dated 05/01/23 through 06/05/23 and corresponding physician orders were reviewed and revealed the following: a. The resident was prescribed primidone (an anticonvulsant medication) 1 tablet at bedtime. Review of the MAR indicated the resident was not administered the medication as prescribed between 05/01/23 and 06/01/23. Staff documented on the MAR "medication not available." In an interview on 06/08/23, Staff 3 (RCC) reported the facility was unable to obtain a refill on the medication because it had been filled but delivered to the resident's previous residence prior to his/her admission to this facility. There was no documented evidence the facility notified Resident 2's primary care physician that the medication was unavailable or requested instructions from the physician. b. Progress notes indicated the facility staff were administering wound care to two knee abrasions and applying barrier cream to a pressure wound on Resident 2's buttock. There were no written, signed physician orders documented in Resident 2's facility record for the treatments. The need to ensure medications were administered as prescribed and the facility had signed physician orders for the treatments it was administering was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 on 06/08/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 04/2019 with diagnoses including dementia and hypertension. Resident 1's MAR dated 05/01/23 through 06/05/23 and corresponding physician orders were reviewed and revealed the following: * The resident had an order for metoprolol succinate 25 mg - one tablet by mouth twice daily for hypertension. Call the doctor if heart rate is less than 55 beats per minute. On 06/03/23, the resident's heart rate was documented as 51 beats per minute on the MAR. On 06/08/23 at 8:41 am, Staff 3 (RCC) confirmed the facility had no documentation the doctor was alerted when the resident's heart rate was lower than 55 beats per minute. * Resident 1's 05/2023 MAR indicated s/he received one 40 mg tablet of furosemide daily for three days for heart failure. The corresponding signed physician order was requested. On 06/08/23 at 8:41 am, Staff 3 confirmed the facility did not have a signed physician order. The need to ensure physician orders were carried out as prescribed and the facility had signed physician orders for the medications it was administering was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 on 06/08/23. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2021 with diagnoses including dementia and Type 2 Diabetes. Resident 3's MAR/TAR dated 05/01/23 through 06/06/23 and corresponding progress notes and prescriber orders were reviewed and revealed the following: Resident 3 was receiving the following medications: * Humalog 100U/ml kwikpen 5X3ML - inject 4 units subcutaneously three times daily before meals. Hold if CBG less than 100 and notify MD; and * Insulin glargine Solostar subcutaneous pen-injector 100 unit/ml - inject 18 units subcutaneously every morning with breakfast. The resident's CBGs were documented as follows: * 05/22/23 at 11:30 am: 109 mg/dl; * 05/23/23 at 11:30 am: 103 mg/dl; * 05/29/23 at 11:30 am: 101 mg/dl; and * 05/30/23 at 11:30 am: 102 mg/dl. The Humalog was "held per MD orders" on the above dates despite no documented evidence the physician had instructed the facility to hold the medication. The insulin glargine Solostar was "held per MD orders" on 05/22/23 and 05/23/23 despite no documented evidence the physician had instructed the facility to hold the medication. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings, and no additional information was provided.

Facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer. 1. HSD will ensure Res 1 has signed MD orders for all medications listed on the EMAR, including the Furosemide found to be missing. HSD will ensure Res 2 has all medications on site and available for use. Completed on 7/11/23. HSD will assess current condition of knee abrasions and wound on bottom. If treatment is still needed then HSD will communicate with MD for treatment orders, which will be added to the TAR. Completed 7/11/23. Res 3 passed away after the completion of this survey. ED/Designee will reeducate HSD on Medication Management, following physician orders, and medication availabilty guidelines per company by 7/14/23. 2. HSD will review the medication variance report on ALIS daily to determine if any medications were held, why they were held and if the MD was notified as required. HSD will also review the variance report for medications that are marked as "not available" and will follow up that these were ordered from the pharmacy and are being delivered. A med tech training will be held quarterly to review on-going issues and provide skills training. The first such meeting will be held on 7/12/23. Training will include appropriately following medication parameters, when to notify the MD and what to do if a medication is unavailable. 3. HSD will review variance report daily. ED will audit variance reports weekly to provide additional oversight. Trainings will be held quarterly to med tech staff. EMAR audits/ reconcilation  will be completed by HSD/Designee every month. ED/Designee wil continue to work with outside pharmacy to set up for quarterly pharmacy audits to review all medication orders. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. ED and HSD have responsibility in completing corrections and ensuring the systems are maintianed and remain in compliance.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for 2 of 3 sampled residents (#s 1 and 3) who had documented medication and treatment refusals. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 04/2019 with diagnoses including dementia. The resident's MAR dated 05/01/23 through 06/05/23 was reviewed and revealed facility staff documented Resident 1 refused the following orders:   * Clonidine three times; * Diclofenac sodium four times; * Furosemide 20 mg one time; * Furosemide 40 mg one time; * Health shake one time; * Hydrocodone-acetaminophen two times; * Losartan three times; * Metoprolol succinate three times; * Omeprazole two times; * Potassium chloride two times; * Quetiapine two times; * Senexon three times; * Tamsulosin two times; and * Vitamin D3 two times. On 06/08/23 at 8:41 am, Staff 3 (RCC) confirmed there was no documented evidence the facility notified Resident 1's physician of the refusals. The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 on 06/08/23. They acknowledged the findings, and no additional documents were provided. 2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including dementia. The resident's MAR dated 05/01/23 through 06/05/23 was reviewed and revealed facility staff documented Resident 3 refused the following orders: * Calcium carbonate 19 times; * Diltiazem four times; * Duloxetine four times; * Furosemide six times; * Humalog 12 times; * Insulin two times; * Lamotrigine four times; * Magnesium oxide 20 times; * Omeprazole five times; * Polyethylene glycol 11 times; * Rosuvastatin four times; * Senna four times; and * Vitamin B-12 17 times. During an interview on 06/07/23 at 1:30 pm, Staff 2 (Health Services Director - LPN) stated facility policy was to notify the physician immediately when a resident refused to consent to an order. There was no documented evidence the facility notified the physician each time the resident refused to consent to the orders. The need to ensure the facility notified physicians of medication refusals was discussed with Staff 1 (ED), Staff 2 and Staff 3 (RCC) on 06/09/23. They acknowledged the findings.

The need to notify the physician or other practitioner when a resident refused consent to an order. 1. HSD will report any medication refusals for Res 1 to his current primary care MD and document this communication. Completed 7/11/23 Res 3 has passed away since this survey was conducted. 2. HSD/Designee will hold an inservice to reeducate all med tech/nurses on the process of medication refusal, including the requirement to notify the MD when a refusal occurs and proper documentation by 7/13/23 HSD/Designee will audit this  process by pulling a Medication Exception/Variance report daily in ALIS and following-up to ensure the MD has been notified and that there is documentation to show this communication.Any noted medication refusals will be added to a resident's care plan along with interventions. 3.  HSD will audit ALIS weekly for refusals. ED will audit ALIS monthly to follow-up on frequent refusals and ensure care plans have been updated. 4. Results will be reported to QAPI Director and committee at next scheduled meeting.The ED and HSD have responsibility to ensure the violation is corrected and the system is maintained.

2. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. Review of the 05/01/23 through 06/05/23 MAR revealed the following routine medications lacked documentation of a reason for use: * Acetaminophen; * Atorvastatin; * Gabapentin; * Melatonin; * Oxycodone; * Pantaprazole; * Primidone; * Quetiapine fumarate; * Senna; and * Sertraline. The need to ensure the resident's MAR was accurate was reviewed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings. 5. Resident 5 was admitted to the facility in 12/2022 with diagnoses including Alzheimer's disease. The resident's 05/01/23 through 06/06/23 MAR was reviewed on 06/06/23. The following was noted: The following medications lacked reason for use: * Donepezil 5 mg; * Finastride 5 mg; * Gabapentin 100 mg; * Levothyroxine 75 mg; and * Memantine 10 mg. The need to ensure medication administration records for all medications administered by the facility included reasons for use was discussed with Staff 1 (ED) on 06/07/23. She acknowledged the findings. 4. Resident 1 was admitted to the facility in 04/2019 with diagnoses including dementia. Review of the 05/01/23 through 06/05/23 MAR revealed the following: a. The following medications lacked reason for use: * Furosemide; * Hydrocodone-acetaminophen; * Senexon; and * Lorazepam. b. The following PRN medications lacked resident specific instructions or parameters: * Senexon; * Terbinafine; * Acetaminophen; * Calcium carbonate; * Hyoscyamine sulfate; and * Lorazepam. The need to ensure medication administration records for all medications administered by the facility included reasons for use or diagnosis and PRN medications included resident specific instruction or parameters was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, included reasons for use for all medications, and provided clear instruction and parameters for administration of PRN medications for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted in 07/2022 with diagnoses including dementia. Review of Resident 4's 05/01/23 through 06/06/23 MAR/TAR, identified the following deficiencies: a. The following routine medications lacked a reason for use: * Acetaminophen 325mg; * Furosemide 20mg; * Gabapentin 600mg; * Hydrocodone 5-325mg; * Losartan 25mg; * Metformin 500mg; * Metoprolol 100mg; * Mirtazapine 30mg; * Olanzapine 5mg; * Omeprazole 20mg; * Quetiapine 25mg; * Trazadone 50mg; and * Venlafaxine 150mg. b. The following PRN medications lacked documented effectiveness of the medications: * PRN Hydrocodone 5-325 on six occasions; and * PRN Olanzapine 5mg on one occasion. On 06/08/23, the need to ensure residents' MARs were accurate was discussed with Staff 1 (ED). She acknowledged the findings. 3. Resident 3 was admitted to the facility in 03/2021 with diagnoses including dementia. Review of the 05/01/23 through 06/06/23 MAR revealed the following PRN medications lacked documentation of a reason for use or resident-specific parameters and instructions: * Acetaminophen; and * Benzonatate. The need to ensure the resident's MAR was accurate was reviewed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

The need to ensure residents' MARs are accurate. 1. The EMAR will be updated by the HSD and RCC to include all missing information for Res 1, 2, 4, and 5. Res 3 passed away after this survey was completed. Missing information to include a reason for giving for every medication, individualized interventions to be used for each psychotropic PRN medication, and effectiveness to be documented for each PRN given. HSD/designee will audit all resident MARS and ensure reason for administration of routine and prn medications are documented by 8/7/2023 2. A med tech training will be held on 7/12, to inlcude training on the importance of documenting effectiveness of PRN medications, the use of interventions before giving psychotropic PRN medications and the requirement to ensure every order approved shows a reason for use. HSD/Designee will run a weekly PRN Administration report on Alis. The report will allow the HSD/Designee to audit that all PRN's were documented for effectiveness by the med tech and that all psychotropic PRN's had interventions documented. HSD and Charge Nurse will audit 5-6 residents MAR each every week on a rotating schedule to ensure all orders have required information on them, including reason for use. This ensures every resident MAR is audited by a nurse every 5 weeks. This rotating schedule will be on the nursing follow-up spreadsheet to alert HSD of who is due. This will happen indefinetly. Facility will continue to partner with pharmacy who conducts quarterly MAR audits and  provide recommendations for corrections. HSD/Designee will follow up on recommendations ongoing quarterly. 3. HSD will review ALIS reports weekly, nursing dept will audit the EMAR on a monthly rotating schedule and the pharmacy will audit the EMAR quarterly. 4. Results will be reported to QAPI Director and committee at next scheduled meeting.The ED/Designee have responsibility to ensure the violation is corrected and the system is maintained.

Based on interview and record review, it was determined the facility failed to maintain an accurate treatment administration record (TAR) for all treatments administered by the facility, for 2 of 2 sampled residents (#s 1 and 2) for whom facility staff were administering wound care. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. Review of progress notes for Resident 2 indicated the facility was administering wound care, including dressing changes, to two abrasions on the resident's knees and was administering barrier cream to a pressure wound on the resident's buttock. There was no documentation of the treatments on the resident's medication administration record or treatment administration record. The need to ensure the facility maintained an accurate TAR for any treatments administered by the facility was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 04/2019 with diagnoses including dementia. Resident 1's progress notes dated 02/26/23 through 06/06/23 and medical chart were reviewed and revealed the facility administered wound care to the resident's shins and left buttock. The resident's wound care included cleansing, bandage changes and the application of barrier cream. On 06/08/23 at 2:22 pm, Staff 1 (ED) confirmed wound care treatments performed by the facility should be located on the resident's MAR/TAR, and the treatments Resident 1 received were not on his/her MAR/TAR. The need to ensure the facility maintained an accurate TAR for any treatments administered by the facility was discussed with Staff 1 on 06/08/23. She acknowledged the findings.

The need to ensure the facility maintained an accurate TAR for any treatments administered by the facility. 1. The HSD will assess the need for on-going treatment for Res 1 and 2 on 7/11/23. If treatment is still needed then the MD will be notified and treatment instructions will be requested. HSD will follow-up and enter MD treatment orders on the TAR and document the order. HSD/Designee will audit all resident's treatment records for accuracy and make any changes needed by 8/7/2023.   2. The nursing department will follow Sinceri policy titled Skin Care Oversight Guidelines for any future skin concerns. HSD will review all Skin Bath Review forms submitted dialy, as well as IR's and alert monitoring notes to ensure she is up to date on all incidents and concerns. HSD will add all skin concerns to the nursing follow-up spreadsheet with start date and next monitoring date necessary. HSD/Designee will conduct a clinical staff training by 7/13/23  to include company guidelines for skin care, the importance of notifying HSD/Designee of any changes in skin variances, documentation of changes and notification to MD. 3. HSD/Designee will review all documentation daily in ALIS and on forms submitted. HSD monitors the follow-up spreadsheet weekly to ensure all tasks are completed. HSD completes a Wound Care Report weekly and RDHS reviews it to ensure appropriate care is being provided. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. ED/Designee have responsibility in completing corrections and ensuring the systems are maintianed and remain in compliance.

2. Resident 2 was admitted to the facility in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. Review of the MAR between 05/01/23 and 06/05/23 indicated the resident was prescribed PRN quetiapine fumarate (an antipsychotic medication) for agitation. The resident was administered the medication on two occasions. There was no documented evidence the facility attempted non-pharmacological interventions with ineffective results prior to administering the medication on those two occasions. The need to ensure staff documented non-pharmacological interventions were tried with ineffective results prior to administering a PRN psychotropic medication was reviewed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions were attempted with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 2 and 4) who were prescribed PRN psychotropic medications. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 07/2022 with diagnoses including dementia. Resident 4 had a physician's order for Olanzapine 5mg as needed for anxiety. On 05/16/23, Resident 4 was administered Olanzapine. There was no documented evidence staff had attempted non-drug interventions with ineffective results prior to administering the psychotropic medication. On 06/08/23, the need to attempt non-drug interventions prior to administering PRN psychotropic medications was reviewed with Staff 1 (ED). She acknowledged the findings.

The need to attempt non-drug interventions prior to administering PRN psychotropic medications. 1. HSD will add individualized interventions to PRN psychotropic medications for Res 2 and 4 that are to be attempted before giving the medication. These will be entered into the order notes on ALIS. To be completed by 7/14/23. It was reviewed if there were options to change how interventions are documented in ALIS, for example could they be checked off on the actual order when giving versus the med tech making a separate observation note. However, it was found that this was not an option. Facility will continue process of requiring MT to make an observation note after giving a PRN psychotropic medication to document interventions used and if they were effective or not. HSD/Designee will reeducate all med techs meeting the regulation to ensure prn interventions are used and documented, prior to the admnistration of any psychotropic medications, training to be completed by 7/13/23 . 2. All PRN psychotropic medications will now be approved by HSD, RCC or charge nurse only. This will assure that individualized interventions are added to the order before it is approved. HSD/Designee will audit all PRN psychotropic medications ordered to ensure accuracy, each prn psychtropic has listed interventions prior to admnistration of psychoptropic. HSD/Designee will pull daily medication prn administration reports to review for admnistration of these meds. Facility will continue to partner with pharmacy who conducts quarterly MAR audits and  provide recommendations for corrections. HSD/Designee will follow up on recommendations ongoing quarterly. 3. HSD will monitor variance reports daily. ED will monitor variance reports weekly for additional oversight. Pharmacy will audit EMAR quarterly. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. ED and HSD have responsibility in completing corrections and ensuring the systems are maintianed and remain in compliance.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medication used to treat resident behaviors had written, resident-specific parameters and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication for 2 of 3 sampled residents (#s 6 and 10) prescribed psychotropic medication. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2021 with diagnoses including dementia. Review of the resident's 09/01/23 through 09/19/23 MAR, progress notes, and current physician orders revealed orders for: * lorazepam 0.5 mg, one tablet to be administered every 4 hours as needed for anxiety/insomnia; and * haloperidol 2 mg/ml oral concentrate, to be administered 0.25 ml by mouth every 2 hours as needed for nausea/vomiting, agitation or delirium. The MAR lacked resident-specific parameters for staff describing how the resident presented behaviors such as anxiety and agitation, and when to give lorazepam versus haloperidol. In an interview with Staff 19 (RCC) on 09/20/23, she stated that if the MT did not know which medication to administer, that MT would ask the lead MT, who would decide what to give based on the situation. The need to ensure there were resident-specific descriptions of how the resident behaviors presented, that there were clear parameters for un-licensed staff to follow, and that non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication, was discussed with Staff 2 (Health Service Director - LPN), Staff 3 (Former RCC/Marketing Director), Staff 19 and Staff 21 (Charge Nurse) on 09/21/23. They acknowledged the findings. 2. Resident 10 was admitted to the facility in 05/2023 with diagnoses including dementia and was identified during the acuity interview as receiving hospice services. Review of the MAR between 09/01/23 and 09/19/23 revealed the resident was prescribed two antipsychotic medications, PRN haloperidol for agitation/delirium/nausea and PRN lorazepam for anxiety/insomnia/delirium. The MAR lacked documentation of non-pharmacological interventions to try before giving the medications, resident-specific parameters for staff describing how the resident presented behaviors such as anxiety or agitation, and when to give lorazepam versus haloperidol. The need to ensure psychotropic medications had written, resident-specific parameters and non-pharmacological interventions to try prior to administering the medications was discussed with Staff 2 (Health Service Director - LPN), Staff 3 (Former RCC/Marketing Director), Staff 19 (RCC) and Staff 21 (Charge Nurse). They acknowledged the findings, and no further information was provided.

C330- Psychotropic Medications 1. Medication orders for Res 6 and 10 will be updated with resident specific parameters and non-pharmacological interventions by 10/20/23. An audit of all psychotropic PRN medications will be completed to ensure all have required parameters and interventions by 10/20/23. 2. Regional Health Service Director will reeducate HSD/Designee on proper use of psychotropic medications, state and company guidelines and proper documentation of parameters and interventions by 10/20/23. A MT/Lead meeting will be held on 10/5. Training will include a re-education of psych PRN medication order processing- when entering the orders to include the parameters and interventions. Training will also include community's 3 way check system for all orders and proper documentation of orders. 3. HSD/Designee will pull daily medication PRN administration report to review for administration of these meds. HSD will continue to update follow-up spreadsheet, which includes a monthly list of residents due for a MAR reconciliation. Community will continue to partner with pharmacy who conducts quarterly MAR audits and provides recommendations. 4. The HSD is responsible for ensuring psychotropic medication orders are in compliance. Results will be recorded at monthyl CQI meeting.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's service plan for 1 of 1 sampled resident (#1) who used a geriatric wheelchair and had side rails on his/her bed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 04/2019 with diagnoses including dementia. Observations during the survey between 06/06/23 and 06/08/23 revealed Resident 1 used a geriatric wheelchair (i.e., a geri-chair) which restricted his/her ability to stand, re-position and self-propel the wheelchair. Additionally, bilateral side rails were observed on the bed in the up position, and staff reported they were used to reduce attempts to transfer independently. There was no documented evidence the following required elements were completed: * Assessment by an RN, PT or OT; * Documentation of less restrictive alternatives evaluated prior to use of the device; * Instruction provided to staff on the correct use and precautions related to the device; and * Documentation of side rails and a geri-chair in the resident's service plan. The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, included documentation of all required elements and was included in the resident's service plan was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings, and no additional documents provided.

Facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's service plan. 1. RN will complete an assessment for the use of a geri-chair and side rail for Res 1. Facility will then complete a TSP for use of the devices, to include instructions to caregivers and precautions for the device. Any devices in use will be added to the care plan. To be completed by 7/14/23. HSD/Designee was reeducated on the company guidelines for use of supportive devices on 7/12/23 by ED.T 2.The nursing department will follow Sinceri policy named "Supportive Devices. RN will complete all assessments for devices with restraining qualities, will document less restrictive methods attempted and will provide oversight for instructions given to staff. To be completed by 7/14/23. A nursing follow-up spreadsheet has been created for the HSD which will include all current devices in use and when the next assessment due date is. HSD will utilize the spreadsheet weekly to ensure all assessments are completed on time by the RN. 3. The nursing follow-up spreadsheet will be reviewed by the HSD weekly for tasks due. The HSD/Designee will review each care plan quarterly for accurateness to ensure all devices are listed on the care plan with instructions for use. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. ED and HSD have responsibility in completing corrections and ensuring the systems are maintianed and remain in compliance.

2. Resident 6 was admitted to the facility in 06/2021 with diagnoses including dementia. Observations during the survey between 09/19/23 and 09/21/23 revealed Resident 6 had bilateral half side-rails on his/her hospital bed which potentially restricted his/her ability to exit the bed, and used a geriatric wheelchair (geri-chair) which potentially restricted his/her ability to re-position and self-propel. Therefore, the side rails and geri-chair were considered devices with restraining qualities. There was no documented evidence the following required elements were completed: * Instruction provided to staff on the correct use and precautions related to the device; and * Documentation of the device in the resident's service plan or on a temporary service plan. The need to ensure documentation of the use of a supportive device with potentially restraining qualities included instructions to staff on the correct use and precautions and was included in the resident's service plan was discussed with on 09/21/23 with Staff 2 (Health Service Director - LPN), Staff 3 (Former RCC/Marketing Director), Staff 19 (RCC) and Staff 21 (Charge Nurse). They acknowledged the findings, and no further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities had documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's service plan for 2 of 3 sampled residents (#s 6 and 10) who used a geriatric wheelchair and/or side rails. This is a repeat citation. Findings include, but are not limited to: 1. Resident 10 was admitted to the facility in 05/2023 with diagnoses including dementia. Observations during the survey between 09/19/23 and 09/21/23 revealed Resident 10 used a geriatric wheelchair (i.e., a geri-chair) which restricted his/her ability to re-position and self-propel. Therefore, the geri-chair was considered a device with restraining qualities. There was no documented evidence the following required elements were completed: * Instruction provided to staff on the correct use and precautions related to the device; and * Documentation of the geri-chair in the resident's service plan or on a temporary service plan. The need to ensure documentation of the use of a supportive device with potentially restraining qualities included instructions to staff on the correct use and precautions and was included in the resident's service plan was discussed with Staff 2 (Health Service Director - LPN), Staff 3 (Former RCC/Marketing Director), Staff 19 (RCC) and Staff 21 (Charge Nurse). They acknowledged the findings, and no further information was provided.

C340- Supportive Devices 1. Res 10 and 6 service plans will be updated to include the use of geri-chairs. Half rails for res 6 were removed and are not in use. HSD/Designee will complete an audit of all supportive devices, ensure an RN assessment has been completed, will document less restricitve methods attempted and ensure the use of device has been communicated to staff. 2. Regional Health Services Director will reeducate HSD.Designee on state and company guidelines for supportive devices proper documentation. ED/HSD will reeducate staff on the use of supportive devices per company guidelines by 10/20/23. HSD has a nursing follow-up spreadsheet which tracks all devices in use, whether they have had an RN assessment, have a TSP and have had the service plan updated. HSD/Designee will communicate resident updates and changes as it relates to supportive devices ongoing. 3. Nursing department will meet daily to provide thorough communication of updates and progress. HSD will update spreadsheet weekly to track progress. 4. HSD is responsible to ensure supportive devices are in compliance with OAR's.  Results will be reported at monthly CQI meeting.

Based on interview and record review, it was determined the facility failed to ensure written fire drill records included all required components and fire and life safety instruction to staff was provided on alternate months of fire drills. Findings include, but are not limited to: Fire drill and fire and life safety training records from 12/06/22 to 06/06/23 were reviewed with Staff 4 (Maintenance Director) on 06/07/23. The following were identified: 1. Fire drills conducted and recorded on 12/31/22, 02/23/23 and 04/08/23 lacked the following information: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and * Number of occupants evacuated. 2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ED) and Staff 4 on 06/07/23. They acknowledged the findings.

The requirements regarding fire drills and fire and life safety instruction for staff. 1. ED will work with regional maintenance director to update Sinceri fire drill forms used in Oregon. The updated form will include all requirements outlined in the OAR. ED will create an annual fire and life safety training calendar based on topics from the Disaster Manual. Completed Trainings will be conducted every other month and a training record will be kept to document trainings. Completed on 7/5/23 2. Maintenance Director will complete a fire drill every other month as required. ED and MD will conduct the fire and life safety training every opposite month and maintain documentation. 3. ED will audit fire drill records and training records quarterly to ensure everything has been completed. 4. Results will be reported to QAPI Director and committee at next scheduled meeting ED and Maintenance Director have responsibility in correcting the violation and maintaining a system of compliance.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to: Observations of the facility between 06/06/23 and 06/08/23 showed the following areas in need of cleaning or repair: a. Laundry Room: * Two floor drains had laminate missing from the perimeter, leaving the surfaces uncleanable: and * A washing machine was not in working order and another washing machine was damaged with pieces of plastic missing from the door, near the hinges. b. Resident room 27: * The entryway to the bathroom was missing a transition strip; and * There was a pervasive unpleasant odor of urine in the bedroom and bathroom. c. Corridors: * There was a pervasive unpleasant odor in the corridors near the front desk, units five and six, and the south dining room throughout the survey. The need to ensure the environment was clean, in good repair and free from unpleasant odors was discussed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 06/07/23. They acknowledged the findings.

The need to ensure the environment was clean, in good repair and free from unpleasant odors. 1. Maintenance Director will inquire with outside vendor about repairing the floor in the laundry room and schedule the repair to be completed. MD will repair both washing machines to proper working order with no missing parts. MD will repair room 27 entry to bathroom and throughly clean bathroom floors. If this does not remove the odor then MD will inquire with outside vendor to replace the floor and schedule to have the repair completed to remove odors. MD will work with housekeeping staff to complete thorough carpet cleaning of front lobby area, unit 5, unit 6, and the area in front of the south dining room. Housekeeping will also complete a thorough cleaning of the south dining room floors. 2. MD will maintain a regular carpet cleaning schedule of all areas of the building. For future planning facility has approval to replace flooring in 5 rooms a year under capital expenditure. Three rooms have been replaced since completion of the survey and 2 more are scheduled during the month of July. MD will purchase an enzyme spray that can be used in between carpet cleaning, as well as air freshener that is accessible to staff throughout the day if needed. MD and ED will conduct a building walk-through once a month to identify areas that need repaired or replaced, specifically focusing on "uncleanable surfaces" and odors. MD utilizes the TELS program which provides a weekly, monthly, and quarterly checklist of building maintenance. ED audits TELS monthly to ensure all tasks are completed as required. 3. MD completes all TELS tasks monthly, which includes a carpet cleaning schedule. ED and MD will complete building walk through monthly. ED will audit TELS for completion of all tasks monthly. ED will also complete capital expenditure request annually to identify areas of the building that need to be updated or have surfaces replaced. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. ED and Maintenance Director have responsibility in correcting the violation and maintaining a system of compliance.

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 and C513.

Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420 and C513 1. Facility will complete correction plan for C420 and C513 as outlined in the POC by 8/7/23. 2. Facility will correct and maintain systems outlined in the POC for C420 and C513. This includes maintaining fire drill documentation that complies with the OAR's, completing fire and life safety training, conducting monthly walk through's of the building to identify areas in need of repair, and maintaining a carpet cleaning schedule to minimize odors. 3. System corrections will include monthly checklists, monthly walk through and quarterly audits. 4. ED and MD are responsible for making corrections to C420 and C513 as outlined in the POC.

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, C280, C300, C303, C305, C310, C315, C330 and C340.

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, C280,C300, C303, C305, C310, C315, C330 and C340. 1. Facility will complete correction plan for C252, C260, C270, C280, C300, C303, C310, C315, C330, and C340 as outlined in the POC by 8/7/23. 2. Facility will correct and maintain systems outlined in POC for C252, C260, C270, C280, C300, C305, C310, C315, C330 and C340. 3. Systems outlined in the POC will have oversight and audits to be performed weekly, monthly and quarterly by ED/Designee. 4. ED/Designee have responsibility to correct violations and maintain systems found to be out of compliance in C252, C260, C270, C280, C300, C303, C305, C310, C315, C330, and C340.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are limited to: Refer to C260, C270, C330 and C340.

Z162- Compliance with Rules Health Care 1. Reach compliance with C260, C270, C330, and C340. 2. Nursing dept will utilize systems put in place through the POC and company policy. ED will provide oversight to the nursing dept with regular meetings and audits. 3. Processes put in place through the POC take place either daily, weekly or monthly. 4. ED and HSD are responsible for ensuring compliance with C260, C270, C330, and C340.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2 and 3's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status and needs of the resident. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

The need to develop individualized service plans addressing residents' nutrition and hydration needs. 1. Service plans for Res 1 and 2 will be updated to include individualized information for nutrition and hydration needs. To be completed by 7/14/23. Res 3 passed away after the completion of this survey. HSD/Designee will audit all resident records to ensure all individual hydration and nutrition needs are care planned. 2. ED/Designee will reeducated HSD/RCC on creating a comprehensive and accurate care plans on 7/11/23. HSD/Designee  will complete an online training entitled Person Centered Care Planning for People Living with Dementia on Relias by 8/7/23. ED, HSD and RCC will complete a webinar training on the ALIS via of Relias by 8/7/23. ED, HSD and RCC will all participate in a triple check system for creation of all service/care plans. All 3 staff will read each service plan to determine they are up to date, accurate and thorough. ED/Designee will conduct a staff inservice with all clinical staff on how to update service plans by 7/13/2023. 3. HSD/Designee will audit and monitor  service plans will be reviewed as due- initial, 30 day, 90 day and when a change of condition occurs and on-going every 90 days . ED will provide quarterly oversight of the care planning process to ensure all care plans are thorough and individualized. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. ED and HSD have responsibility in completing corrections and ensuring the systems are maintianed and remain in compliance.

Based on interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose activity plans were reviewed. Findings include, but are not limited to: During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms, sat in lounge areas in gerichairs or walked around the facility. Due to a history of behaviors with other residents, Resident 1 sat in a gerichair in the south TV room and was occasionally separated from other residents during activities. Due to health conditions, Resident 2 stayed in his/her room in bed and either slept or watched television. Resident 3 attended activities once or twice a week, but often stayed in his/her room, sleeping or listening to music, due to health conditions. Resident 1, 2 and 3's service plans were reviewed. Though the activity section of the service plan offered some information about the resident's past and current interests, the facility had not fully evaluated the resident's: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. The need to develop individualized activity plans which were based on a thorough assessment of the resident's interests, abilities and needs was discussed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

The need to develop individualized activity plans which were based on a thorough assessment of the resident's interests, abilities and needs. 1. Care plans and assessments for Res 1 and 2 will be updated to include more individualized information about preferences, abilities and include a more specific activity plan which details what, when, how and how often staff should offer and assist the residents with more individualized activities. To be completed by 7/14/23. ED is working with the corporate Regulatory Group to determine if evaluation forms can be changed on ALIS to include all criteria listed in OAR 411-057-0160(2d) Activities. Although we will update care plans to reflect the required information, the long term goal is to improve the evaluation form to better reflect the OAR requirements. 2.  Programming Director will complete a thorough Life Story form for each resident upon admission to assist with gathering as much information as possible specific to the resident preferences, routines and abilities. ED/Designee will reeducate HSD/RCC on creating a comprehensive and accurate care plans after change of condition, completed 7/11/23. HSD and RCC will complete an online training entitled Person Centered Care Planning for People Living with Dementia by Relias 8/7/23. ED, HSD and RCC will complete a webinar training on the ALIS via of Relias by 8/7/23. ED, HSD and RCC will all participate in a triple check system for creation of all service/care plans. All 3 staff will read each service plan to determine they are up to date, accurate and thorough. 3. All service plans will be reviewed as due- initial, 30 day, 90 day and when a change of condition occurs. Otherwise, all care plans will be reviewed on-going every 90 days when care conferences are due. ED will provide quarterly oversight of the care planning process to ensure all care plans are thorough and individualized. ED will audit completion of Life Stories for new admissions each month. 4. The ED/Designee will have responsibility in ensuring corrections are complete and the system is maintained.

Based on interview and record review, it was determined the facility failed to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation, for 5 of 5 sampled residents (#s 6, 7, 8, 9 and 10). This is a repeat citation. Findings include, but are not limited to: During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which many residents attended. Some residents did not attend the activities and, instead, stayed in their rooms, sat in lounge areas in geri chairs or walked around the facility. Residents' 6, 7, 8, 9 and 10's service plans were reviewed. Though the activity section of the service plan offered some information about the resident's past and current interests, the facility had not fully evaluated the resident's: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for participation; and * Activities that could be used as behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. In an interview with Staff 18 (Activities Director) on 09/21/23, he stated he had experience developing resident specific activity plans, but had not been included in the service planning process at this community. The need to evaluate the resident for activities and develop an individual activity plan based on their activity evaluation was discussed on 09/21/23 with Staff 2 (Health Service Director - LPN), Staff 3 (Former RCC/Marketing Director), Staff 19 (RCC) and Staff 21 (Charge Nurse). They acknowledged the findings.

Z164- Activities 1. HSD/Designee and Life Enrichment Director will work to update service plan 6, 7, 8, 9 and 10 as listed in the SOD to include more personalized details of resident specific activity needs and interventions. HSD/Designee and Life Enrichment Director will review all other care plans ensuring personalized details are included as outlined by OAR. 2. Regional Health Services Director will reeducate HSD/Designee on creating a comprehensive and individualized careplan by 10/20/23. 3. HSD/Designee will continue to update service plans for accuracy every quarter or as need for COC. 4. The ED and HSD are responsible for ensuring service plans include all required information. Results will be reported at monthly CQI meeting.

Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impact the resident and others in the community were evaluated and included on the service or care plan, for 1 of 2 sampled residents (#2) who had challenging behaviors in the MCC. Findings include, but are not limited to: Resident 2 was admitted to the MCC in 04/2023 with diagnoses including dementia with behavior disturbance, cardiomyopathy, systolic heart failure, essential tremor and acute cystitis with hematuria. Review of the record indicated Resident 2 frequently exhibited escalated verbal behavior including yelling for and at staff, calling staff names or making racially-offensive comments, repeatedly pushing the call light when assistance had just been provided, calling 911 and making false claims about lack of care and putting him/herself on the floor. On several occasions the resident also tried to manipulate staff of the opposite sex into providing massage of his/her genital areas. Triggers for some of the behavior included pain at his/her catheter site, other areas of body pain, staff allegedly not responding to the call light quickly enough, frustration when concerns weren't resolved to his/her satisfaction immediately, frustration with his/her limited physical mobility and being uncomfortable in bed. The current service plan, dated 05/11/23, lacked resident-specific information that informed staff of the specific behaviors of concern and lacked individualized interventions for staff to try when responding to the behaviors. The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 1 (ED), Staff 2 (Health Services Director - LPN) and Staff 3 (RCC) on 06/08/23. They acknowledged the findings.

The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community. 1. Facility will update the care plan for Res 2 to include all current and past behavioral issues. This will also include all interventions staff are to utilize, risks related to potential negative impact towards staff and other residents, activities to utilize to minimize behavior and appropiate response to behavior issues. Completed by 7/14/23. HSD/Designee will audit all resident records to ensure all indivualized behaviors and interventions are listed  on the service plan. 2. ED/Designee will reeducated HSD/RCC on creating a comprehensive and accurate care plans on 7/11/23. HSD/Designee  will complete an online training entitled Person Centered Care Planning for People Living with Dementia on Relias 8/7/23. ED, HSD and RCC will complete a webinar training on the ALIS via of Relias by 8/7/23. ED, HSD and RCC will all participate in a triple check system for creation of all service/care plans. All 3 staff will read each service plan to determine they are up to date, accurate and thorough. For new or on-going behavior concerns facility will utilize a TSP to communicate concerns, interventions and items to monitor to all staff. Facility will follow the Sinceri policy labeled Management of Behavior. 3. All service plans will be reviewed as due- initial, 30 day, 90 day and when a change of condition occurs. Otherwise, all care plans will be reviewed on-going every 90 days when care conferences are due. ED will provide quarterly oversight of the care planning process to ensure all care plans are thorough and individualized. HSD will provide weekly oversight by reviewing all observation notes made by staff and pschotropic PRN usage in order to help identify potential behavioral issues. 4. Results will be reported to QAPI Director and committee at next scheduled meeting. The ED/Designee will have responsibility in ensuring corrections are complete and the system is maintained.

Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impact the resident and others in the community were evaluated and included on the service or care plan, for 1 of 2 sampled residents (#7) who had challenging behaviors in the MCC. This is a repeat citation. Findings include, but are not limited to: Resident 7 was admitted to the facility in 09/2022 with diagnoses including dementia, atopic dermatitis, and history of alcohol dependence. Review of the record indicated Resident 7 had a history of physical conflicts with peers that involved slapping peers and being slapped by peers, and being pushed or pulled out of his/her wheelchair. Recently, the resident had altercations with one particular resident on three separate occasions. The resident evaluation noted the resident was provoked by others entering his/her personal space, and could provoke peers by getting into their personal space, touching them or making aggressive statements. The evaluation further noted the resident did not work well with others in groups and required one-on-one activities. The activity section of the evaluation noted the resident liked activities to keep his/her hands busy, liked to look at pictures and was easily redirected with chocolate. Interventions noted in the evaluation included: * Frequent checks when around peers; * Redirect away from peers due to altercations; * Separate the resident from conflicts and offer a snack/drink and see if s/he would like to watch a movie or do an activity that was going on; and * Redirect the resident to a quiet area and sit and talk to him/her one-on-one. The evaluation and behavior plan lacked individualized information about specific triggers, such as the identity of the peer with whom the resident had been in recent, repeated conflicts and the specific behavior that led to the aggressive physical responses. In an interview on 09/21/23, Staff 15 (CG) reported when the resident was upset, touching or trying to talk with him/her would likely continue to escalate the resident, that the resident did not seem to enjoy watching the TV and she did not know what kind of specific activities the resident might enjoy. The interventions noted in the evaluation and behavior plan were not individualized to the resident's specific preferences and needs, and did not offer staff adequate details regarding which activities to offer as redirection and how and when they should be offered. The need to ensure the facility evaluated and developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 2 (Health Services Director - LPN), Staff 3 (Former RCC/Marketing Director) and Staff 21 (Charge Nurse) on 09/21/23. They acknowledged the findings.

Z165- Behavior 1. HSD/Designee will update service plan for Res 7 to include more personalized interventions for behaviors, along with more information about triggers, peers and symptoms by 10/20/23. HSD/Designee will audit all other resident care plans and make changes needed listing specific interventions for resident behavior. 2. Regional Health Services Director will reeducate HSD/Designee on creating a comprehensive and individualized care plan and listing any interventions needed for behaviors by 10/20/23. 3. HSD/Designee will continue to update service plans for accuracy every quarter or as needed for COC. 4. The ED and HSD are responsible for ensuring service plans include all required information. Results will be reported at monthly CQI meeting.

Based on observation, interview, and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C260, C270, C330, C340, Z164 and Z165.

C455- Inspections and Investigation 1. Reach compliance with C260, C270, C330, C340, Z164 and Z165. 2. Nursing department will utilize systems put in place through the POC and company policy. ED will provide oversight to the nursing department with regular meetings and audits. 3. Processes put in place throught the POC take place either daily, weekly or monthly. 4. ED and HSD are responsible for enuring compliance of C260, C270, C330, C340, Z164 and Z165.

The findings of the re-licensure survey, conducted 06/06/23 through 06/08/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 06/08/23, conducted 09/19/23 through 09/21/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 06/08/23, conducted 12/19/23 through 12/20/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 01/11/23 at 1:15 pm, the facility kitchen was observed to need cleaning in the following areas: Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following: * Multiple white floor drains; * Oven interiors, knobs, doors and handles; * Caulking behind the dish machine; * Pipes and garbage disposal in dish machine area; * A floor fan; and * A black, three-shelf rolling cart. The areas that required cleaning were observed and discussed with Staff 2 (Culinary Director) on 01/11/23. He acknowledged that the areas observed needed to be cleaned. He stated that the areas that needed to be cleaned would be discussed with staff. The need to ensure the kitchen was kept clean in accordance with the Food Sanitation Rules was discussed with Staff 1 (Executive Director) during the exit interview on 01/11/23. No further information was provided.

Plan of correction for spills, splatters, debris, dirt and black matter observed: 1. The following areas will be cleaned immediately by kitchen staff, to be completed by 1/30/23- -White floor drains -oven interiors, knobs, doors, handles on oven -pipes and garbage disposal in dish machine area -floor fan -black, three shelf rolling cart The following items have been submitted to maintenance to fix, completed by 1/30/23: - caulking behind dish machine 2. To prevent these violations from happening in the future all cleaning items will be added to the kitchen staff monthly cleaning checklist. These checklists are initialed by the staff completing the task and the Culinary Director collects them at the end of the month and monitors that items are actually completed. To prevent issues related to the maintenance of the kitchen from happening in the future the Culinary Director will complete a monthly environmental audit where he will inspect all areas of the kitchen for broken, worn out items or areas that are in need of maintenance. This will be given to the Maintenance Director so the items can be addressed. 3. All cleaning tasks will be evaluated monthly by the Culinary Director. All environmental items will also be evaluated monthly by the Culinary Director. The Executive Director will also walk through the kitchen monthly and address any areas of concern with the Culinary Director. 4. Persons involved in the plan of correction are the Executive Director, Culinary Director and the Maintenance Director.

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

The findings of the kitchen inspection, conducted 01/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 01/11/23, conducted 04/12/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.