Maple Grove Memory Care

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

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 02/25/24 at 10:35 am, the facility kitchen was observed to need cleaning in the following areas: * Spice container holders – food debris build up; * Oven doors and sides – drips/spills; * Prep counter next to the stove/oven – debris/spills; * Single door refrigerator exterior door & interior bottom shelf – smears/drips/spills; * Commercial can opener – blade finish worn off/black matter around housing; * Ceiling area around vents between cooking equipment and steamtable – accumulation of dust build up; * Ceiling and wall above entrance door near dishwashing area – accumulation of dust build up; * Ceiling and sprinkler head between lights in dishwashing area – accumulation of dust build up; * Exterior of dishwasher – spills/drips; * Exterior of garbage disposal – spills/drips; and * Exterior of toaster on shelf above steam table – drips/spills. The areas of concern were observed and discussed with Staff 1 (Culinary Manager) and Staff 3 (Corporate Culinary Director) and discussed with Staff 2 (Executive Director) on 02/25/25. The findings were acknowledged.

All identified areas were cleaned by the Culinary Services Director Specialist (CSDS) and the Culinary Services Director (CSD) by 2/27/2025. CSD was educated by the CSDS and National Director of Culinary Services on 2/27/2025 about daily, weekly and monthly cleaning schedules. The CSD/CSDS will educate Culinary staff on cleaning expectations and schedules. Daily, weekly and monthly cleaning schedules are posted in the kitchen for staff to follow. CSD will audit cleaning schedules/cleanliness at least 3 days/week. Executive Director (ED) will audit kitchen cleaning and schedules weekly x 4 weeks, bi-weekly x 4 weeks, and then randomly ongoing.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

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 Executive Director will educate all leadership staff on this Plan of Correction. The ED will do audits of the kitchen cleanliness and cleaning schedules weekly x 4 weeks, and then bi-weekly x 4 weeks and then randomly ongoing.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

Based on observation, interview, and record review it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents regarding multi licensing violations related to Oregon Fire Code (OFC) including the facility’s kitchen fire suppression system which put residents’ health and safety at serious risk. Findings include, but are not limited to: Review of a fire inspection report conducted by Witness 1 (Fire Inspector, Gresham Fire Department), dated 11/25/24 identified multiple OFC violations that could threaten the health, safety, or welfare of residents. That required immediate corrective action to be taken by the facility. On 11/26/24 at 4:41pm an immediate jeopardy was issued, and an immediate plan of correction was requested per OAR 411-054-0025 (4). 1. On 11/26/24 at 6:00 pm an immediate plan of correction was received and included the following: * Fire lane markings: River City Environmental, INC. will be onsite in the first two weeks of December to do the striping. This is dependent on weather and temperature. Contract is signed for work to be completed. * Two fire extinguishers are located in the kitchen, one is a class ABC and one is Level K as of 11/26/2024. All staff will be trained by the MTD (Maintenance Director)/Designee on their location and specific usage by 11/27/2024. * Automatic fuel shut off and duct work will be completed by PSI by December 4, 2024. Contract is signed and they are scheduled. * Escutcheon plate for the sprinkler system. Service was completed in April, 2024. The MTD or designee will keep service inspections in a binder accessible at the community. This will be audited monthly at CQI (Continuous Quality Improvement) meeting three times a month, then quarterly. * Manual pull fire alarm station had a key broken in the box. MTD immediately corrected this. * Egress fire doors do not close automatically. Will be assessed by Carpentry Phoenix and should be repaired by mid-December. * Kitchen fire door had holes drilled in it. Kitchen fire door is on order, there is an approximate four-week lead time on this door since it is a custom order. * Sprinkler system, escutcheon plate in ceiling. Will be repaired by PSI (Performance Systems Integration) by December 4, 2024. * PSI is the vendor for the kitchen. Work is scheduled to be done on 12/04/2024 per PSI. Sinceri Leadership have a call scheduled with PSI 11/27/2024 to follow up on any permits and communication with Fire Marshall. * Fire suppression systems were blocked in riser rooms. Storage in riser rooms was removed by the MTD on 11/26/2024. The MTD or designee will monitor weekly x four weeks, then monthly x three months to maintain compliance. The digital access code will be changed for the doors so that the ED and MTD only will have access. * Facility emergency plan is on site. A copy will be provided to the Fire Marshall by 12/02/2024. * Fire watch is provided throughout the community by a specified person every 15 minutes utilizing the log provided by the Fire Marshall. * At 5:00 pm on 11/26/2024 the gas was shut off to the kitchen and kitchen is not being used. 2. During a monitoring visit on 11/27/24 at 9:03 am, the facility, including the kitchen was toured, and the following areas continued to be out of compliance: * Fire Lane markings in the parking lot. * Automatic fuel shut off and duct work to the fire suppression system in the kitchen were not completed. * The facility continued to use a Panasonic II commercial grade microwave that was located under the hood vent and fire suppression system. * Escutcheon plate for the sprinkler system above the cooking area. * Eight egress fire doors located outside of the kitchen were not corrected. * Kitchen fire door was not replaced and/or repaired. * Facility emergency plan was onsite however it was not provided to the Fire Marshall. * Fire Watch logs failed to include checks every 15 minutes, failed to include full name of the person completing the watch, their job title and the areas observed and/or appropriate comments related to what was observed. During an interview with Witness 1 on 11/27/24 at 11:54 am, the Panasonic II commercial microwave was taken out of service per the recommendation from the Fire Inspector. The findings were discussed with Staff 1 (Administrator) and Staff 2 (Business Office Manager/Designee in Charge) on 11/27/24 at approximately 12:45 pm. They acknowledged the findings. 3. During a monitoring visit on 12/05/24, the facility, including the kitchen was toured and the following areas continued to be out of compliance: * Eight egress fire doors located outside of the kitchen were not corrected. * Kitchen fire door was not replaced and/or repaired. * Facility emergency plan was onsite; however, it was not provided to the Fire Marshall. The facility provided verification the kitchen fire door and egress doors were on order and the facility management plan was in process and would be submitted to the Fire Marshall by end of day 12/05/24. 4. On 12/06/24 at 8:51 am, Witness 1 reported to the facility and the Department “PSI has deemed the equipment to be in compliance, we will allow the kitchen to be used…the kitchen door is a violation…The fire watch shall continue based on the door egressing issues in each of the units.? On 12/06/24 at 4:31 pm the Department notified the facility that the kitchen could be opened for use. Although the immediate plan of correction received corrected the immediate health and safety risks of residents’, the facility would need to continue correcting the remaining OFC violations, follow the recommendations from the local fire jurisdiction and continue looking at their systems to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

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 C160.

Based on observation and interview, conducted during a site visit on 10/14/24, it was confirmed the facility failed to provide three daily nutritious, palatable meals with snack available seven days a week. Findings include, but are not limited to: · At 8:16 am on 10/14/24, breakfast had just been served in Flower House, an unsampled residents eggs temped at 106 Fahrenheit; · At 8:24 am on 10/14/24, pans covered with foil were sitting on the counter in the kitchenette of River House; · At 8:40 am on 10/14/24, breakfast was served in River House and the temperature of the egg was taken at 117 Fahrenheit; · At 10:50 am on 10/14/24, staff were observed getting Resident 7 out of bed for the morning, staff were overheard asking where Resident 7's breakfast was. Staff fed Resident 7 an applesauce for breakfast; · At 12:11 pm lunch was delivered to the kitchenette in Mountain House. Staff were observed taking temperatures of the food which were as follows: o Stuffing - 119 Fahrenheit o Turkey - 119 Fahrenheit o Brussel sprouts - 120 Fahrenheit o Soup - 140 Fahrenheit · The food was not observed to be microwaved before being served to residents. In interviews on 10/14/24, residents stated the following: · The food was good, but cold; · No one offered to reheat meals; · Food was cold, s/he doesn't eat much and doesn't eat a lot of breakfast here; · The food was basic, but usually cold, all meals were cold; and · Occasionally s/he has had to ask staff to reheat the food. In an interview on 10/14/24, Staff 8 (Caregiver) stated Resident 7 did not get breakfast and only received an applesauce. The facility failed to provide three daily nutritious, palatable meals with snack available seven days a week. The findings were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 (Director of Nursing) on 10/14/24. Facility Plan of Correction: All culinary staff were re-educated on temperature checks and recordings, flow of dishing to ensure food remains consistent temperature by the Culinary Services Director on 10/15/2024. Culinary Director or designee will review procedure and checklist/temp logs twice a week for four weeks, weekly for four weeks and then periodically for one month to maintain compliance.

Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 5). Findings include but not limited to the following: A review of Resident 5's signed physician orders, dated 07/16/24, 07/01/24 - 07/31/24 MAR and Medication Error Report indicated the following: · Risperidone (a psychotropic medication) 0.5 mg tab, take 1.5 tabs by mouth twice daily; · MAR indicated Risperidone was given as prescribed; and · On 07/21/24 - 07/25/24 Resident 5's 8:00 pm doses of Risperidone were given at the incorrect dosage, according to Medication Error Report. In an interview on 10/14/24, Staff 5 (Med tech) stated s/he was aware there were issues with Resident 5's Risperidone dosage, but was unfamiliar with the details. In an interview on 10/14/24, Staff 3 (Director of Nursing) stated s/he was the person that caught the medication error for Resident 5. Resident 5's Risperidone came in a 0.5 mg card and a 0.25 mg card and the full dose to be given was one from each card. During his/her audit s/he discovered multiple doses of the 0.25 mg had not been given. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24. Facility Plan of Correction: 1. Clinical meeting will continue to be held Monday through Friday of each week. Mandatory Attendees are the Health Services Director, Continuous Quality Improvement nurse, ED. Other attendees that rotate via electronic methods are the Regional Director of Health Services, Regional Director of Operations, Vice President of Clinical Operations. During this meeting the med pass exception report and the med pass report are pulled daily (for 72 hours over the weekend when the meeting is on Monday). The Continuous Quality Improvement nurse or designee will follow up on any medications not available by calling the physician, pharmacy, or responsible party, and will provide an updated report to the regional and corporate team 5 days a week to track follow up on medication arrivals. 2. All med techs were to be re-educated by the Continuous Quality Improvement  nurse or designee by Tuesday October 22, 2024 on the medication re-ordering policy and process. 3. The Continuous Quality Improvement  nurse or designee was to complete weekly cart audits and follow up on identified items for four weeks, then every other week for four weeks, and monthly for one month or until substantial compliance is achieved. The Results of these audits will be reported at the monthly Continuous Quality Improvement  meeting. 4. The community was to complete a MAR to cart audit done by Omnicare pharmacy by 10/22/2024. The Continuous Quaility Improvement nurse or designee was to follow up with any recommendations made from this report within one week of receiving the report. Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1). Findings include but not limited to the following: A review of Resident 1's signed admitting physician orders, dated 07/16/24, and 07/01/24 - 07/31/24 MAR indicated the following: · Lidocaine 5% patch (for pain), with instructions to place 1 patch onto the skin daily, keep applied for 12 hours then remove for 12 hours. Medication had two refills remaining. · On 07/24/24 and 07/25/24 Lidocaine patch was marked as medication not available. In an interview on 10/14/24, Staff 3 (Director of Nursing) stated when Resident 1 moved-in to facility the facility pharmacy should have been set up to start auto-filling medications, but did not. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24. Facility Plan of Correction: 1. Clinical meeting will continue to be held Monday through Friday of each week. Mandatory Attendees are the Health Services Director, Continuous Quality Improvement nurse, ED. Other attendees that rotate via electronic methods are the Regional Director of Health Services, Regional Director of Operations, Vice President of Clinical Operations. During this meeting the med pass exception report and the med pass report are pulled daily (for 72 hours over the weekend when the meeting is on Monday). The Continuous Quality Improvement nurse or designee will follow up on any medications not available by calling the physician, pharmacy, or responsible party, and will provide an updated report to the regional and corporate team 5 days a week to track follow up on medication arrivals. 2. All med techs were to be re-educated by the Continuous Quality Improvement  nurse or designee by Tuesday October 22, 2024 on the medication re-ordering policy and process. 3. The Continuous Quality Improvement  nurse or designee was to complete weekly cart audits and follow up on identified items for four weeks, then every other week for four weeks, and monthly for one month or until substantial compliance is achieved. The Results of these audits will be reported at the monthly Continuous Quality Improvement  meeting. 4. The community was to complete a MAR to cart audit done by Omnicare pharmacy by 10/22/2024. The Continuous Quaility Improvement nurse or designee was to follow up with any recommendations made from this report within one week of receiving the report. Based on interview and record review, conducted during a site visit on 10/14/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: A review of Resident 2's signed physician orders dated 06/03/24 and 07/01/24 - 07/31/24 MAR indicated the following: · Quetiapine 25 mg tablet (Psychotropic medication), take 0.5 tablets (12.5 mg total) by mouth at bedtime; and · On 07/24/24 and 07/25/24 the medication was marked as "Medication not available." In an interview on 10/14/24, Staff 5 (Med Tech) stated staff are supposed to reorder medications when there are seven days remaining, but many med techs were newer and didn't know when to order. When a resident runs out of medications staff are to document "medication not available and medication ordered". Staff 5 was unsure if Resident 5's quetiapine had been reordered prior to him/her ordering it on 07/24/24. The facility failed to carry out medication and treatment orders as prescribed. The findings were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24. Facility Plan of Correction: 1. Clinical meeting will continue to be held Monday through Friday of each week. Mandatory Attendees are the Health Services Director, Continuous Quality Improvement nurse, ED. Other attendees that rotate via electronic methods are the Regional Director of Health Services, Regional Director of Operations, Vice President of Clinical Operations. During this meeting the med pass exception report and the med pass report are pulled daily (for 72 hours over the weekend when the meeting is on Monday). The Continuous Quality Improvement nurse or designee will follow up on any medications not available by calling the physician, pharmacy, or responsible party, and will provide an updated report to the regional and corporate team 5 days a week to track follow up on medication arrivals. 2. All med techs were to be re-educated by the Continuous Quality Improvement  nurse or designee by Tuesday October 22, 2024 on the medication re-ordering policy and process. 3. The Continuous Quality Improvement  nurse or designee was to complete weekly cart audits and follow up on identified items for four weeks, then every other week for four weeks, and monthly for one month or until substantial compliance is achieved. The Results of these audits will be reported at the monthly Continuous Quality Improvement  meeting. 4. The community was to complete a MAR to cart audit done by Omnicare pharmacy by 10/22/2024. The Continuous Quaility Improvement nurse or designee was to follow up with any recommendations made from this report within one week of receiving the report.

Based on observation, interview, and record review, conducted during a site visit on 10/14/24, the facility's failure to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled resident (# 3) was substantiated. Findings include, but are not limited to: The facility implemented the ODHS ABST. All residents had a completed ABST evaluation, the census was 46, all sampled residents' ABST profiles were reviewed and updated at required times, and 2 of 3 sampled residents (#s 1 and 2) service plans accurately captured care needs and were reflected in the ABST evaluation. Deficiencies identified were Resident 3's service plan and ABST evaluation which did not accurately capture his/her care needs, the posted staffing plan did not account for total ABST care time, and the care time did not include unscheduled needs, fire and life safety, segregated areas, high acuity, behavioral needs, or universal task time related to meal service in addition to ABST. Staff 3 (Director of Nursing) stated s/he was responsible for updating the facility's ABST. S/He updated service plans and ABST quarterly, with a change of condition, when a resident had a new medication order, or were going on an alert. The census was 46. To calculate staffing by ABST, s/he compiled the total hours of care and divided that by 7.5 to determine staffing levels. Fire and life safety was not captured in the tool. Universal worker care time was calculated by adding time to resident laundry and housekeeping services. The facility was divided into four distinct and separate communities referred to as "Houses." The four houses were "Flower," "Mountain," "Lighthouse," and "River." The posted staffing plan indicated for day shift, there were two Med Techs (MTs) for all houses, two Caregivers (CGs) for each house, and one float CG who covered all houses. For swing shift, there were two MTs for all houses and two CGs for each house. For night shift, there was one MT for all houses, and one CG for each house. On 10/14/24, during day shift, there were two MTs for all houses, two CGs in Flower, one CG in Mountain, two caregivers in Lighthouse, and one CG in River. During swing shift, there was one MT for all houses, two CGs in Flower, two CGs in Mountain, two CGs in Lighthouse, and one CG in River. The facility's staffing schedule, dated 10/07/24 through 10/14/24, indicated there was one instance where the facility was not scheduling enough CGs, and eight instances where the facility was not scheduling enough MTs to match their posted staffing plan. Staffing schedules were requested, but the facility did not provide a staffing schedule for 10/11/24 for swing and night shift, or 10/13/24 for all shifts. Staff 9 (CG) stated s/he was the only CG on day shift in the house s/he was assigned to. Staff 10 (CG) stated s/he was the only CG working swing shift in the house s/he was assigned to, and was scheduled until 4:00 pm. At approximately 2:41 pm, no staff had come to check on Staff 10 or provided assistance to residents in that house. Staff 11 (MT) stated s/he was the only MT working swing shift and was assigned to all houses. Staff 12 (CG) stated there were not enough staff to care for everyone. There were five residents who required full assistance with eating and there were two CGs scheduled, so they are unable to feed all residents at once. Management didn't help or provide staff support. S/He believed the house s/he was assigned to needed three CGs. Staff 6 (CG) stated on Mondays and Sundays s/he usually works a house by him/herself and management wouldn't assist. Staff 4 (Business Office Manager) stated regarding staffing, s/he had openings for a MT. The facility did not have enough MTs. CGs are "perfectly staffed" if no one calls in, except for night shift. That was to schedule "bare minimum." If they needed to schedule an extra float, they could not. S/He staffs according to his/her staffing plan. Staff 3 updates the ABST to generate the posted staffing plan. The staffing plan for day shift was two CGs per house plus one CG float, and two MTs. For swing shift, there were two CGs per house and two MTs. For night shift, there was one CG per house and one MT. Resident 1 was unavailable for interview. During an interview regarding Resident 1's care needs, Staff 9 stated s/he needed help getting up in the morning. S/He had been sick lately and hadn't been out of his/her room much. S/He required the assistance of one staff member with getting dressed and toileting. Resident 1 could toilet him/herself but needed more help with the steps of toileting. Staff assisted more with reminders and cuing for next steps because s/he had increased confusion. Resident 2 was unavailable for interview. During interviews regarding Resident 2's care needs, Staff 6 and Staff 7 (CG) stated staff served his/her food and s/he would bring her meal trays out. S/He required one person standby assistance for showering. S/He was independent with dressing, grooming, and will check the activity calendar schedule his/herself and decide to go to activities. S/He was one of the more independent residents in the facility. Resident 3 was unavailable for interview. During an interview regarding Resident 3's care needs, Staff 12 (CG) stated s/he was mostly independent. Staff were standby assistance with showers, cleaned his/her laundry, and changed his/her bed sheets. Resident 3 was independent with transferring, dressing, toileting, and ambulation. S/He changed his/her own brief, removed his/her trash, and left it outside the room for staff to pick up. Resident 3 had behavioral challenges "almost every day," and s/he didn't like when other residents were in his/her way, in his/her space, or trying to open his/her room. S/He was hard of hearing and didn't like when staff changed the music or tv channel. Staff tried to anticipate his/her triggers and they had to regularly intervene and redirect Resident 3. Resident 3's ABST evaluation, updated 07/31/24, and Service Plan, dated 07/30/24, revealed the following discrepancies: -ABST evaluation had time allotted for personal hygiene and mouth care. The service plan indicated s/he was independent with oral care; -ABST evaluation had time allotted for assisting with leisure activities. The service plan indicated s/he was independent with needs; -ABST evaluation had time allotted for dressing and undressing. The service plan does not mention the resident requires dressing assistance; and -ABST evaluation had time spent on nail care and brushing hair. The service plan states nail care was being provided by an outside provider. It was determined the facility's failure to fully implement and update an ABST for Resident 3 was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.

Based on observation, interview, and record review, conducted during a site visit on 10/14/24, the facility's failure to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled resident (# 3) was substantiated. Findings include, but are not limited to: The facility implemented the ODHS ABST. All residents had a completed ABST evaluation, the census was 46, all sampled residents' ABST profiles were reviewed and updated at required times, and 2 of 3 sampled residents (#s 1 and 2) service plans accurately captured care needs and were reflected in the ABST evaluation. Deficiencies identified were Resident 3's service plan and ABST evaluation which did not accurately capture his/her care needs, the posted staffing plan did not account for total ABST care time, and the care time did not include unscheduled needs, fire and life safety, segregated areas, high acuity, behavioral needs, or universal task time related to meal service in addition to ABST. Staff 3 (Director of Nursing) stated s/he was responsible for updating the facility's ABST. S/He updated service plans and ABST quarterly, with a change of condition, when a resident had a new medication order, or were going on an alert. The census was 46. To calculate staffing by ABST, s/he compiled the total hours of care and divided that by 7.5 to determine staffing levels. Fire and life safety was not captured in the tool. Universal worker care time was calculated by adding time to resident laundry and housekeeping services. The facility was divided into four distinct and separate communities referred to as "Houses." The four houses were "Flower," "Mountain," "Lighthouse," and "River." The posted staffing plan indicated for day shift, there were two Med Techs (MTs) for all houses, two Caregivers (CGs) for each house, and one float CG who covered all houses. For swing shift, there were two MTs for all houses and two CGs for each house. For night shift, there was one MT for all houses, and one CG for each house. On 10/14/24, during day shift, there were two MTs for all houses, two CGs in Flower, one CG in Mountain, two caregivers in Lighthouse, and one CG in River. During swing shift, there was one MT for all houses, two CGs in Flower, two CGs in Mountain, two CGs in Lighthouse, and one CG in River. The facility's staffing schedule, dated 10/07/24 through 10/14/24, indicated there was one instance where the facility was not scheduling enough CGs, and eight instances where the facility was not scheduling enough MTs to match their posted staffing plan. Staffing schedules were requested, but the facility did not provide a staffing schedule for 10/11/24 for swing and night shift, or 10/13/24 for all shifts. Staff 9 (CG) stated s/he was the only CG on day shift in the house s/he was assigned to. Staff 10 (CG) stated s/he was the only CG working swing shift in the house s/he was assigned to, and was scheduled until 4:00 pm. At approximately 2:41 pm, no staff had come to check on Staff 10 or provided assistance to residents in that house. Staff 11 (MT) stated s/he was the only MT working swing shift and was assigned to all houses. Staff 12 (CG) stated there were not enough staff to care for everyone. There were five residents who required full assistance with eating and there were two CGs scheduled, so they are unable to feed all residents at once. Management didn't help or provide staff support. S/He believed the house s/he was assigned to needed three CGs. Staff 6 (CG) stated on Mondays and Sundays s/he usually works a house by him/herself and management wouldn't assist. Staff 4 (Business Office Manager) stated regarding staffing, s/he had openings for a MT. The facility did not have enough MTs. CGs are "perfectly staffed" if no one calls in, except for night shift. That was to schedule "bare minimum." If they needed to schedule an extra float, they could not. S/He staffs according to his/her staffing plan. Staff 3 updates the ABST to generate the posted staffing plan. The staffing plan for day shift was two CGs per house plus one CG float, and two MTs. For swing shift, there were two CGs per house and two MTs. For night shift, there was one CG per house and one MT. Resident 1 was unavailable for interview. During an interview regarding Resident 1's care needs, Staff 9 stated s/he needed help getting up in the morning. S/He had been sick lately and hadn't been out of his/her room much. S/He required the assistance of one staff member with getting dressed and toileting. Resident 1 could toilet him/herself but needed more help with the steps of toileting. Staff assisted more with reminders and cuing for next steps because s/he had increased confusion. Resident 2 was unavailable for interview. During interviews regarding Resident 2's care needs, Staff 6 and Staff 7 (CG) stated staff served his/her food and s/he would bring her meal trays out. S/He required one person standby assistance for showering. S/He was independent with dressing, grooming, and will check the activity calendar schedule his/herself and decide to go to activities. S/He was one of the more independent residents in the facility. Resident 3 was unavailable for interview. During an interview regarding Resident 3's care needs, Staff 12 (CG) stated s/he was mostly independent. Staff were standby assistance with showers, cleaned his/her laundry, and changed his/her bed sheets. Resident 3 was independent with transferring, dressing, toileting, and ambulation. S/He changed his/her own brief, removed his/her trash, and left it outside the room for staff to pick up. Resident 3 had behavioral challenges "almost every day," and s/he didn't like when other residents were in his/her way, in his/her space, or trying to open his/her room. S/He was hard of hearing and didn't like when staff changed the music or tv channel. Staff tried to anticipate his/her triggers and they had to regularly intervene and redirect Resident 3. Resident 3's ABST evaluation, updated 07/31/24, and Service Plan, dated 07/30/24, revealed the following discrepancies: -ABST evaluation had time allotted for personal hygiene and mouth care. The service plan indicated s/he was independent with oral care; -ABST evaluation had time allotted for assisting with leisure activities. The service plan indicated s/he was independent with needs; -ABST evaluation had time allotted for dressing and undressing. The service plan does not mention the resident requires dressing assistance; and -ABST evaluation had time spent on nail care and brushing hair. The service plan states nail care was being provided by an outside provider. It was determined the facility's failure to fully implement and update an ABST for Resident 3 was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.

Based on observation, interview, and record review, conducted during a site visit on 10/14/24, the facility's failure to fully implement and update an acuity-based staffing tool (ABST) for 1 of 3 sampled resident (# 3) was substantiated. Findings include, but are not limited to: The facility implemented the ODHS ABST. All residents had a completed ABST evaluation, the census was 46, all sampled residents' ABST profiles were reviewed and updated at required times, and 2 of 3 sampled residents (#s 1 and 2) service plans accurately captured care needs and were reflected in the ABST evaluation. Deficiencies identified were Resident 3's service plan and ABST evaluation which did not accurately capture his/her care needs, the posted staffing plan did not account for total ABST care time, and the care time did not include unscheduled needs, fire and life safety, segregated areas, high acuity, behavioral needs, or universal task time related to meal service in addition to ABST. Staff 3 (Director of Nursing) stated s/he was responsible for updating the facility's ABST. S/He updated service plans and ABST quarterly, with a change of condition, when a resident had a new medication order, or were going on an alert. The census was 46. To calculate staffing by ABST, s/he compiled the total hours of care and divided that by 7.5 to determine staffing levels. Fire and life safety was not captured in the tool. Universal worker care time was calculated by adding time to resident laundry and housekeeping services. The facility was divided into four distinct and separate communities referred to as "Houses." The four houses were "Flower," "Mountain," "Lighthouse," and "River." The posted staffing plan indicated for day shift, there were two Med Techs (MTs) for all houses, two Caregivers (CGs) for each house, and one float CG who covered all houses. For swing shift, there were two MTs for all houses and two CGs for each house. For night shift, there was one MT for all houses, and one CG for each house. On 10/14/24, during day shift, there were two MTs for all houses, two CGs in Flower, one CG in Mountain, two caregivers in Lighthouse, and one CG in River. During swing shift, there was one MT for all houses, two CGs in Flower, two CGs in Mountain, two CGs in Lighthouse, and one CG in River. The facility's staffing schedule, dated 10/07/24 through 10/14/24, indicated there was one instance where the facility was not scheduling enough CGs, and eight instances where the facility was not scheduling enough MTs to match their posted staffing plan. Staffing schedules were requested, but the facility did not provide a staffing schedule for 10/11/24 for swing and night shift, or 10/13/24 for all shifts. Staff 9 (CG) stated s/he was the only CG on day shift in the house s/he was assigned to. Staff 10 (CG) stated s/he was the only CG working swing shift in the house s/he was assigned to, and was scheduled until 4:00 pm. At approximately 2:41 pm, no staff had come to check on Staff 10 or provided assistance to residents in that house. Staff 11 (MT) stated s/he was the only MT working swing shift and was assigned to all houses. Staff 12 (CG) stated there were not enough staff to care for everyone. There were five residents who required full assistance with eating and there were two CGs scheduled, so they are unable to feed all residents at once. Management didn't help or provide staff support. S/He believed the house s/he was assigned to needed three CGs. Staff 6 (CG) stated on Mondays and Sundays s/he usually works a house by him/herself and management wouldn't assist. Staff 4 (Business Office Manager) stated regarding staffing, s/he had openings for a MT. The facility did not have enough MTs. CGs are "perfectly staffed" if no one calls in, except for night shift. That was to schedule "bare minimum." If they needed to schedule an extra float, they could not. S/He staffs according to his/her staffing plan. Staff 3 updates the ABST to generate the posted staffing plan. The staffing plan for day shift was two CGs per house plus one CG float, and two MTs. For swing shift, there were two CGs per house and two MTs. For night shift, there was one CG per house and one MT. Resident 1 was unavailable for interview. During an interview regarding Resident 1's care needs, Staff 9 stated s/he needed help getting up in the morning. S/He had been sick lately and hadn't been out of his/her room much. S/He required the assistance of one staff member with getting dressed and toileting. Resident 1 could toilet him/herself but needed more help with the steps of toileting. Staff assisted more with reminders and cuing for next steps because s/he had increased confusion. Resident 2 was unavailable for interview. During interviews regarding Resident 2's care needs, Staff 6 and Staff 7 (CG) stated staff served his/her food and s/he would bring her meal trays out. S/He required one person standby assistance for showering. S/He was independent with dressing, grooming, and will check the activity calendar schedule his/herself and decide to go to activities. S/He was one of the more independent residents in the facility. Resident 3 was unavailable for interview. During an interview regarding Resident 3's care needs, Staff 12 (CG) stated s/he was mostly independent. Staff were standby assistance with showers, cleaned his/her laundry, and changed his/her bed sheets. Resident 3 was independent with transferring, dressing, toileting, and ambulation. S/He changed his/her own brief, removed his/her trash, and left it outside the room for staff to pick up. Resident 3 had behavioral challenges "almost every day," and s/he didn't like when other residents were in his/her way, in his/her space, or trying to open his/her room. S/He was hard of hearing and didn't like when staff changed the music or tv channel. Staff tried to anticipate his/her triggers and they had to regularly intervene and redirect Resident 3. Resident 3's ABST evaluation, updated 07/31/24, and Service Plan, dated 07/30/24, revealed the following discrepancies: -ABST evaluation had time allotted for personal hygiene and mouth care. The service plan indicated s/he was independent with oral care; -ABST evaluation had time allotted for assisting with leisure activities. The service plan indicated s/he was independent with needs; -ABST evaluation had time allotted for dressing and undressing. The service plan does not mention the resident requires dressing assistance; and -ABST evaluation had time spent on nail care and brushing hair. The service plan states nail care was being provided by an outside provider. It was determined the facility's failure to fully implement and update an ABST for Resident 3 was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 2 (Regional Director of Operations) and Staff 3 on 10/14/24.

The findings of the on-site investigation, conducted 10/14/24, are documented in this report. The investigation 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. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to provide service plans reflective of resident needs for 2 of 2 sampled residents (#s 21 and 22). Findings include, but are not limited to: On 06/25/24 and 06/26/24, Residents 21 and 22 were observed being fed lunch by staff members. Resident 21's meal was not observed to be mechanical soft. Resident 21's service plan, dated 05/21/24, indicated: "Resident will receive diet consistency as ordered of chopped meats" and "receive diet as ordered of mechanical soft." During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 21's service plan had been updated in February 2024 to include a "mechanical soft" requirement, although there were no physician orders to support the change. There was no documented evidence Resident 21 had physician orders for a mechanical soft diet. Resident 22's service plan, dated 04/30/24, showed no indication Resident 22 was in need of feeding assistance. During an interview on 06/17/24, Staff 17 (Caregiver) stated Resident 22 "sometimes" required feeding assistance. During an interview on 06/26/24, Staff 10 (Caregiver) stated staff responsible for creating and updating service plans did not ask floor staff for input or recommendations. It was determined the facility failed to provide service plans reflective of resident needs. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: Completed review of all service plans, completed last month, updated last month. Facility to continue to update service plans as resident's needs change. Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to implement services for 1 of 1 sampled resident (# 8). Findings include, but are not limited to: Resident 8's service plan, dated 05/13/24, indicated s/he was to receive "total assistance with eating," assistance washing hands, as well as "total assistance with bathing" twice a week. On 06/25/24, staff were observed assisting Resident 8 to the dining room table for lunch and bringing food for Resident 8. No staff members were observed assisting Resident 8 with handwashing nor eating. Resident 8 was observed to be spilling food and having difficulties feeding his/herself. On 06/25/24, Staff 10 (Caregiver) stated the facility used a shower schedule and shower logs to keep track of resident showers. The facility's shower schedule indicated Resident 8 was to receive showers on Tuesdays and Fridays. Facility shower logs for Resident 8, dated 04/22/24 through 06/17/24, indicated s/he had received seven showers, roughly one a week. There was no documented evidence Resident 8 had received a shower between 05/17/24 and 06/13/24. It was determined the facility failed to implement services for a resident. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: Manager on duty was to begin performing rounds to assure resident's hands were washed and audit ADLs after showers. Dining manager will ensure residents are assisting residents with feeding. Daily stand-up meetings will review who changing needs for feeding assistance. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: Resident 8's service plan, dated 05.13.24, indicated "[Resident 8] does not like male caregivers to help." During an interview on 06/26/24, Staff 17 (Caregiver) stated Resident 8 preferred female care staff but was "not sure" if it was in his/her care plan. During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 8 was to receive "female only" care, and there had been a day when a male caregiver was training and provided care to Resident 8. It was determined the facility failed to implement a resident's service plan. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: There had been no further incidences of male caregivers attending to the Resident. There were no males scheduled to care for residents with female only preference, staff had been trained.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to determine and document an action or intervention needed for a change of condition for 1 of 1 sampled resident (# 6). Findings include, but are not limited to: Physician orders, dated 02/22/24, indicated staff were to apply Nystatin powder (for skin irritation) twice daily as needed. During an interview om 06/26/24, Witness 1 (Family Member) stated s/he had discovered an ointment instead of a powder applied to Resident 6's rash. Progress notes for Resident 6, dated 05/03/24, indicated Staff 2 (Health Services Director, RN) had been notified of a rash on Resident 6 and instructed a med tech to apply the nystatin, and added skin checks to Resident 6 ' s MAR. Resident 6's service plan, dated 04//02/24, did not indicate regular skin checks were necessary for Resident 6. There was no documented evidence skin checks had been performed on Resident 6 prior to 05/03/24. Resident 6's MAR, dated 05/01/24 through 05/31/24, indicated his/her Nystatin powder had not been applied until 05/04/24 at approximately 8:00 pm. It was determined the facility failed to determine and document an action or intervention needed for a change of condition. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: Facility to immediately begin reviewing skin logs and changes of condition daily at stand-up meeting. Responsibility will fall on Health Services Director until Resident Care Coordinator has been appropriately trained. Next all-staff meeting staff were to be retrained on skin log completion.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 6 of 6 sampled residents (#s 2, 14, 15, 16, 17, and 18). Findings include, but are not limited to: Physician orders for Resident 2 indicated the following: · As of 03/22/22 s/he was to receive Risperidone 0.25mg (mood regulation) daily at 8:00 am, 12:00 pm, and 5:00 pm; · As of 07/01/22, s/he was to receive Fiber Supplement Powder (supplement) daily at 8:00 am; and · As of 11/08/22, s/he was to receive Polyethylene Glycol 17mg (constipation) daily at 8:00 am. Resident 2's MAR, dated 06/01/24 through 06/25/24, indicated s/he had not been administered his/her morning doses of Risperidone 0.25mg, Fiber Supplement Powder, or Polyethylene Glycol on 06/16/24. An incident report, dated 06/17/24, indicated Resident 2 had "missed [his/her] fiber supplement, Miralax, and 2 doses of Risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24." Physician orders for Resident 14 indicated the following: · As of 10/17/23, Resident 14 was to receive Acetaminophen 500mg (pain management), two tabs three times a day; · As of 11/15/23, Resident 14 was to receive Aspercreme with Aloe (pain management) three times a day; · As of 07/31/23, Resident 14 was to receive Aspirin EC 81mg (cardiovascular health) once a day; · As of 11/01/23, Resident 14 was to receive D-Mannose with Cranberry 500-200 (supplement) three times a day; · As of 07/31/23, Resident 14 was to receive Fiber-lax 625mg (constipation) once a day; · As of 07/31/23, Resident 14 was to receive Memantine HCL 10mg (dementia) twice a day; · As of 08/09/23, Resident 14 was to receive Super Papaya Enzyme Plus (supplement) three times a day; and · As of 07/31/23, Resident 14 was to receive Vitamin D3 50mcg (osteoporosis) once a day. Resident 14's MAR, dated 06/01/24 through 06/25/24, indicated s/he had not been administered his/her 8:00 am doses of the above prescribed medications on 06/16/24. An incident report, dated 06/18/24, indicated Resident 14 "missed [his/her] Acetaminophen, Aspercreme, Aspirin, D-mannose cranberry, Fiber-lax caps, Memantine, Miralax, Super papaya enzyme plus, and Vitamin D3 soft gel. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24." Physician orders for Resident 15 indicated s/he was to receive Acetaminophen 325mg (pain management) two tablets three times daily beginning on 04/09/22, as well as Ensure/Health Shake (weight management) three times a day beginning 04/12/23. There was no documented evidence on Resident 15's MAR, dated 06/01/24 through 06/25/24, that s/he had received his/her first dose of Acetaminophen of Ensure on 06/17/24. An incident report, dated 06/16/24, indicated "on 06/17/24, [Resident 15] missed [his/her] Acetaminophen and Ensure. Agency Med Tech did not document passing the medications ... Medications were in the cart upon investigation the afternoon of 06/18/24." Physician orders for Resident 16 indicated the following: · As of 06/06/24, Resident 16 was to receive two tablets of Acetaminophen 325mg (pain management) three times a day; · As of 04/18/22, Resident 16 was to receive Ammens Medicated 5% powder (skin irritation) once a day; · As of 05/19/24, Resident 16 was to receive Miconazole 2% powder (skin integrity) once a day; · As of 01/24/23, Resident 16 was to receive 17g of Polyethylene Glycol 3350 (constipation) once daily · As of 10/26/22, Resident 16 was to receive Sodium Fluoride 1.1% gel (gum health) twice a day; and · As of 07/07/23, Resident 16 was to receive Risperidone 0.25mg (mood stabilizer) three times a day. Resident 16's MAR, dated 06/01/24 through 06/25/24, indicated Resident 16 had not been administered the above medications on 06/16/24 on at least one instance. An incident report, dated 06/17/24, indicated  " On 06/16/24, [Resident 16] missed [his/her] Ammens medicated powder, Miconazole powder, Miralax, Sodium fluoride gel, and risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24." During an interview on 06/27/24, Staff 2 stated an agency med tech had not asked staff where resident ' s medication was when passing medication on 06/16/24, and the agency med tech on 06/17/24 had not passed medication to residents. These issues affected multiple residents including Residents 2, 14, 15, 16, and 18. Physician orders for Resident 17, dated 11/04/23, indicated s/he was to receive Terazosin 2mg (blood pressure) daily at 8:00pm. Resident 17's MAR, dated 06/01/24 through 06/25/24, indicated s/he did not receive Terazosin 2mg from 06/11/24 through 06/16/24. An incident report, dated 06/17/24, indicated Resident 17 had missed "6 doses of Terazosin 2mg on 06/11/24, 06/12/24, 06/13/24, 06/14/24, 06/15/24, 06/16/24 at 8 pm." During an interview on 06/27/24, Staff 2 stated Resident 17's insurance had denied a refill and the pharmacy had not notified the facility. Resident 18's physician orders, indicated s/he was to receive a Boost Plus Lower Calorie (weight management) twice daily beginning on 12/01/22, as well as Polyethylene Glycol (constipation) 17mg once a day at 8:00 am. Resident 18's MAR, dated 06/01/24 through 06/25/24, failed to indicate whether s/he had received his/her Boost and Polyethylene Glycol. An incident report, dated 06/18/24, indicated Resident 18 did not receive his/her Miralax and Boost on 06/17/24, an agency med tech had not recorded the medications, and the medications had been found in the medication cart on 06/18/24. It was determined the facility failed to carry out medication and treatment orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication errors. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to ensure medications administered by the facility were set-up or poured and documented by the same person who administers the medications for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated an agency staff did not have a log-in to the facility's electronic MAR system and had used a facility med tech's initials to sign resident's MARs on the morning of 06/16/24 for all residents in the 100 and 200 halls of the facility. An incident report, dated 06/17/24, indicated Resident 2 had "missed [his/her] fiber supplement, Miralax, and 2 doses of Risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24." Resident 2's MAR, dated 06/16/24, was signed with the initials of a facility staff member. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: facility implemented agency orientation check sheet prior to working the floor, and check-ins with med techs for assignments. Agency logins were being provided upon arrival.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 6 of 6 sampled residents (#s 2, 14, 15, 16, 17, and 18). Findings include, but are not limited to: Physician orders for Resident 2 indicated the following: · As of 03/22/22 s/he was to receive Risperidone 0.25mg (mood regulation) daily at 8:00 am, 12:00 pm, and 5:00 pm; · As of 07/01/22, s/he was to receive Fiber Supplement Powder (supplement) daily at 8:00 am; and · As of 11/08/22, s/he was to receive Polyethylene Glycol 17mg (constipation) daily at 8:00 am. Resident 2's MAR, dated 06/01/24 through 06/25/24, indicated s/he had not been administered his/her morning doses of Risperidone 0.25mg, Fiber Supplement Powder, or Polyethylene Glycol on 06/16/24. An incident report, dated 06/17/24, indicated Resident 2 had "missed [his/her] fiber supplement, Miralax, and 2 doses of Risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24." Physician orders for Resident 14 indicated the following: · As of 10/17/23, Resident 14 was to receive Acetaminophen 500mg (pain management), two tabs three times a day; · As of 11/15/23, Resident 14 was to receive Aspercreme with Aloe (pain management) three times a day; · As of 07/31/23, Resident 14 was to receive Aspirin EC 81mg (cardiovascular health) once a day; · As of 11/01/23, Resident 14 was to receive D-Mannose with Cranberry 500-200 (supplement) three times a day; · As of 07/31/23, Resident 14 was to receive Fiber-lax 625mg (constipation) once a day; · As of 07/31/23, Resident 14 was to receive Memantine HCL 10mg (dementia) twice a day; · As of 08/09/23, Resident 14 was to receive Super Papaya Enzyme Plus (supplement) three times a day; and · As of 07/31/23, Resident 14 was to receive Vitamin D3 50mcg (osteoporosis) once a day. Resident 14's MAR, dated 06/01/24 through 06/25/24, indicated s/he had not been administered his/her 8:00 am doses of the above prescribed medications on 06/16/24. An incident report, dated 06/18/24, indicated Resident 14 "missed [his/her] Acetaminophen, Aspercreme, Aspirin, D-mannose cranberry, Fiber-lax caps, Memantine, Miralax, Super papaya enzyme plus, and Vitamin D3 soft gel. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24." Physician orders for Resident 15 indicated s/he was to receive Acetaminophen 325mg (pain management) two tablets three times daily beginning on 04/09/22, as well as Ensure/Health Shake (weight management) three times a day beginning 04/12/23. There was no documented evidence on Resident 15's MAR, dated 06/01/24 through 06/25/24, that s/he had received his/her first dose of Acetaminophen of Ensure on 06/17/24. An incident report, dated 06/16/24, indicated "on 06/17/24, [Resident 15] missed [his/her] Acetaminophen and Ensure. Agency Med Tech did not document passing the medications ... Medications were in the cart upon investigation the afternoon of 06/18/24." Physician orders for Resident 16 indicated the following: · As of 06/06/24, Resident 16 was to receive two tablets of Acetaminophen 325mg (pain management) three times a day; · As of 04/18/22, Resident 16 was to receive Ammens Medicated 5% powder (skin irritation) once a day; · As of 05/19/24, Resident 16 was to receive Miconazole 2% powder (skin integrity) once a day; · As of 01/24/23, Resident 16 was to receive 17g of Polyethylene Glycol 3350 (constipation) once daily · As of 10/26/22, Resident 16 was to receive Sodium Fluoride 1.1% gel (gum health) twice a day; and · As of 07/07/23, Resident 16 was to receive Risperidone 0.25mg (mood stabilizer) three times a day. Resident 16's MAR, dated 06/01/24 through 06/25/24, indicated Resident 16 had not been administered the above medications on 06/16/24 on at least one instance. An incident report, dated 06/17/24, indicated  " On 06/16/24, [Resident 16] missed [his/her] Ammens medicated powder, Miconazole powder, Miralax, Sodium fluoride gel, and risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24." During an interview on 06/27/24, Staff 2 stated an agency med tech had not asked staff where resident ' s medication was when passing medication on 06/16/24, and the agency med tech on 06/17/24 had not passed medication to residents. These issues affected multiple residents including Residents 2, 14, 15, 16, and 18. Physician orders for Resident 17, dated 11/04/23, indicated s/he was to receive Terazosin 2mg (blood pressure) daily at 8:00pm. Resident 17's MAR, dated 06/01/24 through 06/25/24, indicated s/he did not receive Terazosin 2mg from 06/11/24 through 06/16/24. An incident report, dated 06/17/24, indicated Resident 17 had missed "6 doses of Terazosin 2mg on 06/11/24, 06/12/24, 06/13/24, 06/14/24, 06/15/24, 06/16/24 at 8 pm." During an interview on 06/27/24, Staff 2 stated Resident 17's insurance had denied a refill and the pharmacy had not notified the facility. Resident 18's physician orders, indicated s/he was to receive a Boost Plus Lower Calorie (weight management) twice daily beginning on 12/01/22, as well as Polyethylene Glycol (constipation) 17mg once a day at 8:00 am. Resident 18's MAR, dated 06/01/24 through 06/25/24, failed to indicate whether s/he had received his/her Boost and Polyethylene Glycol. An incident report, dated 06/18/24, indicated Resident 18 did not receive his/her Miralax and Boost on 06/17/24, an agency med tech had not recorded the medications, and the medications had been found in the medication cart on 06/18/24. It was determined the facility failed to carry out medication and treatment orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication errors. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 19). Findings include, but are not limited to: An incident report, dated 06/12/24, indicated a med tech had processed a physician order incorrectly and administered medication to Resident 19 that was not his/hers. Resident 19's MAR, dated 06/01/24 through 06/25/24, indicated Resident 19 had received one dose of Cephalexin 500mg (antibiotic) on 06/12/24. There was no documented evidence of a physician order for Cephalexin 500mg for Resident 19. During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 19 had been administered a medication prescribed to someone who had never lived at the facility. S/He further stated the "pharmacy put it in wrong [and] we approved wrong." It was determined the facility failed to carry out medication orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication error. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 4). Findings include, but are not limited to: An incident report, dated 05/29/24, indicated "Resident [4] missed 88 doses of Atorvastatin [cholesterol medication] 40mg daily at 8pm. The order was hand-written on the quarterly signed physician orders and staff missed putting it in the MAR. No staff initials or documentation is found to indicate who received the orders." During an interview on 06/27/24, Staff 2 (Health Services Director, RN) confirmed a quarterly review of Resident 4's physician orders in February contained a handwritten order for Atorvastatin 40mg. A physician order for Resident 14, dated 05/23/24, indicated Resident 14 was to begin Atorvastatin 40mg. The facility was unable to provide a copy of the handwritten physician orders from February. Resident 14's MARs for 02/2024, 03/2024, and 04/2024, did not include Atorvastatin for Resident 4. Resident 14's MAR, dated 05/01/24 through 05/31/24, indicated s/he had received Atorvastatin 40mg beginning on 05/28/24. It was determined the facility failed to carry out medication orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication error. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: Physician orders for Resident 3, dated 04/17/24, indicated s/he was to receive Cranberry 250mg capsule (supplement) three times a day with meals. Resident 3's MAR, dated 04/01/24 through 04/31/24, indicated s/he had only received his/her morning dose of Cranberry 250mg. An incident report, dated 04/16/24, indicated the order for Cranberry 250mg "was written for 3 times per day but scheduled for once per day. " During an interview on 06/27/24, Staff 2 (Health and Wellness Director, RN) stated "whoever approved it on our end didn't catch it" and confirmed Resident 3 had been receiving the Cranberry 250mg once a day when s/he should've received it three times a day. It was determined the facility failed to administer medication as prescribed for Resident 3. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication error to the local Seniors and People with disabilities office. Staff had been re-educated on the facility's three-check process for processing physician orders. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 8). Findings include, but are not limited to: A physician order for Resident 8, dated 11/20/23, indicated s/he was to receive Sennosides Oral Tablet 8.6mg (bowel care) on Monday, Wednesday, and Friday. The order was to be discontinued on 05/03/24. Resident 8's MARs, dated 11/01/23 through 05/31/24, indicated s/he had received Sennosides Oral Tablet 8.6mg daily. During an interview on 06/26/24, Staff 2 (Health Services Director, RN) stated "we clicked approve without checking it was supposed to be Monday/Wednesday/Friday. " It was determined the facility failed to carry out medication orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. The medication error had been resolved. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 12). Findings include, but are not limited to: Physician orders for Resident 12, dated 08/16/23, indicated Resident 12 was to receive Memantine HCL 10mg (for dementia) twice daily at 8:00 am and 6:00 pm. Resident 12's MAR, dated 05/01/24 through 05/31/24, indicated s/he had not received his/her 8:00 am dose of Memantine on 05/12/24 through 05/14/24, and had not received his/her 6:00 pm dose on 05/12/24 and 05/13/24. Notes indicated "medication not available" and "awaiting delivery." A medication error report, dated 05/13/24, indicated Resident 12 had missed his/her doses of Memantine beginning on 05/12/4. Notes indicated Resident 12's medication was not reordered timely from the pharmacy. During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated the facility had failed to reorder Resident 12's medication timely. It was determined the facility failed to carry out medication and treatment orders as prescribed. Verbal plan of correction: The facility self-reported the medication error. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 13). Findings include, but are not limited to: Physician orders for Resident 13, dated 01/30/24, indicated Resident 13 was to receive Alpha Lipoic Acid 300mg (supplement) 2 capsules a day at 8:00 am, for a total of 600mg a day. An incident report, dated 05/11/24, indicated a med tech had been giving Resident 13 two 600mg capsules a day. During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated the pharmacy had originally sent 300mg capsules, and when the pharmacy refilled the prescription with 600mg capsules "no one checked the dose on the bottle," and continued to give Resident 13 two capsules. It was determined the facility failed to carry out medication and treatment orders as prescribed. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication error. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: Physician Orders for Resident 2, dated 03/22/22, indicated s/he was to receive Risperidone ODT 0.5mg (emotion regulation) daily at 8:00 am, 12:00 pm, and 7:30 pm. Resident 2's MAR, dated 03/01/24 through 03/31/24, indicated s/he had not received his/her 12:00 pm dose of Risperidone. An incident report, dated 04/01/24, indicated Resident 2 had not received his/her mid-day scheduled dose of Risperidone on 03/31/24. During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 2 had not received his/her medication due to a  " staffing issue. " It was determined the facility failed to administer medication as prescribed for Resident 1. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication error to the local Seniors and People with disabilities office. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: Resident 1's physician orders, dated 02/19/24, indicated s/he was to be administered Acetaminophen 325mg (pain medication) daily at 8:30 am, 1:00 pm, and 7:00 pm. Resident 1's MAR, dated 03/01/24 through 03/31/24, indicated s/he had not received his/her 1:00 pm dose of Acetaminophen. An incident report, dated 04/01/24, indicated Resident 1 had not received his/her mid-day scheduled dose of Acetaminophen on 03/31/24. During an interview on 06/27/24, Staff 2 (Health Services Director, RN) confirmed Resident 1 was to receive Acetaminophen three times a day and stated Resident 1 had received his/her AM dose of Acetaminophen late because there had only been one med tech on duty on 03/31/24. S/he further stated the med tech had been advised by the previous RN to hold the mid-day dose as it would've been too closely administered to the AM dose. It was determined the facility failed to administer medication as prescribed for Resident 1. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication error to the local Seniors and People with disabilities office. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: Physician orders for Resident 3, dated 04/17/24, indicated s/he was to receive Cranberry 250mg capsule (supplement) three times a day with meals. Resident 3's MAR, dated 04/01/24 through 04/31/24, indicated s/he had only received his/her morning dose of Cranberry 250mg. An incident report, dated 04/16/24, indicated the order for Cranberry 250mg "was written for 3 times per day but scheduled for once per day. " During an interview on 06/27/24, Staff 2 (Health and Wellness Director, RN) stated "whoever approved it on our end didn't catch it" and confirmed Resident 3 had been receiving the Cranberry 250mg once a day when s/he should've received it three times a day. It was determined the facility failed to administer medication as prescribed for Resident 3. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility self-reported the medication error to the local Seniors and People with disabilities office. Staff had been re-educated on the facility's three-check process for processing physician orders. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to keep an accurate Medication Administration Record for 1 of 1 sampled resident (# 17). Findings include, but are not limited to: Physician Orders for Resident 17, dated 11/04/23, indicated s/he was to receive Terazosin 2mg (blood pressure) once a day. Resident 17's MAR, dated 06/01/24 through 06/25/24, indicated: · S/he had not received his/her Terazosin on 06/05/24, 06/08/24, and 06/11/24 through 06/16/24. Notes indicated "medication unavailable;" and · Terazosin 2mg was marked as administered on 06/06/24, 06/07/24, 06/09/24, and 06/10/24. During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated "I know they didn't have the med here in the building when they marked it." Physician orders for Resident 17, dated 11/04/23, indicated Resident 17 was to receive Memantine HCL 10mg (Alzheimer ' s medication) twice daily, at 8:00 am and 8:00 pm. Resident 17's MAR, dated 06/01/24 through 06/25/24, indicated: · Memantine HCL was not administered to Resident 17 on 06/21/24 at 8:00 am, notes indicated "refused;" · Memantine HCL was not administered 06/22/24 at 8:00 am, 06/23/24 at 8:00 am or 8:00 pm, nor 06/24/24 at 8:00 am. Notes indicated "medication not available;" and · Memantine HCL was marked as administered on 06/21/24 and 06/22/24 at 8:00 pm. In an interview on 06/27/24, Staff 2 stated there were "two documentations in error for Memantine" for the 21st and 22nd. It was determined the facility failed to keep an accurate Medication Administration Record. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: The facility had begun to implement weekly audits to monitor their medication exception report.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs for 1 of 1 sampled resident (# 8). Findings include, but are not limited to: During an interview on 06/26/24, Staff 17 (Caregiver) stated "I think needs get behind [when understaffed]" and "showers won't be able to get done." Resident 8's service plan, dated 05/13/24, indicated s/he was to receive "total assistance with bathing" twice a week. On 06/25/24, Staff 10 (Caregiver) stated the facility used a shower schedule and shower logs to keep track of resident showers. The facility's shower schedule indicated Resident 8 was to receive showers on Tuesdays and Fridays. Facility shower logs for Resident 8, dated 04/22/24 through 06/17/24, indicated s/he had received seven showers, roughly one a week. There was no documented evidence Resident 8 had received a shower between 05/17/24 and 06/13/24. The facility's posted staffing plan indicated: · Day shift: Two med techs and eight caregivers; · Swing shift: Two MT and eight CG; and · Night shift: One MT and four CG. The facility's staff schedule, dated 06/04/24 through 06/11/24, indicated the facility did not staff to their posted staffing schedule on four out of seven days. It was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of a resident. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: Manager on duty was to begin auditing ADLs after showers. Business Office Manager had taken over all staffing issues, the facility to had begun to implement corrective action per policy and increased recruiting efforts. In the event of callouts shifts were offered to staff, and agency staff were being utilized. CGs and MTs had been hired the week of 06/23/24 through 06/28/24. Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to have enough staff to meet the scheduled and unscheduled needs of 1 of 1 sampled resident (# 6). Findings include, but are not limited to: The facility's posted staffing plan indicated: · Day shift (6:00 am to 2:00 pm): 2 med techs and 8 caregivers; · Swing shift (2:00 pm to 10:00 pm): 2 med techs and 8 caregivers; and · Night shift (10:00pm to 6:00 am): 1 med tech and 4 caregivers. The facility was observed to be divided into four separate numbered halls, or "houses:" Lighthouse (100), Mountain (200), River (300), and Flower (400). In an interview on 06/25/24, Staff 1 (Executive Director) stated there were supposed to be two caregivers for each of the four halls in the facility, as well as two med techs, one responsible for halls 100 and 200 and the other for halls 300 and 400, although the facility tried to staff extra in Flower because it ' s a  " loud hall "  and requires more care. During an interview on 06/26/24, Staff 17 (Caregiver) stated the facility gets behind on needs, and showers don ' t get done when there are not enough staff. S/He further stated three caregivers was needed in Flower, and  " I don't think two [caregivers on shift was] working every day." During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated there had been medication errors due to "staffing issues." S/He further stated "weekends are super hard, a lot of call-ins"  and the facility was sometimes "scrambling for agency [staff coverage]." In an interview on 06/26/24, Staff 15 (Caregiver) stated the facility is "sometimes short staffed over the weekend." At approximately 2:42 pm on 06/25/24, only one caregiver was observed in the 100 hall. Staff 22 (Caregiver) stated s/he was the only caregiver in the hall as s/he was "waiting for someone to show up." During an interview on 06/27/24, Staff 12 stated "all this week staffing is a mess," and "lately we've been short staffed  ... a lot of call outs." On 06/27/24 from approximately 2:30pm-3:00pm, the following was observed: · In Mountain, a caregiver was by his/herself with a resident requiring a two-person assist; · A caregiver was alone in Flower, where one resident required a two-person assist. The caregiver assigned to the hall stated  " this house is supposed to [have] three [caregivers]; · A caregiver was alone in the Lighthouse hall; · There were two day-shift caregivers in River, waiting on swing shift staff to arrive; and · There was one med tech on shift who was waiting on swing shift med techs to arrive. During an interview on 06/27/24, Staff 1 stated swing shift and agency staff were "on their way." It was determined the facility failed to have enough staff to meet the scheduled and unscheduled needs of residents. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 2 had not received his/her medication due to a "staffing issue." The facility's posted staffing plan indicated: · Day shift: 2 MT and 8 caregivers (CG); · Swing shift: 2 MT and 8 CG; and · Night shift: 1 MT and 4 CG. Facility timecards indicated only one med tech had worked the day shift on 03/31/24. Physician Orders for Resident 2, dated 03/22/22, indicated s/he was to receive Risperidone ODT 0.5mg (emotion regulation) daily at 8:00 am, 12:00 pm, and 7:30 pm. Resident 2's MAR, dated 03/01/24 through 03/31/24, indicated s/he had not received his/her 12:00 pm dose of Risperidone. An incident report, dated 04/01/24, indicated Resident 2 had not received his/her mid-day scheduled dose of Risperidone on 03/31/24 because there had only been one MT on shift. It was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of Resident 2. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: Business Office Manager had taken over all staffing issues, the facility to had begun to implement corrective action per policy and increased recruiting efforts. In the event of callouts shifts were offered to staff, and agency staff were being utilized. CGs and MTs had been hired the week of 06/23/24 through 06/28/24. Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: During an interview on 06/27/24, Staff 2 (Health Services Director, RN) confirmed Resident 1 was to receive Acetaminophen (pain medication) three times a day and stated Resident 1 had received his/her AM dose of Acetaminophen late because there had only been one med tech (MT) on duty on 03/31/24. S/he further stated the MT had been advised by the previous RN to hold the mid-day dose as it would ' ve been too closely administered to the AM dose. The facility's posted staffing plan indicated: · Day shift: 2 MT and 8 caregivers (CG); · Swing shift: 2 MT and 8 CG; and · Night shift: 1 MT and 4 CG. Facility timecards indicated only one med tech had worked the day shift on 03/31/24. Resident 1's physician orders, dated 02/19/24, indicated s/he was to be administered Acetaminophen 325mg daily at 8:30 am, 1:00 pm, and 7:00 pm. Resident 1's MAR, dated 03/01/24 through 03/31/24, indicated s/he had not received his/her 1:00 pm dose of Acetaminophen on 03/31/24. An incident report, dated 04/01/24, indicated Resident 1 had not received his/her mid-day scheduled dose of Acetaminophen on 03/31/24 because there had only been one MT on shift. It was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of Resident 1. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24. Verbal plan of correction: Business Office Manager had taken over all staffing issues, the facility to had begun to implement corrective action per policy and increased recruiting efforts. In the event of callouts shifts were offered to staff, and agency staff were being utilized. CGs and MTs had been hired the week of 06/23/24 through 06/28/24.

Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST) for 2 of 3 sampled residents (#s 8 and 20). Findings include, but are not limited to: On 06/26/24, Resident 8 was observed to communicate with staff non-verbally through tapping and gesturing, which took staff time to understand his/her needs. Resident 8's service plan, dated 05/13/24, indicated s/he "has difficulty communicating and receiving information." The facility's ABST, reviewed on 06/28/24, failed to include time needed for communication with Resident 8. On 06/26/24, Resident 20 was observed to have his/her left arm in a sling and was provided transferring and feeding assistance by staff. A "Change in Plan of Care Communication" form, dated 06/21/24, indicated Resident 20 had suffered a broken clavicle. A "Change in Plan of Care Communication" form, dated 06/24/24, indicated "[Resident 20] is unable to use [his/her] left arm to "push" off [his/her] chair for transferring, [s/he] may need extra assistance with transferring during this time." During an interview on 06/27/24, Staff 20 (Caregiver) stated Resident 20 sometimes required transferring and feeding assistance due to his/her recent injury. The facility's ABST, reviewed on 06/28/24, failed to include time required for feeding assistance or transferring for Resident 20 because of his/her recent change of condition. During an interview on 06/28/24, Staff 2 (Health Services Director, RN) stated s/he was responsible for updating the facility's ABST, Resident 20 had experienced a recent change of condition, and s/he had not updated the facility's ABST to reflect Resident 20's increased care needs since the change of condition occurred. It was determined the facility failed to fully implement and update their ABST. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Based on observation, interview and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision, and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to: During the relicensure survey, conducted 03/18/24 through 03/21/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations. 1. Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area: OAR 411-054-0040 (1-2): Change of Condition and Monitoring; OAR 411-054-0045 (1)(a-f)(A)(C-F): Resident Health Services; and OAR 411-054-0055 (1)(a): System: Medications and Treatments. The facility put immediate plans of correction in place during the survey and the situations were abated. 2. Refer to deficiencies in the report.

ED will educate all managers on this POC and their responsibilities in this POC by 3/28/2024 ED is responsible for daily follow up at stand up with items on this POC ED will develop and implement a weekend manager on duty schedule ED will be educated by the RDO, RDHS, and VP Clinical Services on expectations of weekend MOD ED will educate leadership team on expectations of weekend MOD

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received services in a manner that protected privacy, respect and dignity in a homelike environment for 1 of 4 sampled residents (#1) during meal service, and multiple unsampled residents. Findings include, but are not limited to: 1. During the survey, multiple staff were observed on several occasions to communicate with staff with their language (non-English) and laugh while escorting residents to the dining room and/or to the TV area. The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and  Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia. Observations and interviews with staff during the survey identified s/he relied on staff for incontinence care needs. On 03/21/24 at 8:44 am, the surveyor observed Staff 10 (CG) assist Resident 1 in wheelchair into the dining area where other residents and staff were present. Resident 1 was without pants, shoes, or socks and was wearing a sweatshirt and incontinence briefs. Surveyor requested Staff 10 to assist Resident 1 with dressing to include pants, socks and shoes, which was performed. The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and  Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings b. On 03/18/24 observed staff on two separate occasions escort unsampled residents into each of their bathrooms, the staff exited while the residents remained alone in their bathroom. The door to their rooms and bathrooms were left ajar. Another unsampled resident wandered into one of the open rooms and stood by the bathroom door while the resident was using the bathroom. One minute later a caregiver found the resident and escorted him/her out of the room. c. During lunch service on 03/18/24 and beginning of lunch on 03/19/24, multiple caregivers were observed standing over residents while assisting with meals, not providing a dignified dining experience. d. On 03/20/24, the surveyor overheard Staff 2 (Assistant ED) requesting a key be made for a resident per the family member's request. Staff 3 (Maintenance Director) stated the key would be a master key and Staff 2 confirmed that would be fine. On 3/21/24, with the permission of a resident's family member who resided in Flower house, the survey team observed that this resident's key unlocked multiple separate resident units in Flower. Staff 18 (CG) confirmed that one key will get into all of the units in Flower. The same key was used to try and open resident units in a different house, River, and confirmed the key was not able to unlock the resident doors. The need to ensure residents were treated with dignity and respect, and their privacy was protected, was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and  Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. 3a. On 03/19/24 at 12:25 pm, during lunch service, an unsampled resident was sitting with three other people who self-identified as the resident's family. At that time, the resident was served a "veggie meal", did not have eating utensils, and the family requested additional food to be provided for the resident. The resident began eating with his/her hands. The family requested eating utensils from the staff. When the utensils were provided, the resident began eating with the utensils provided. Over a 45-minute period, the family requested additional food to be provided on three separate occasions before food was provided to the resident.

All staff will be educated by the ED/AED/RN/Designee on resident rights and dignity, including language,dignity with dining, and privacy/dignity with cares. Resident key was replaced with a key specifically for that door. ED will create and implement a manager on duty schedule for dining. All staff will receive this education at time of hire, and at a minimum annually.

3. Resident 2 was moved into the facility in 01/2022 with diagnoses including dementia. Observations of the resident from 03/18/24 to 03/21/24 revealed the resident required staff assistance with incontinent care and meal assistance. Progress notes and incident reports dated 12/02/23 through 03/17/24 indicated the following: * On 12/13/23 staff documented the resident had a fall at 8:00 am in dining room. S/he was sitting at the dining table while staff was getting breakfast ready and had redness, bruising and swelling to left side of face; * On 02/06/24 the resident had an unwitnessed fall at 2:25 am in the room, getting out of bed; and * On 03/14/24 the resident had an unwitnessed fall at 9:00 am in the room, with a large, raised skin area on the left forehead. 12/08/23 Temporary service plan indicated "staff to provide 1:1 feeding support for all meals and snacks." The 02/22/24 service plan and Temporary service plan showed staff to check two times per shift safety checks and assisted to get the resident "up around 7-8 am". There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result of abuse or neglect due to the possibility of not receiving morning care timely and safety checks as outlined on the service plan. During an interview on 03/21/24, Staff 1 (ED) confirmed she had not reported the above incidents to the local unit. The need to investigate incidents of suspected abuse or neglect care and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 1, Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings. The facility was directed to self-report the incidents to the local SPD office. Confirmation of the report was received on 03/21/24 prior to the survey team exiting from facility.

Based on observation, interview and record review, it was determined the facility failed to ensure reports of abuse and suspected abuse were reported to the local Seniors and Peoples with Disabilities (SPD) office immediately and incidents and injuries of unknown cause were investigated to rule out abuse and neglect or reported to the local SPD office for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose records were reviewed. Findings include but are not limited to: 1. Resident 3 was admitted to the facility in 08/2023 with diagnoses including dementia with mood disorder. Review of the 12/18/23 through 03/16/24 progress notes, incidents reports and 03/08/24 service plan and Temporary Service Plans (TSP's) noted the following: * 01/12/24 - "Resident was very agitated, being verbally aggressive toward staff and peers. The continuing hollering agitated [unsampled resident]. [Unsampled resident] walked up behind resident's neck and then squeezed."; and * 02/06/24 - "Resident was sitting at the dining room table when [s/he] seen a peer walking towards [him/her], [s/he] began to yell and became verbally aggressive using vulgar language towards [him/her]. [Unsampled resident] walked by but when resident didn't stop, [unsampled resident] turned and grabbed resident by [his/her] arm then squeezed." The facility lacked documented evidence the reports of abuse were immediately reported to the local SPD office and investigations into the abuse lacked documentation of an administrator's review. In a 03/21/24 interview with Staff 1 (ED), she confirmed the reported abuse was not reported to the local SPD office and the investigations into the reports of abuse lacked documentation of an administrator's review. The need to ensure reports of abuse were immediately reported to the local SPD office and investigations into reported abuse included an administrator's review was discussed with Staff 1 and Staff 6 (Health Services Director, RN) on 03/21/24. They acknowledged  the findings. The facility was directed to self-report the incidents to the local SPD office. Confirmation of the report was received on 03/21/24 prior to survey exit. 2. Resident 5 was admitted to the facility on 01/04/24 with diagnoses including Alzheimer's disease with agitation. Review of the 01/04/24 through 03/18/24 progress notes, incident reports, 02/22/24 service plan and Temporary Service Plans (TSP's) indicated the following: * 01/19/24 - "Resident was found in the room of a peer and they were both undressed in [his/her] bed"; * 01/20/24 - "Resident found in [unsampled resident] room nude."; and * 02/29/24 - "[Resident 5] came into river house and walked over to [unsampled resident] and another...resident. [Unsampled resident] tried to sit next to the other two residents in river house when [Resident 5] began close fist hitting [unsampled resident] They were separated by care staff and [unsampled resident] taken back to [his/her] pod..." The facility lacked documented evidence the reported abuse and suspected abuse was reported to the local SPD office immediately and investigation into the suspected abuse included an administrator's review. In a 03/21/24 interview, Staff 1 (ED) confirmed the reported abuse and suspected abuse were not reported to the local SPD office and investigations into the suspected abuse did not included an administrator's review. The need to ensure incidents of suspected abuse were immediately reported to the local SPD office and investigations into suspected included an administrator's review was discussed with Staff 1 and Staff 6 (Health Services Director, RN) on 03/21/24. They acknowledged the findings. The facility was directed to self-report the incidents to the local SPD office. Confirmation of the report was received on 03/21/24 prior to survey exit. 4.  Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia The resident's current service plan, dated 12/22/23, progress notes, dated 12/23/23 through 03/07/24, Temporary Service Plans, incident reports and investigations were reviewed, and staff were interviewed. Multiple incidents were identified: * 12/18/23: Unwitnessed, fall with lip injury; * 12/28/23: Unwitnessed, fall with skin tear to left arm; * 01/05/24: Unwitnessed, fall with injury to head and right knee; * 01/10/24: Unwitnessed, fall with injury to right hand and fingers; * 01/23/24: Unwitnessed, fall with re-opened scab to right knee; * 01/25/24: Unwitnessed, fall with new skin tear to right knee; * 01/30/24: Unwitnessed, fall without injury; * 02/07/24: Unwitnessed, fall without injury; and * 03/03/24: Unwitnessed, fall with rib pain and difficulty breathing. There was no documented evidence the facility conducted an investigation to reasonably conclude the falls were not the result of abuse or neglect. During an interview on 03/20/24 at 10:35 am, Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) confirmed the above incidents had not been reported to the local unit. The surveyor requested the incidents be reported to the local SPD office. Verification the facility reported the unwitnessed falls was received on 03/21/24. The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 6 and Staff 7 on 03/21/24. They acknowledged the findings. 5. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. Review of the 12/18/23 through 03/06/24 progress notes, incidents reports, outside provider notes and Temporary Service Plans (TSP's) indicated the following: * On 02/08/24 progress notes indicated "resident is on alert for 2 abrasions unwitnessed injury/on the right side under shoulder blade". An outside provider note on 02/08/24 from the hospice MSW (Medical Social Worker) noted that "Per med aide, Pt [patient] fell today, but was more of a slide out of [his/her] wc [wheelchair]"; * On 02/09/24 an incident report identified Resident 6 had an unwitnessed fall in the bathroom and no injuries were identified; and * On 02/09/24 an outside provider note from the hospice nurse identified resident's right ring finger was "red, swollen and tender to touch, patient cannot recall exactly how it occurred." There was no documented evidence the unwitnessed falls and injuries of unknown cause were investigated to rule out abuse or neglect. The surveyor requested the incidents be reported to the local SPD office. Verification the facility reported the unwitnessed falls and injuries of unknown cause was received on 03/21/24. The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

ED completed abuse/neglect/reporting training on 3/20/2024. All incidents were reported while survey team was on site. All staff will complete abuse/neglect training. The BOM/designee will create a tracker list and monitor for completeness. ED/AED/designee will investigate and self report to APS as required any report of potential abuse/neglect as required. This will be monitored by the RN 3 days/week x 2 months, 2 days/week x 1 month, and weekly x 2 months or until compliance is achieved. This will be monitored by review of incident reports, progress notes, and shift report logs.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were updated or changed as appropriate within the first 30-days after move-in for 1 of 1 sampled resident (#5) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 5 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease with agitation. a. The resident's new move-in evaluation dated 12/27/23 was reviewed and the following elements were not addressed: * Customary routines including eating and bathing; * Mental Health issues including history of treatment; * Cognition including decision making abilities; * Personality including how the person copes with change or challenging situations; * Fluid preferences; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including but not limited to noise. b. The resident's initial evaluation was not updated or changed as appropriate within the first 30 days after move-in. The need to ensure the move-in evaluation included all required elements and was updated or changed as appropriate within the first 30-days of move-in was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24 at 2:55 pm. They acknowledged the findings.

An audit of all evaluation due dates will be completed by the ED/AED/Designee. The ED/AED/Designee will audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families. A weekly audit of evaluation/service plan dates will be done by the ED/AED/Designee x 4 weeks, every other week x  weeks and then monthly so that evaluations/service plans are completed prior to move in, within 30 days, quarterly and with changes of condition.

4. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the most recent service plan, dated 02/24/24, and temporary service plans, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not being implemented in the following areas:   * Eating, including diet texture and fluid consistency, cutting up food and aspiration precautions/coughing; * Instructions for oxygen use including when to use, liter flow, cleaning and replacing supplies; * Fall precautions including use of fall mat and height of bed; and * Skin integrity including ongoing redness in peri-area.   The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and was implemented was discussed with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. 2. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia. The current service plan, dated 02/22/24, and Temporary Service Plans from 12/08/23 to 02/02/24 were reviewed, and observations of Resident 2 and interviews with staff were completed during the survey. The service plan was not reflective of the resident's current status, did not provide clear direction to staff, and was not implemented in the following areas: * Weight loss status; * Fall interventions; * Level of assistance required with toileting, oral care, grooming and dressing; and * Conflicting direction for meal assistance. The need to ensure service plans were reflective of  the resident's current needs and preferences, provided clear direction regarding the delivery of services and were implemented was discussed with Staff 1 (ED), Staff 6 (Health Service Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. 3. Resident 4 was moved into the facility in 09/2023 with diagnoses including dementia, idiopathic sleep with oxygen desaturation (drops in blood oxygen levels) during sleep and type II diabetes with current use of insulin. The current service plan, dated 02/22/24, and observations and interview of Resident 4 were completed during the survey. The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas: * Oxygen treatment including setting and tubing care; * Use of side rails; and * Monitoring low and high blood sugar. The need to ensure service plans were reflective of  the resident's current needs and preferences and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 6 (Health Service Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. 5. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia. a. Observations of the resident, interviews with staff and review of the most recent service plan, dated 12/22/23, and temporary service plans, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not being implemented in the following areas: * Use of psychotropic medications; * Frequency of location checks; * Use of fall mat; * Use of alternating pressure mattress; * Frequency of routine incontinence care; * Use of glasses; * Assistance required with meals and transfers; * Blood pressure checks; * Use of bed rail; and * Hospice provider. b. The service plan was not readily available to staff upon survey entry. The surveyor requested Staff 6 (Health Service Director, RN) to ensure the service plan be readily available to staff on 03/20/24 at 11:30 am. The service plan was not observed to be available to staff until 03/21/24 at 1:45 pm.   The need to ensure resident service plans were readily available to staff, reflective of current care needs, provided clear direction to staff, and was implemented was discussed with Staff 1 (ED), Staff 6, and  Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, were implemented, reviewed and updated within 30-days of move-in, and was readily available to staff, for 5 of 6 sampled residents (#s 1, 2, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease with agitation. a. Observations of the resident, interviews with staff, review of the 02/22/24 service plan, temporary service plans dated 01/04/24 through 02/10/24, and "Observation" notes dated 01/05/24 through 03/06/24 identified Resident 5's service plan was not reflective of his/her needs and preferences, lacked clear direction to staff, and/or was not implemented in the following areas: * Relationship status with other memory care resident(s); * Customary routines including eating and bathing; * Sleep patterns including interventions for insomnia; * Skin integrity and care; * Oral and dental assistance; * Mobility with assistive devices for fall risks including the use of glasses; * Toileting and incontinent assistance and care; * Interests, hobbies, social and leisure activities; * Speech and communication; * Cognition including memory, orientation, confusion, and decision making abilities; * Use of PRN psychotropic medication; * Personality including how the person copes with change or challenging situations; * Nutrition including texture of diet and fluid preferences; and * Emergency evacuation. b. The service plan was not reviewed and updated to reflect the resident's needs and preferences within 30-days of move-in to ensure changes accurately reflected the resident's needs and preferences. c. The service plan was not readily available to staff upon survey entry. On 03/19/24, this surveyor asked Staff 2 (Assistant ED) if the service plan available to staff was the most recent service plan. Staff 2 stated it was not the most recent service plan and was aware it needed to be printed and available to staff. On 03/21/24 at 10:25 am, the service plan was not observed to be available to staff. The need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, services were implemented, were reviewed and updated within 30-days of move-in, and was readily available to staff was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24 at 2:55 pm. They acknowledged the findings.

An audit of all evaluation due dates will be completed by the ED/AED/Designee. The ED/AED/Designee will audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families and reflective of current care needs and updated as appropriate. A weekly audit of evaluation/service plan dates will be done by the ED/AED/Designee x 4 weeks, every other week x  weeks and then monthly so that service plans are completed prior to move in, within 30 days, quarterly and with changes of condition and they are readily available to staff.

2. Resident 2 was admitted to the facility 01/2022 with diagnoses including dementia. a. Observations of the resident on 03/18/24 and 03/21/24 revealed the resident required hands-on assistance to eat meals and drink liquids. Resident 2's 02/22/24 service plan, Temporary Service Plans (TSPs), 12/02/23 through 03/17/24 progress notes, 08/30/23 physician orders and 09/2024 through 03/2024 weight records were reviewed and showed the following: * On 08/30/23, physician order indicated to measure and record the resident's weight monthly; * 12/03/23 through 12/08/23, the resident was on alert charting for "pocketing food/chocking [sic] risk"; and * A 12/08/23 TSP informed staff that the resident's "diet has changed to puree, staff to provide 1:1 feeding support for all meals and snacks." Resident 2's weight record showed the resident experienced a weight loss of 9.4 pounds between 09/2023 (117.4 lbs) and 12/2023 (108.0 lbs) or 8 % of his/her total body weight. The resident experienced another significant weight loss of 6.11 % in one month from 12/2023 to 01/2024 (101.4 lbs). There were no weights recorded in 02/2024 to review. During the survey, the resident's weight was measured on 03/21/24, and the weight was 95.4 pounds. During the survey on 03/20/24 between 9:00 am and 1:00 pm, the following was observed: * From 9:00 am to 10:40 am, the resident was in the recliner in TV area; * From 10:40 am to 11:45 am, the resident was walking around the facility without breaks; * None of staff offered beverages or snacks to the resident during the observation between breakfast and lunch; and * At 12:49 pm, the resident was in the dining room for lunch. Staff provided 1 on 1 meal assistant. The resident consumed most of food. There was no documented evidence in the resident's records the weight loss had been evaluated, actions or interventions had been determined to address the weight loss and communicated to staff, the facility was monitoring for subsequent weight loss, or had referred to the RN for a significant change of condition assessment. During an interview, 03/18/24, Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations) confirmed they had not been monitoring the resident's weights. The facility failed to have a monitoring system in place to review the resident's weights. The weight loss represented a significant to severe amount of weight lost. This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the weight loss was submitted and the situation was abated. b. The following short-term changes lacked documented evidence the resident's conditions were monitored until resolution: * 12/13/23: Fall with injury on head and face; * 12/17/23: Alert for having diarrhea; and * 01/06/24: Alert for medication changes. On 03/21/24, the need to monitor the resident's conditions through resolution, with at least weekly documentation, was discussed with Staff 1 (ED), Staff 6 and Staff 7. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 08/2023 with diagnoses including dementia with mood disorder. a. Review of the 12/06/23 through 03/13/24 progress notes, 03/08/23 service plan, and Temporary Service Plans (TSP's) revealed Resident 3 experienced the following short-term changes of condition: * 12/20/23 - Medication refusals; * 12/28/23 - Positive for Covid-19; * 12/29/23 - Medication refusals; * 01/03/24 - Aggressive behaviors; and * 01/23/24 - Medication refusals. The facility lacked documented evidence actions or interventions were developed and communicated to staff on each shift and changes of condition were monitored, with progress noted at least weekly through resolution, for each of Resident 3's short-term changes of condition. b. Review of the resident's 09/03/23 through 02/02/24 weight records revealed Resident 3 experienced the following weight changes: * 09/03/23 - 166.9 ponds; * 10/26/23 - 173.6 pounds; * 12/03/23 - 183.2 pounds; and * 01/05/24 - 172.4 pounds. According to the records, Resident 3 gained 16.3 pounds in a three month period between 09/2023 and 12/2023 for a total of 9.76% increase in total body weight. This constituted a significant change of condition. The facility lacked documented evidence the resident was evaluated for the significant change of condition and referred to the facility RN for assessment. The need to ensure the facility had a system to refer residents who experienced significant changes of condition to the RN for assessment, determine and document what actions or interventions were needed for a resident's short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, and ensure progress was documented at least weekly until the conditions resolved was discussed with Staff 1 (ED) and Staff 6 (Health Services Director, RN) on 03/21/24. They acknowledged the findings.

Based on observation, interview and record review it was determined the facility to ensure short term changes were evaluated, actions or interventions communicated to staff on each shift, resident specific interventions determined and documented, and the condition monitored with weekly progress noted until resolution for 4 of 4 sampled residents (#1, 2, 3, and 6) who experienced short term changes in the areas of skin and medication changes; and failed to evaluate and monitor service plan interventions for 1 of 1 sampled residents (#1) who had repeated falls, and 2 of 2 sampled residents (#s 2 and 6 ) who had significant weight loss. Resident 1 continued to have falls with injury, and Residents 2 and 6 continued to have weight loss. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia. Interviews with staff, observations of the resident, and review of the resident's 12/22/23 service plan, 12/18/23 through 03/03/24 Temporary Service Plans (TSPs), progress notes, and incident investigations were reviewed. Fall prevention interventions listed on the 12/22/23 service plan included hands on assistance from two people for all transfers, use of wheelchair and ambulation for short distances with supervision, and for staff to assess him/her when restless and getting out of bed without assistance for unmet needs such as discomfort, need to toilet, or hunger. a. Resident 1 experienced the following unwitnessed 10 falls between 12/18/23 and 03/03/24: * 12/18/23: Fall with lip injury; * 12/28/23: Fall with skin tear to the left arm; * 01/03/24: Non-injury fall, found crawling on floor; * 01/05/24: Fall with skin tears to scalp and right knee; * 01/10/24: Fall with injury to right hand and fingers; * 01/23/24: Fall with re-opened scab to right knee; * 01/25/24: Fall with new skin tear to right outer knee; * 01/30/24: Non-injury fall, found on fall mat next to bed; * 02/07/24: Non-injury fall; and * 03/03/24: Fall with rib pain and difficulty breathing. Resident 1 experienced the following witnessed four falls between 12/18/23 and 02/16/24: * 12/18/23: Fall with redness to the left thigh and a cut "the size of a bean" on the left toe; * 12/21/23: Non-injury fall in room; * 02/08/24: Fall out of wheelchair, hit head with no new injuries; and * 02/16/24: Non-injury fall in activities room. During an interview on 03/18/24 at 2:35 pm, Staff 13 (CG) stated staff always used a fall mat while Resident 1 was sleeping, and this recommendation came from hospice staff. Staff 13 stated that there was no specific time frame, but staff "had to keep an eye" on Resident 1 due to frequent falls, but it was difficult when assisting other residents. Staff 13 stated Resident 1 generally required assistance of one person for transfers, ambulation and wheelchair mobility. The resident was observed sleeping in his/her bed multiple times on 03/19/24 and 03/20/24 with a gray fall mat placed beside it. During interviews on 03/20/24, Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) confirmed there was no additional documentation for review. There was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident subsequent to each fall. The resident continued to fall and sustained multiple injuries. This represented a situation that placed the resident at risk for further falls. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the falls was submitted and the situation was abated. b. TSPs were created, but progress was not documented at least weekly through resolution, for the following interventions: * 12/18/23: "Check to see if [s/he] is constipated."; and * 12/28/23: "Monitor resident every 2 hours" and "Report to MT for any behavior changes." The need to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, implemented, and reviewed for effectiveness, and the condition was monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 6 and Staff 7 03/21/24.  No further documentation was provided. 3. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's 02/24/24 service plan, 02/26/24 physician orders, 12/18/23 through 03/06/24 progress notes, 02/01/24 through 03/18/24 MARs, incident reports and investigations and outside provider notes were reviewed. The following was identified: a. The service plan indicated Resident 6 used utensils for eating and required food to be cut up "to nickel size of [or] smaller prior to serving it to [him/her.]" Physician orders indicated an order for mechanical soft diet with nectar thickened liquids. Observations of the resident during lunch on 03/18/24 and 03/19/24 revealed the resident required his/her food to be cut up, assistance with meal set up and supervision for meal assistance while eating. Resident 6's weight record was reviewed during the survey and revealed the following: * 12/05/23 - 181.6 pounds; * 01/05/24 - 169.7 pounds; * 03/06/24 - 163.3 pounds; and * 03/20/24 - 161.7 pounds (weight obtained during survey). From 12/2023 to 01/2024, Resident 6 had weight loss of 11.9 pounds or 6.6% of his/her body weight in one month, which resulted in a severe loss and represented a significant change of condition. Weights documented after 01/2024 revealed the resident experienced another significant weight loss of 11% in three months from 12/2023 to 03/2024. There were no weights recorded in 02/2024 to review. There was no documented evidence in the resident's records the weight loss had been evaluated, actions or interventions had been determined to address the weight loss and communicated to staff, the facility was monitoring for subsequent weight loss, or had referred to the RN for a significant change of condition assessment. Resident 6 continued to experience severe weight loss. During the survey the following was observed: * On 3/18/24 Resident 6 was served lasagna, not cut up, regular sized pieces of green salad with dressing, two rolls, pre-thickened apple juice and milk. The resident was observed eating lasagna with his/her fingers. S/he consumed 100% of the meal. * On 3/19/24 Resident 6 was served noodles, cut up pieces of beef, a roll and regular sized pieces of salad with cut up tomatoes and dressing, and pre-thickened water, apple juice and milk to drink. S/he did not initiate eating until staff prompted him thirteen minutes after food was delivered and placed a spoon in his/her hand. The resident set the spoon down, then proceeded to eat noodles and beef with his/her fingers, grabbed handfuls of salad and licked his/her fingers and hand afterwards. S/he ate 98% of his/her meal including drinks. * Resident 6 was not offered dessert of chocolate cream pie on 3/19/24. * The resident coughed throughout lunch on 3/18/24 and 3/19/24.   In an interview on 03/20/24 with Staff 6 (Health Services Director, RN) she acknowledged Resident 6 had not been evaluated and referred to the facility nurse for  the severe weight loss in January 2024 and again in March 2024. The failure to evaluate the significant change of condition, and update the service plan as needed resulted in ongoing severe weight loss. This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the weight loss was submitted and the situation was abated. b. The following short-term changes lacked documented evidence that actions or interventions were determined, documented, communicated to all staff on all shifts and/or monitored until resolution: * 01/09/24 - "persistent groin redness"; * 02/05/24 - Multiple missed medications; * 02/08/24 - Two abrasions on back; * 02/09/24 - Non-injury fall; * 02/09/24 - Right ring finger "red, swollen and tender to the touch"; * 03/01/24 - Redness on right big toe;   * 03/15/24 - Redness on coccyx; and * Multiple medications that were missed, refused, and/or not available. On 03/20/24 and 03/21/24, the need to evaluate changes of condition, refer changes to the facility nurse when needed, determine actions or interventions and communicate them to staff, and monitor through resolution, with at least weekly documentation, was discussed with Staff 1 (ED), Staff 6, and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Med Techs, Caregivers and culinary staff educated by the ED/AED/RN about the weight process, nutrition and hydration, and snacks a. All falls whether witnessed or unwitnessed will be investigated within 24 hours by the ED/AED or designee and appropriate interventions placed on a TSP and on the service plan. i. Interventions in place at this time for this resident are: 1. Low bed 2. Fall mat on the floor beside the bed ii. A call was placed on 3/21/2024 to Bristol hospice to request: 1. Non-skin cushion for wheelchair 2. Geri hip protectors iii. The service plan will be updated on 3/21/2024 to reflect interventions in place and new interventions and a TSP will be put into place and a change of condition will be completed by the RN by EOD 3/21/2024. d. The ED will monitor the EHR at least 4 days/week for incidents and progress notes.   e. The ED/AED or designee is responsible to complete an investigation on every incident within 24-48 hours, and document on the QAPI. f. The ED/AED or designee will put into place a TSP for each incident. The RN will be notified and will review the TSP, add the interventions to the care plan, and monitor effectiveness of the interventions. g. The ED/AED or designee will self report to APS as required any report of potential abuse/neglect.  This will be monitored by the RN 3 days per week x 2 months, 2 days per week x 1 month, and weekly x 2 months or until compliance is achieved 100% of the time by review of incident reports, progress notes and shift report logs. h. The ED/AED or designee is responsible to notify the RN of any resident with 2 or more falls. 2. Weight Loss-Significant change of condition a. The med techs, caregivers, and culinary staff will be educated by the ED, VP of Clinical Operations, and RN about the weight process, nutrition and hydration, and snacks by 3/25/2024. b. The ED/AED is responsible to ensure that the weights are done by the 5th of each month and logged in the binder/EHR system. c. A review of monthly weights will be done by an RN by the 10th of each month. The RN will complete any change in condition assessment, contact the physician and family, and ensure interventions are on the care plan.   d. The ED/AED is responsible to ensure that weekly weights are done as ordered. e. A review of the weekly weights will be done by an RN weekly. f. Hydration stations were put into place at the med tech station, and each neighborhood on 3/21/2024. The culinary staff will ensure that they are refreshed two times per day (morning and afternoon). i. Interventions in place for (female) resident with weight loss include: 1. Referral to hospice (by NP) 2. Fortified foods with meals 3. Offer snack/fluid at snack times throughout the day (10,3,7) in addition to meals. 4. 1:1 feeding assist at meal times ii. Interventions for (male) include: 1. Hospice is on board and has been and will obtain their notes from November on, and request interventions from them.   2. Encouragement or hand over hand feeding at meal times if needed 3. Staff will offer snack/fluids at snack times during the day (10, 3, 7) in addition to meal times. The RN is enrolled in the "Role of the Nurse" Course in April 2024.

Based on observation, interview, and record review, it was determined the facility failed to ensure the RN performed an assessment which documented findings, resident status, and interventions made as a result for 2 of 2 sampled residents (#s 2 and 6) who experienced a significant change of condition in weight status. Resident 2 and 6 continued to have weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia. Observations of the resident on 03/18/24 and 03/21/24 revealed the resident required hands-on assistance to eat meals and drink liquids. Resident 2's weight record was reviewed during the survey and revealed the following: * 09/2023 - 117.4 pounds; * 12/2023 - 108.0 pounds; * 01/2024 - 101.4 pounds; and * 03/21/24 - 95.4 pounds. From 09/2023 to 12/2023, Resident 2 had weight loss of 9.4 pounds or 8.00 % of his/her body weight, which represented a significant change of condition. Weights documented after 12/2023 revealed the resident experienced another significant weight loss of 6.11 % in three months from 12/2023 to 03/2024. There were no weights recorded in 02/2024 to review. There was no documented evidence the RN completed an assessment of the resident's condition which included findings, resident status and interventions made as a result of the assessment to address the weight loss. During the survey on 03/20/24 the following was observed: * From 10:40 am to 11:45 am, the resident was walking around the facility without breaks; * None of staff offered beverages or snacks to the resident during the observation; and * At 12:49 pm, the resident was in the dining room for lunch. Staff provided 1 on 1 meal assistance. The resident consumed the most of the meal. The failure to complete a RN assessment at the time of the significant weight loss and failure to initiate interventions resulted in additional weight loss. This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the weight loss was submitted and the situation was abated. On 03/21/24, the above findings, lack of an RN assessment and further weight loss were shared with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings. Refer to C270, example 2a. 2. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. Observations of the resident on 03/18/24 and 03/19/24 revealed the resident required his/her food to be cut up, assistance with meal set up, and supervision for meal assistance while eating. Resident 2's weight record was reviewed during the survey and revealed the following: * 12/05/2023 - 181.6 pounds; * 01/05/2024 - 169.7 pounds; and * 03/06/2024 - 163.3 pounds. From 12/2023 to 01/2024, Resident 6 had weight loss of 11.9 pounds or 6.6% % of his/her body weight, which represented a significant change of condition. Weights documented after 01/2024 revealed the resident experienced another significant weight loss of 10% in three months from 12/05/23 to 03/06/24. There were no weights recorded in 02/2024 to review. On 3/20/24 at 11:20 am an interview with Staff 6 (Health Services Director, RN) acknowledged there was no RN assessment done for the significant weight loss on 01/05/24 and 03/06/24. During the survey the following was observed: * On 3/18/24 Resident 6 was served lasagna, not cut up, regular sized pieces of green salad with dressing, two rolls, pre-thickened apple juice and milk. The resident was observed eating lasagna with his/her fingers. S/he consumed 100% of the meal. * On 3/19/24 Resident 6 was served noodles, cut up pieces of beef, a roll and regular sized pieces of salad with cut up tomatoes and dressing, and pre-thickened water, apple juice and milk to drink. S/he did not initiate eating until staff prompted him thirteen minutes after food was delivered and placed a spoon in his/her hand. The resident set the spoon down, then proceeded to eat noodles and beef with his/her fingers, grabbed handfuls of salad and licked his/her fingers and hand afterwards. S/he ate 98% of his/her meal including drinks. * Resident 6 was not offered dessert of chocolate cream pie on 3/19/24. * The resident coughed throughout lunch on 3/18/24 and 3/19/24.   From 12/05/23 through 03/06/24, the resident lost a total of 18.3 pounds, or 10% of his/her total body weight. An RN assessment was not completed that included findings, resident status, and interventions made as a result of the assessment. There was no documented evidence new actions or interventions were identified. Resident 6 continued to have significant weight loss. This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the weight loss was submitted and the situation was abated. The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment, as well as ensuring they were completed in a timely manner, was discussed with Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. Refer to C270, example 6a.

Med Techs, Caregivers and culinary staff educated by the ED/AED/RN about the weight process, nutrition and hydration, and snacks a. All falls whether witnessed or unwitnessed will be investigated within 24 hours by the ED/AED or designee and appropriate interventions placed on a TSP and on the service plan. i. Interventions in place at this time for this resident are: 1. Low bed 2. Fall mat on the floor beside the bed ii. A call was placed on 3/21/2024 to Bristol hospice to request: 1. Non-skin cushion for wheelchair 2. Geri hip protectors iii. The service plan will be updated on 3/21/2024 to reflect interventions in place and new interventions and a TSP will be put into place and a change of condition will be completed by the RN by EOD 3/21/2024. d. The ED will monitor the EHR at least 4 days/week for incidents and progress notes.   e. The ED/AED or designee is responsible to complete an investigation on every incident within 24-48 hours, and document on the QAPI. f. The ED/AED or designee will put into place a TSP for each incident. The RN will be notified and will review the TSP, add the interventions to the care plan, and monitor effectiveness of the interventions. g. The ED/AED or designee will self report to APS as required any report of potential abuse/neglect.  This will be monitored by the RN 3 days per week x 2 months, 2 days per week x 1 month, and weekly x 2 months or until compliance is achieved 100% of the time by review of incident reports, progress notes and shift report logs. h. The ED/AED or designee is responsible to notify the RN of any resident with 2 or more falls. 2. Weight Loss-Significant change of condition a. The med techs, caregivers, and culinary staff will be educated by the ED, VP of Clinical Operations, and RN about the weight process, nutrition and hydration, and snacks by 3/25/2024. b. The ED/AED is responsible to ensure that the weights are done by the 5th of each month and logged in the binder/EHR system. c. A review of monthly weights will be done by an RN by the 10th of each month. The RN will complete any change in condition assessment, contact the physician and family, and ensure interventions are on the care plan.   d. The ED/AED is responsible to ensure that weekly weights are done as ordered. e. A review of the weekly weights will be done by an RN weekly. f. Hydration stations were put into place at the med tech station, and each neighborhood on 3/21/2024. The culinary staff will ensure that they are refreshed two times per day (morning and afternoon). i. Interventions in place for (female) resident with weight loss include: 1. Referral to hospice (by NP) 2. Fortified foods with meals 3. Offer snack/fluid at snack times throughout the day (10,3,7) in addition to meals. 4. 1:1 feeding assist at meal times ii. Interventions for (male) include: 1. Hospice is on board and has been and will obtain their notes from November on, and request interventions from them.   2. Encouragement or hand over hand feeding at meal times if needed 3. Staff will offer snack/fluids at snack times during the day (10, 3, 7) in addition to meal times. The RN is enrolled in the "Role of the Nurse" Course in April 2024.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. During the acuity interview on 03/18/24, the resident was identified to receive insulin injections from non-licensed staff. Resident 4's MARs, reviewed from 03/01/24 through 03/18/24, revealed insulin had been given by Staff 9 (MA) Staff 25 (MA), Staff 26 (MA), and Staff 27 (MA) on multiple occasions. a. Review of Resident 4's delegation documentation on 03/20/24 revealed there was no documented evidence Staff 25 and Staff 27 were delegated for the insulin administration to Resident 4. On 03/20/24 at 12:25 pm, Staff 6 (Health Services Director, RN) confirmed there was no documented delegation completed for Staff 25 and Staff 27. Staff 6 was informed that Staff 25 and Staff 27 should not administer insulin to Resident 4 until staff were delegated. b. The most recent periodic inspection, supervision and re-evaluation of the delegation of insulin for Staff 9 and Staff 26, completed 12/20/23 and 12/19/23, was reviewed. The initial re-evaluation was not completed within 60 days of the initial delegation for Staff 9 and Staff 26. The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations) on 03/21/24 at 2:25 pm. They acknowledged the findings.

RN is scheduled for Role of the Nurse course 4/23-4/25 The AED will ensure that the med techs scheduled are delegated and there is a plan in place for delegation All med techs will be educated regarding signing out of ALIS; closing computer screen when leaving med cart; locking med cart at all times when back is turned. Agency training checklist will be implemented and signed off when an agency staff comes in for a shift RN will upload delegations into ALIS under staff profile (and also keep in binder as required) RN Will set expiration dates on delegation to track timelines

2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia. Resident 1 was identified during the acuity interview on 03/18/24 as receiving hospice services. Review of progress notes and "Outside Provider Communication Forms" from 01/22/24 through 03/13/24 included the following information made by the provider: * 01/22/24: "P.T. eval. today [with] fall prevention recommendations, please see back for recs."; and * 01/30/24: "Staff to continue with visual checks, fall mat out, call hospice with falls." The facility was unable to provide the back page of the physical therapist's recommendations on 01/22/24. The facility requested the note from the hospice provider on 03/21/24, and it included the following information: * "Rec [recommended] pursue soft palm protector that is secured around hand and palm to decrease risk for sores and nails [fingernails]causing injury to palm."; * "PT rec [recommended] room arrangement including moving bed to wall where TV, this will allow direct line of site for cg, head of bed towards window but placing table between window and bed as PT also rec [recommended] moving recliner chair next to HOB [head of bed] and may need a bit of room at head to assure space."; and * "Rec [recommended] bed rails in place with padding, RN to order for pt [patient] safety, and fall mat in place, removing blue (very slick) pad and keeping grey fall mat next to bed, then placing w/c [wheelchair] near foot of bed with brakes locked in place if pt [patient] does attempt to get out of bed, keep doors open but this will allow frequent visual site of pt [patient]." The facility lacked documented evidence the information was communicated to direct care staff or the service plan was adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site outside providers were communicated to staff and service plans adjusted if necessary, and protocols were in place for 2 of 2 sampled residents (#s 1 and 6) who received outside services. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. Resident 6 was identified during the acuity interview on 03/18/24 as receiving hospice services. Review of progress notes and "Outside Provider Communication Forms" from 01/29/24 through 03/18/24 included the following information made by the provider: * 02/09/24: "R [right] hand ring finger is red, swollen and tender to touch,"; * 02/16/24: "R [right] ring finger still tender to touch"; * 03/01/24: "R [right] big toe presenting with redness"; and * 03/15/24: "Coccyx has redness present..." The facility lacked documented evidence the information was communicated to direct care staff or the service plan was adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Outside provider notes will be reviewed weekly to ensure any orders are properly written and carried out and communicated to staff by the ED/AED/RN/Designee.    Recommendations from an outside provider are not considered an order, the ED/AED/RN/Designee will follow up on recommendations weekly to obtain proper orders for these items and implement TSPs for the staff communication.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 2 of 2 sampled residents (#s 2 and 6) who received incontinence care and meal assistance from staff and multiple unsampled residents. Findings include, but are not limited to: 1a. Resident 2 moved into the facility in 01/2022 with diagnoses including dementia. Observations and interviews with staff during the survey identified the resident relied on staff for incontinence care needs and was on a pureed-texture diet requiring meal assist. During the survey, from 03/18/24 through 03/20/24, multiple care staff who performed universal duties, including resident ADL care, were observed to assist with meal service to Resident 2. Care staff were not wearing aprons or some other barrier to prevent the potential for cross contamination when assisting with meal service. b. Lunch service was observed on 03/18/24 and 03/20/24. Staff were observed setting tables with napkins and silverware, serving meals and beverages, touching residents, removing dirty dishes and opening the kitchenette door without changing their gloves or performing hand washing. The above observation was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. The staff acknowledged that appropriate infection control practices were not followed. 4. Observations were made during the survey to determine adherence to universal precautions for infection control. * On 03/18/24, at 12:03 PM, the surveyor observed Staff 20 (CG) providing lunch meal service to the residents of Mountain house. At 12:48 pm, Staff 20 was observed handling two partially eaten plates of food bare handed. The thumbs of both hands were visible on the surface of the plates near the partially eaten food. Staff 20 set the plates on the counter in the kitchenette and proceeded to touch the kitchenette door handle, the door handle and door frame of unit 304 and the kitchenette door handle again with her right hand without performing proper hand hygiene. On 03/18/24 at 12:53 pm, the surveyor spoke to Staff 20 regarding the need to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. She acknowledged the findings. On 03/21/24, the need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) and Staff 6 (Health Services Director, RN) They acknowledged the findings. 2. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. During interviews and observations from 03/18/24 through 03/21/24, Resident 6 was noted to require one to two person assist for toileting and one person assist with dressing. During an ADL observation on 03/19/24 at 1:00 pm the following was noted: * A caregiver escorted the resident into his/her bathroom in a wheelchair and donned gloves. The resident transferred to the toilet with assistance from the caregiver, she doffed his/her pants, removed the soiled brief and put it on the floor, then assisted the resident in sitting down onto the toilet. With the same soiled gloves, the caregiver retrieved a clean brief outside the bathroom touching the resident's cabinet door and bathroom door handles. While she assisted in donning the clean brief, she also touched Resident 6's pants, shoes, arms, shirt and wheelchair push handles and brakes. * The caregiver then bagged up the dirty briefs, removed the gloves, threw away the trash and performed hand hygiene. The observation was discussed with Staff 6 (Health Services Director, RN) on 3/21/24 and she acknowledged appropriate infection control practices needed to be followed in regards to incontinence care. 3. On 03/18/24, observations during lunch service identified the following: At 12:35 pm, a caregiver provided meal assistance to two unsampled residents and was not wearing a protective garment. The caregiver stood between the two residents while she provided meal assistance to both residents with her left hand. She was observed holding each of the resident's forks and cups as she alternated assisting each resident simultaneously with no handwashing in between. 12:42 pm, the caregiver briefly stopped providing meal assistance to these two residents while she left the table to bring desserts to another group of residents. Afterwards, she returned to the table and resumed meal assistance for the two residents.  No handwashing was observed prior to serving desserts or resuming meal assistance. The need to ensure staff consistently used universal precautions when providing incontinence care and meal service was discussed Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

all staff will complete infection control training to include handwashing, incontinence cares, dining assistance. The BOM/designee will have a list of staff names, track completion certificates and follow up. Observe 2 random care staff per week providing incontinence care x 8 weeks, 1 staff per week x 4 weeks, and then 1 x per month until compliance is achieved. ED/CSD will educate all staff that culinary services staff will plate food at each meal. The caregivers will be responsible for delivering the plates to the residents and assisting with meals. ED will develop MOD in dining room and educate all managers on the expectations of meal service and expectation of following the schedule Program director will implement the handwashing out of meaningful moments and ensure that the staff are educated on the process MOD in the dining room will ensure this is happening at meals

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related to failure to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, to have an effective system for tracking controlled substances, to follow or have physician orders, a system in place to notify the physician/practitioner if a resident refused consent, inaccurate medication records, to ensure proper use of PRN psychoactive medications, and a system to complete demonstrated competency staff training in medication administration. Findings include, but are not limited to: This constituted a finding needing an immediate plan of correction for the health and safety of residents. During the re-licensure survey, conducted 03/18/24 through 03/21/24, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas: * C 282: RN Delegation and Teaching; * C 302: Systems: Tracking Control Substances; * C 303: Systems: Medication and Treatment Orders; * C 305: Systems: Resident Right to Refuse; * C 310: Systems: Medication Administration; and * Z 155: Staff Training Requirements. On 03/21/24 at 10:05 am the survey team requested an immediate plan of correction to address the issues identified. At 2:30 pm, a plan was received and accepted by the survey team and the situation was abated. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed on 03/21/24 with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings.

a. Upon hire, medication techs will receive an orientation checklist. The ED/BOM will track the return of the orientation checklist within 3 working days.    b. The BOM/designee will audit 10% of employee files weekly x 2 months, bi-weekly x 2 months, and then monthly to maintain compliance.   c. When the medication tech has completed the orientation checklist, the AED/lead med tech or designee will do a return demonstration medication pass audit with the medication tech. d. The ED/AED/RN will complete a return demonstration med pass audit with each current medication tech by 3/25/2024. e. The RN, AED, or designee will complete a return demonstration med pass audit with each med tech quarterly. f. The medication techs will be inserviced by the ED, AED, RN by 3/25/2024 to include: i. Notifying the physician of medication refusals. ii. Documentation of non-pharmacological interventions tried prior to giving a PRN. iii. Calling the RN on call when they feel a PRN is needed prior to giving. g. The ED/AED will pull the medication exception report at least 3 times per week to review refusals and ensure the communication was sent to the physician.   h. The RN/designee will complete a full audit of physician orders by 3/22/2024 to ensure that: i. Non-pharmacological interventions are associated with any PRN psychotropic medication, and ii. The order in which to use any PRNs is clearly documented on the MAR. i. The RN/Designee will then complete this audit monthly x 3 months, and then monthly. j. A medication cart audit will be done weekly by the AED/ED or designee to identify medications that are low in supply. This will be done weekly on Wednesdays, and the AED/ED/designee will order any medications that are 7-14 days from running out and are not on cycle fill. Med Techs will have a return demonstration med pass audit completed after the 3 working day orientation checklist is completed. ED/AED/designee Medication Techs will have a quarterly med pass audit performed ED/AED/designee. Immediately done by 3/25/2024 for all current med techs. Audits will be uploaded into ALIS and an expiration date set for quarterly. C302-Controlled Substance Inconsistent Narcotic Count ED/AED/RN a Weekly audit of the narcotic books and count will be completed. Med techs will be educated on the proper narcotic count process C303 Physician Orders Physician Orders not carried out as prescribed Micaela/Cynthia Med cart audit was completed Micaela/Cynthia Weekly medication cart audit will be completed on Wednesday and the AED/ED/Designee will order any medications that are 7-14 days from running out and not on cycle fill. C305 Residents Right to Refuse Medications No physician notification of refusal ED/AED/RN Med techs inserviced on 3/25/2024 by AED of the notification to physicians of medication refusals. The ED/Designee will pull the medication exception report at least 3 x's/week and follow up on any refusal of medications that Physician notification occurred. If it did not occur, the Med tech will be re-educated and the ED/Designee will notify the physician C310-Accuracy of MAR Reason for use Cynthia/Micaela a complete audit of medication orders will be completed initially, and then monthly to ensure the correct diagnosis and reason for use is outlined on the MAR Clear Parameters Cynthia/ Micaela a complete audit of medication orders  will be completed initially and then monthly. Clear parameters will be outlined on the MAR for any medication requiring. Holes in MAR Cynthia/ Micaela A weekly audit of medication exceptions will occur and med techs will be re-inserviced with subsequent corrective action C330-Psychotropic Medication non-pharmacological Interventions on the order for PRN psychotropic use. RN Complete audit of physician orders for non-pharmacological interventions listed Clear direction on which medication to attempt first, second, third, etc. RN If a resident has more than 1 medication for the same reason of use, the directions in which to ive first will be clearly outlined on the MAR Documentation required of non-pharmacological interventions attempted RN Med Techs inserviced about documentation requirements and will call RN prior to administration of PRN medication. Rn/Designee Rn will audit progress notes at least 3x's/weekly for documentation related to nonpharmacological interventions.

2. Resident 7 was moved into the facility in 06/2023 with diagnoses including dementia. A review of Resident 7's 03/15/24 through 03/21/24 MARs showed s/he received morphine 10 mg every four hours scheduled and every hour as needed for pain and/or shortness of breath. The MARs and the Controlled Substance Disposition Record revealed the following discrepancies: * The Controlled Substance Disposition log showed the morphine was administered on five occasions on 03/16/24 and seven occasions on 03/20/24, however, the MAR showed only four occasions on 03/16/24 and six occasions on 03/20/24 that the medication was administered to Resident 7. Inconsistencies between the MAR and Controlled Substance Disposition logs and the need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have an effective system for tracking controlled substances for 2 of 2 sampled residents (#s 6 and 7) who were administered PRN narcotic medication. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident had a physician's order for morphine 0.25 ml (5mg) sublingually, every 15 minutes as needed for moderate pain and/or shortness of breath. A review of Resident 6's 05/01/23 through 03/18/24 MARs and the Controlled Substance Disposition Record revealed the following discrepancies: * The Controlled Substance Disposition log showed the morphine was administered on seven occasions between 05/18/23 through 01/14/24, however, the MAR showed only four occasions the medication was administered to Resident 6. * On 03/21/24 at 1:05 pm, a comparison of the morphine bottle to the disposition log showed the amount of medication left was not reflected accurately on the log. Staff 6 (Health Service Director, RN) was present during this observation and confirmed that the bottled showed approximately 22.00 ml remaining and the disposition log indicated 26.00 ml remaining. Inconsistencies between the medication bottle, MARs and Controlled Substance Disposition logs and the need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 (ED), Staff 6, and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

A Weekly audit of the narcotic books and count will be completed by the ED/AED/Designee. Med techs will be educated on the proper narcotic count process by the AED/Nurse/Designee Hospice providers will be notified that when ordering morphine, they will need to order pre-filled syringes of medication by the RN.

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 5 sampled residents (#s 4 and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 4 was moved into the facility in 09/2023 with diagnoses including dementia and type II diabetes with long-term use of insulin. The resident's 03/01/24 through 03/18/24 MARs and 02/15/24 physician's orders were reviewed and identified the following: a. A physician's order indicated to administer Humalog 10 units with breakfast and dinner and 8 units with lunch. Hold if "CBG before meal is less than 120 mg/dl."                  The MAR showed the insulin was administered when the CBG was 104 mg/dl on 03/02/24 at 8:00 am and the insulin was not administered when CBG was 325 mg/dl on 03/12/24 at 5:00 pm. b. A physician's order indicated to administer glucose 40 % oral gel as needed for low blood sugar and the MAR directed staff to administer the gel when CBG was less than 70. The MAR showed the resident's CBG was 48 mg/dl on 03/04/24 at 8:00 am and CBG was 68 mg/dl on 03/05/24 at 8:00 am. There was no documented evidence on the MAR that staff administered the glucose gel when the resident's CBG was less than 70. On 03/21/24, the physician orders and the MARs were reviewed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings. 2.  Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. Resident 6's 02/01/24 through 03/18/24 MARs, corresponding progress notes, and physician's orders, dated 02/26/24 were reviewed. They showed the following: a. Records revealed the following medications were not given as prescribed on the following dates, with documentation stating the "medication not available": * Minerin cream (for dry itchy skin) on 02/28/24; * Magnesium oxide (supplement) on 02/24/24, 02/28/24, 3/11/24 through 03/15/24; * Secura protective cream (for redness/rash to groin) on 02/28/24; * Sertraline (for depression) on 02/08/24, 02/24/24 through 03/02/24; and * Trazodone (for depression/sleep) on 03/17/24. b. Resident 6's physician orders indicated a mechanical soft diet with nectar thickened liquids. * On 03/18/24 observations during lunch indicated Resident 6 was served pre-thickened nectar thick milk and apple juice. Staff were interviewed and indicated when the resident was served water, an individually packaged cup labeled "lemon flavored moderately thick honey consistency" was noted to be given. On 03/18/24 an interview with Staff 6 (Health Service Director, RN) confirmed the physician orders were not being followed and Resident 6 was given honey thickened water. * On 03/18/24 and 03/19/24 observations during lunch indicated Resident 6 was served regular sized pieces of lettuce and cut up tomatoes with dressing. On 03/21/24, the surveyor reviewed observations of the diet consistency with Staff 6 and she acknowledged Resident 6 did not receive a mechanical soft diet when the salad was served. c. Secura Protection 10% cream (for redness/rash to groin) was being administered once a day without a current signed physician order. The need to have signed physician orders in the resident's chart and follow all physician orders as prescribed was discussed with Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Immediate Med cart audit was completed by the AED/Designee. A complete audit of medication orders  will be completed initially and then monthly by the AED/ED/Nurse for parameters. Clear parameters will be outlined on the MAR for any medication requiring. RN/Designee will educate med techs on medication parameters and actions, and notifying the RN on-call immediately of any vitals out of parameter to seek further direction. Weekly medication cart audit will be completed on Wednesday by the AED/ED/Designee and will order any medications that are 7-14 days from running out and not on cycle fill.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner if a resident refused consent to an order for 1 of 2 sampled residents (# 6) who had documented refusals. Findings include, but are not limited to: Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. The resident's MAR's dated 2/01/24 through 03/18/24, was reviewed and revealed facility staff documented Resident 6 refused the following orders:   * Sertraline (for depression) one time; * Cavlon durable barrier cream (skin protection ) two times; * Secura protective cream (redness/rash ) two times; * Miconazole cream 2% (rash ) one time; * Minerin cream (for dry, itchy skin) one time; * Polyethylene glycol (bowel care ) one time; * Remedy 2% Miconazole powder (for rash with moisture ) two times; and * Acetaminophen (for pain) one time. On 03/20/24  Staff 6 (Health Services Director, RN) confirmed there was no documented evidence the facility notified Resident 6'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 6 and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings on 03/21/24.

Med techs inserviced on 3/25/2024 by AED of the notification to physicians of medication refusals. The ED/Designee will pull the medication exception report at least 3 x's/week and follow up on any refusal of medications that Physician notification occurred. If it did not occur, the Med tech will be re-educated and the ED/Designee will notify the physician

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident specific parameters and staff instructions for 2 of 4 sampled residents (#s 1 and 6) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia. The resident's 03/01/24 through 03/18/24 MARs and physician's orders were reviewed. a. The following PRN medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order: * Senexon-S and enema for constipation; * Acetaminophen, morphine, and oxycodone for pain; and * Lorazepam and quetiapine for anxiety/agitation. b. Midodrine (hypotensive medication) lacked a reason for use and resident specific parameters on when to administer. During an interview on 03/19/24 Staff 2 (Assistant ED) and Staff 9 (MA) confirmed the electronic MAR system did not have parameters on which medication should be administered and in what order listed for staff. Staff 2 also confirmed the electronic MAR lacked a reason for use and resident specific parameters for midodrine. The need to ensure resident's MAR was accurate and included resident specific parameters and staff instructions was reviewed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. 2.  Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. Resident 6's 02/01/24 through 03/18/24 MARs, and physician's orders, dated 02/26/24 were reviewed. a. A physician's order for haloperidol PRN for nausea and/or agitation/anxiety included instructions "Report to hospice for increased unusual somnolence, increased confusion or any other unusual changes." This information was not included on the MARs. b. Silvasorb gel was noted on the MAR to be applied to "wound to back left side of head twice weekly". The February MAR had seven blanks and one occasion marked as "missed dose" on 02/05/24, and the March MAR had nine blanks. A current order and/or an order to discontinue was requested and no documented evidence was provided. On 3/19/24 Staff 17 (MA) indicated Resident 6 did not have a wound on his/her head and was not sure why the treatment was on the MAR. The need to ensure accurate MARs were kept and included instructions for PRN medications was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

a complete audit of medication orders will be completed initially, and then monthly by the ED/AED/RN/Designee to ensure the correct diagnosis, reason for use, clearly outlined instructions on which med to utilize first (if there are multiple orders for the same type of drug) is outlined on the MAR a complete audit of medication orders  will be completed initially and then monthly by the ED/AED/RN/Designee. Clear parameters will be outlined on the MAR for any medication requiring.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potential restraining qualities was assessed thoroughly by an RN, PT or OT prior to use and instruction to caregivers on the correct use and precautions of the device was included on the service plan for 1 of 1 sampled resident (# 4) who had bilateral half-length side rails in use. Findings include, but are not limited to: Resident 4 was moved into the facility in 09/2023 with diagnoses including dementia and Type II diabetes with long-term use of insulin. Observation of the resident's bed during the survey on 03/20/24, revealed half-length, bilateral side rails on the bed. On 03/20/24 at 12:05 pm, the surveyor requested assessment related to use of the side rails. Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) stated they just completed the assessment on 03/19/24 during the survey. The 02/22/24 service plan was reviewed and there was no documentation of the side rails and instruction to caregivers on the use and precautions related to the devices On 03/21/24, the lack of an assessment and documentation requirements for side rails use were reviewed with Staff 1 (ED), Staff 6 and Staff. No further information was provided.

a complete audit of medication orders will be completed initially, and then monthly by the ED/AED/RN/Designee to ensure the correct diagnosis, reason for use, clearly outlined instructions on which med to utilize first (if there are multiple orders for the same type of drug) is outlined on the MAR a complete audit of medication orders  will be completed initially and then monthly by the ED/AED/RN/Designee. Clear parameters will be outlined on the MAR for any medication requiring.

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to accurately reflect all the ADLs for each resident, including the amount of staff time needed to provide care for 3 of 3 sampled residents (#s 2, 3 and 6). Findings include, but not limited to: 1. Resident 2 was moved into the facility in 01/2022  with diagnoses including dementia. Resident 2's 02/22/24 service plan was reviewed, observations were made of the resident and interviews were conducted with staff. The time noted for the following ADL activities that staff provided for Resident 2 was not accurate or not included on the resident's ABST: * Eating assistance; * Bowel and bladder management; and * Additional care services including multiple staff required to assist with incontinence care and completing tasks. The need to have all required ADLs on the ABST with the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 08/2023  with diagnoses including dementia with mood disorder. Resident 3's record was reviewed, observations were made of the resident, and interviews were conducted with facility care staff. The time noted for the following. ADL activities that staff provided for Resident 3 was not accurate or not included on the resident's ABST: * Monitoring behavioral conditions or symptoms; and * Ensuring non-drug interventions for behaviors The need to ensure the ABST addressed all required ADL's for each resident and the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 6 (Health Services Director, RN) on 03/21/24. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia. Resident 6's record was reviewed, observations were made of the resident, and interviews were conducted with facility care staff. The time noted for the following ADL activities that staff provided for Resident 6 were not accurate on the resident's ABST: * Monitoring for physical conditions or symptoms. The need to ensure the ABST addressed all required ADL's for each resident and the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Supportive Device Assessments to be completed quarterly by the RN. Audit completed on 3/19/2024 by RN for supportive Devices. Supportive device (bed rail) assessment completed by RN on 3/20/2024, documented and conversation had with POA explaining risks/benefits of device. RN/designee will monitor expiration dates of Supportive Device assessments and update quarterly with service plans All Management Team members were educated on supportive/restraining quality devices by the VP of Clinical Operations on 4/2/2024, to include notification to RN/ED/AED if items are noted. .

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 11, 16, 23, and 24) completed and documented training in First Aid and abdominal thrust within 30-days of hire. Findings include, but are not limited to: Staff training records were reviewed on 03/20/24 and revealed the following: * There was no documented evidence Staff 11 (MA), Staff 16 (MA), Staff 23 (CG), and Staff 24 (CG), hired 02/04/20, 12/20/23, 11/21/23, and 01/05/24, respectively, completed training in First Aid and abdominal thrust within 30-days of hire. The need for staff to complete all required training within the specified time frames was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Employee File audit completed 3/28/2024 by BOM and Vice President Human Resources All staff will be caught up on pre-service training. BOM will track and provide reminders. BOM Will track training with support of ED and ensure it is completed. Staff that do not have trainings completed timely will be removed from the schedule until training is completed. Orientation checklists will be provided to all staff upon hire. The BOM will track that these are completed within 3 working days and that the AED/ED/designee has signed off, and will place in employee files and upload into ALIS under the staff profile. The BOM/Designee will track annual training requirements and ensure they are completed. The BOM/designee will audit 10% of emplyee files weekly x 2 months, bi-weekly x 2 months, and then monthly to maintain compliance

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: The previous six months of fire drill and fire and life safety training records were reviewed on 03/20/24 with Staff 1 (ED)  and Staff 3 (Maintenance Director). The following deficiencies were identified: a. Fire Drills: * Fire drills were only conducted on 01/26/24, 02/12/24 and 02/29/24, not every other month as required. * The facility was not relocating residents from the simulated fire area. Therefore, there was no documentation of: - The escape route used; - Problems encountered, comments relating to residents who resisted or failed to    participate in the drills; - Evacuation time-period needed;          - Evidence alternate routes were used during fire drills; and - Number of occupants evacuated. * Staff interviewed did not know the designated point of safety. b. Fire and life safety training for staff: * The facility was not consistently providing fire and life safety training for staff on alternate months as required. The need to ensure fire drills and fire and life safety training was conducted per the rules was reviewed with Staff 1 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. No further information was provided.

MTD will be educated by ED/VP Environmental Operations on expectations of fire drills and requirement of bi-monthly training topics. The VP of Environmental Operations and Regional Maintenance support will educate all managers on how to conduct a fire drill. Fire Drills and every other month education will be tracked utilizing the appropriate forms and uploaded into TELS. Fire drills will be reported through the monthly CQM meeting.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to: Fire and life safety records were requested and reviewed with Staff 1 (ED) on 03/20/24 and the following deficiencies were identified: * There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission; and * There was no documented evidence of fire and life safety training provided to residents at least annually. The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

All resident fire safety training will occur by the MTD by 4/15/2024 All residents will receive fire training upon move in with contract signing by the ED/MTD/Designee. Maintenance Director will schedule annual resident fire training in TELS to occur every April. The results of this annual training will be reported to the CQI committee every year in April.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to: The facility was comprised of one building, divided into four separate houses, each house had lockable entry doors. The MCC was toured on 03/19/24 at 11:00 am. The following areas were observed to need cleaning and/or repair: a. Facility wide: * Build up of brown and green debris was along the top of the wood perimeter of the outdoor seating area at the main entrance; * Dead plants were in the planters at the entryway; * Build up of debris was on the outdoor light fixtures at the main entrance; * Florescent lights throughout the interior of the facility contained dead insects; * Build up of dust and debris was in the square ceiling vents; and * Handrails were scraped and gouged with bare wood exposed. b. Flower House: * Wall under the menu board had scuffed and chipped paint; * Gouges and white paint were throughout the middle of the interior wall of the dining area; * Missing light cover was above fire extinguisher; and * Interior door to the right of entrance had chipped paint. c. Lighthouse House: * Exposed nail head was in the wood of perimeter of television area; * Entry way door had scuffs and scrapes; and * Door to the courtyard had paint chips and gouges. d. Mountain House: * Brown staining to ceiling was outside of the main entrance. The surveyor toured the environment with Staff 3 (Maintenance Director) on 03/20/23 and reviewed findings with Staff 1 (ED). They acknowledged the above areas needed to be cleaned and repaired.

VP Environmental Operations/Regional maintenance support, and the Maintenance Director will work in-house and with vendors to address all items noted. Regional Maintenance support will educate ED/MTD on CBC walkthrough form. The MTD/ED will conduct a monthly walk through utilizing the CBC Environmental Tour form and identify/fix concerns immediately

Based on observation and interview, it was determined the facility failed to ensure the environment was kept in good repair and was free of odors. This is a repeat citation. Findings include, but are not limited to: The facility was comprised of one building, divided into four separate houses, each house had lockable entry doors. The MCC was toured between 07/01/24 at 11:40 am and 07/03/24 at 9:30 am. The following areas were observed to need cleaning and/or repair: a. Flower House: * Wall under the menu board had scuffed and chipped paint; and * Pervasive urine odors throughout cottage, concentrated in living room.   d. Mountain House: * Pervasive urine odors in living room and room 207. The surveyor toured the environment with Staff 36 (Senior Maintenance Director) on 07/02/24 and reviewed findings with Staff 34 (Operations Specialist) and Staff 35 (Regional Director of Operations). They acknowledged the above areas needed to be cleaned and repaired.

a- area identified in flower house under menu board being scuffed and chipped of paint. MTD/Designee will have the area in Flower house under the menu board repaired by ___________8/2/2024________. d- Urine oders throughout including concentrated area in Mountain house living room and 207 1.MTD/Designee will have the carpets cleaedf in affected areas of odors by __8/5/2024____ All staff will be educated by the  ED/Designee on environmental issues to report immediately to the MTD/ED/Designee by 7/31/2024 ED/MTD/Designee will conduct weekly walkthroughts x 2 months, every other week x 2 months, and monthly ongoing using the CBC checklist to identify areas that are in need of repair and/or cleaning

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C150, C200, C231, C361, C372, C420, C422, and C513.

Refer to C150, C200, C231, C361,C372, C420, C422, and C513

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 C513.

Z142- refer to plan of correction above

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 16, 23, and 24) had documentation of completed orientation, 3 of 3 sampled newly-hired direct care staff (#s 16, 23, and 24) completed pre-service dementia training prior to performing any job duties, 12 of 14 direct care staff (#s 9, 16, 17, 19, 23, 24, 26, 27, 30, 31, 32, and 33) completed demonstrated competency in all required areas within 30-days of hire, and 3 of 3 tenured staff (#s 4, 11 and 21 ) completed the required infectious disease training annually. Findings include, but are not limited to: The facility's training records were reviewed on 03/20/24 and the following was identified: a. There was no documented evidence Staff 16 (MA) and Staff 24 (CG), hired 12/20/23 and 01/05/24, respectfully, completed any of the required pre-service orientation topics prior to beginning their job duties. Additionally, there was no documented evidence Staff 23 (CG), hired 11/21/23, completed the following pre-service orientation topics prior to beginning their job duties: * Abuse reporting requirements; * Infectious Disease Prevention; * Fire safety and emergency procedures; and * Food handler's certificate. b. There was no documented evidence Staff 16, 23, and 24 completed pre-service dementia training courses in any of the required training topics prior to beginning their job duties. c. There was no documented evidence Staff 9 (MA),16, 17 (MA), 19 (MA), 23, 24, 26 (MA), 27 (MA), 30 (MA), 31 (MA), 32 (MA), and 33 (MA), hired between 02/04/20 and 01/05/24, demonstrated competency in all required areas within the first 30-days of hire. On 03/20/24 at 1:05 pm, the survey team informed Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) that staff training and competency documentation had been reviewed and lacked the required documentation. Survey expanded the sample population for staff competency training to include the additional 10 MAs (Staff 9, 17, 19, 23, 26, 27, 30, 31, 32, and 33) identified to have passed medications. At 1:55 pm, Staff 1 provided documentation of demonstrated competencies for Staff 11 (MA) and Staff 29 (MA), 2 of the 14 staff competencies requested. During interviews with multiple direct care staff, it was determined the facility had a system for training and completing staff competencies but lacked an effective way to document the training. On 03/21/24 at approximately 10:05 am, Staff 1, Staff 6, and Staff 7 were informed all MAs must demonstrate competency in their assigned job duties before continuing to administer medications. The survey team requested an plan of correction (POC) that addressed the medication system and staff training. At approximately 11:30 am, a POC was submitted to the survey team. At approximately 2:30 pm, the POC was accepted. d. There was no documented evidence Staff 11 completed the required number of annual in-service training hours, including at least six hours of dementia care topics. e. There was no documented evidence Staff 4 (Activity Assistant), Staff 11, or Staff 21 (Housekeeping), hired 02/20/17, 02/04/20, and 01/20/21, respectively, had completed the required annual infectious disease prevention training. The need to ensure newly hired direct care staff completed all pre-service orientation and training topics prior to beginning any job duties, demonstrated competencies in the required areas within 30-days of hire, and that the required infectious disease training was completed annually was discussed with Staff 1, Staff 6, and Staff 7 on 03/21/24 at 2:55 pm. They acknowledged the findings.

Refer to C372

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: During  the re-licensure survey, conducted 03/18/24 through 03/21/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations. Refer to C252, C260, C270, C280, C282, C290, C295, C300, C302, C303, C305, C310, and C340. Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area: OAR 411-054-0040 (1-2): Change of Condition and Monitoring; OAR 411-054-0045 (1)(a-f)(A)(C-F): Resident Health Services; and OAR 411-054-0055 (1)(a): System: Medications and Treatments. The facility put immediate plans of correction in place during the survey and the situations were abated.

Refer to C150

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 3 of 4 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to: 1. Resident 2 resided on the memory care unit and had been identified to require meal assistance. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs. Observations performed during the survey at meal times revealed the resident required frequent cueing and hands-on assistance to eat meals. The resident was able to eat most of his/her meals with staff assistance. During observations on 03/18/24 and 03/20/24, the resident was not provided with snacks or fluids between the morning and noon meals. The resident had experienced significant weight loss over the past six months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs and lacked information on interventions to monitor weight changes. The lack of an individualized nutritional plan was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings. 2. Residents 1 and 3 resided on the memory care unit and had been identified to require meal assistance including cueing and set up. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on needs. The lack of an individualized nutritional plan was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

An audit of all evaluation dates will be completed An audit of all evaluations will be completed to ensure the following required items are answered and service planned: nutrition/hydration; activities; behavioral plans; Culinary staff will ensure the hydration stations are refreshed two times per day All staff were educated on nutrition/hydration to include all residents being offered appropriate snacks per their diet  times per day in addition to meals with fluids (10am, 3pm, 7pm)

Based on observation, interview, and record review, it was determined the facility failed to develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3, and 6) whose activity evaluations were reviewed. Findings include, but are not limited to: Service plans and evaluations were reviewed for Resident 1, 2, 3, and 6. Observations and interviews were completed between 03/18/24 and 03/21/24. The following deficiencies were revealed: There was no documented evidence individualized activity plans were developed based on the residents' activity evaluations that reflected each resident's activity preferences and needs. During an interview on 03/20/24 at 9:27 am, Staff 4 (Activities Director) confirmed she was unaware an individualized activity program needed to be developed for each resident. The facility failed to develop individualized activity plans based on each resident's activity evaluation. The need to ensure the facility developed individualized activity plans for each resident was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. The findings were acknowledged.

Life Stories will be obtained for all residents by the PGD/AED/ED/Designee. PGD/ED will give a list of resident specific likes/dislikes for activities to the ED/RN to update service plans. Staff to be educated on engagement kits, not using TV for activity by the PGD/ED/National Director of Programming. Service plans will be updated by the AED/ED/RN/Designee to reflect activity/engagement plans. The ED/AED/HSD/Designee will provide ongoing audit of service plans for activity plans with move in, change in condition, and at least quarterly.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to: During the survey, observations of resident rooms in Flower house revealed rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Direct care staff each carried a key which could open all residents' rooms. Observations on 3/18/24 identified two residents attempted to open the door to their apartments but the doors were locked. One resident left and returned five minutes later and attempted to enter his/her room again. The surveyor did not observe staff unlock the door for either resident. On 3/18/24 an interview with Staff 28 (CG), indicated that all the residents' doors were locked in Flower house because a resident liked to take things. Staff 28 stated only two residents in Flower house had their own keys to their rooms. On 03/21/24, the need to ensure residents were not locked outside their rooms was discussed with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings.

Staff will be educated by the ED/Designee that only doors where the resident has been assessed to have a key and appropriately use the key and has been service planned can be locked when residents are not in their room. The leadership team will audit this at least 3 x's/week x 1 month, 2 x's/week x 1 month, and then at least weekly when rounding and note on Resident Care Connections and provide in the moment, on-going education.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C513.

C 455 to meet substantial compliance refer to plan below

The findings of the relicensure survey conducted 03/18/24 through 03/21/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 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 Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area: OAR 411-054-0040 (1-2): Change of Condition and Monitoring; OAR 411-054-0045 (1)(a-f)(A)(C-F): Resident Health Services; and OAR 411-054-0055 (1)(a): System: Medications and Treatments. The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the first revisit to the relicensure survey of 03/21/24 conducted 07/01/24 through 07/03/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 03/21/24, conducted 08/15/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled residents (# 5). Findings include, but are not limited to: A review of Resident 5's service plan, dated 10/31/23, indicated staff are to assist Resident 5 with putting on his/her TED hose in the morning and taking them off in the evening. Staff to wash if Resident 5 hasn't. Service plan also directed staff are to remind Resident 5 to put "flipper tooth" in in the morning and help remove it at night if needed to be cleaned and stored. Staff are to ensure Resident 5 has his/her tooth in when s/he is finished eating. In an interview on 03/11/24, Resident 5 stated staff do not assist him/her with putting on, taking off or washing his/her TED hose. Resident 5 also stated staff do not assist him/her with his/her teeth, "staff don't pay much attention to his/her needs at all." From 11:57 am to 1 pm, lunch service was observed. Resident 5 was observed eating lunch in the dining area. At 12:53 pm, Resident 5 left the dining room for his/her apartment. No staff interacted with resident to observe flipper tooth. At 1:05 pm Resident 5 pulled up his/her pant leg to show Compliance Specialist that s/he did not have his/her TED hose on. The facility failed to ensure the implementation of services. On 04/02/24, the findings were reviewed with and acknowledged by Staff 1 (Assistant Executive Director), Staff 18 (Administrator), Staff 15 (Regional Director of Nursing), Staff 19 (RN), and Staff 20 (VP of Clinical Operations) via telephone. Based on observation, interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled residents (# 5). Findings include, but are not limited to: A review of Resident 5's service plan, dated 10/31/23, indicated staff are to assist Resident 5 with putting on his/her TED hose in the morning and taking them off in the evening. Staff to wash if Resident 5 hasn't. Service plan also directed staff are to remind Resident 5 to put "flipper tooth" in in the morning and help remove it at night if needed to be cleaned and stored. Staff are to ensure Resident 5 has his/her tooth in when s/he is finished eating. In an interview on 03/11/24, Resident 5 stated staff do not assist him/her with putting on, taking off or washing his/her TED hose. Resident 5 also stated staff do not assist him/her with his/her teeth, "staff don't pay much attention to his/her needs at all." From 11:57 am to 1 pm, lunch service was observed. Resident 5 was observed eating lunch in the dining area. At 12:53 pm, Resident 5 left the dining room for his/her apartment. No staff interacted with resident to observe flipper tooth. At 1:05 pm Resident 5 pulled up his/her pant leg to show Compliance Specialist that s/he did not have his/her TED hose on. The facility failed to ensure the implementation of services. On 04/02/24, the findings were reviewed with and acknowledged by Staff 1 (Assistant Executive Director), Staff 18 (Administrator), Staff 15 (Regional Director of Nursing), Staff 19 (RN), and Staff 20 (VP of Clinical Operations) via telephone. Verbal Plan of Correction: Staff have since been reeducated on how to wash residents' TED hose, where to place them to dry and how and when to put them on resident.

Based on observation and interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to establish and maintain infection prevention and control protocols. Findings include, but are not limited to: At 8:12 am on 03/11/24, signs were observed at the entrance to the facility indicating the facility was under COVID precautions and masks were required. During a walkthrough of the facility between 8:12 am - 8:35 am, Staff 3 (Caregiver), Staff 4 (Caregiver) and Staff 7 (Med Tech) were observed without masks on. At 11:55 am, Staff 4 was observed again without a mask on. In an interview on 03/11/24, Staff 13 (Business Office Manager) stated the facility had an infection control specialist that provided infection control protocols when the facility had COVID outbreaks. A review of an email from Staff 15 (Regional RN), dated 03/04/24, to Staff 18 (Executive Director), Staff 1 (Assistant Executive Director), Staff 13, Staff 14 (Receptionist), Staff 11 (Maintenance Director), Staff 20 (VP of Clinical Operations) and other staff members, indicated the community was in a COVID outbreak and provided 9 steps for the facility to take immediately including: "All staff, unless an approved accommodation is in their file, must wear N95 masks, while in the facility." The facility failed to establish and maintain infection prevention and control protocols. On 04/02/24, via telephone, the findings were reviewed and acknowledged with Staff 1 Staff 18 Staff 15 Staff 19 (RN), and Staff 20. Verbal Plan of Correction: Re-education and training has been completed with staff, they are currently out of their COVID precautions, but will be implementing more manager rounding to ensure staff compliance.

Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#4). Findings include, but are not limited to: A review of Resident 4's MAR, dated 01/01/24 through 01/31/24, and physician orders, dated 02/28/24, indicated the following: -On 01/05/24, s/he was to begin Risperidone 0.25 mg tablet, with the instructions to give one tablet by mouth three times a day, at 08:00am, at 02:00pm, and at 08:00pm. -Between 01/21/24 through 01/26/24, Resident 4 was not administered seven doses of Risperidone. -The "Exception Reason" on the MAR indicated "Medication not available" for all instances of missed Risperidone. On 01/05/24, s/he was to begin Aspirin 81 mg tablet, give one tablet by mouth once a day, at 8:00 am. - Resident 4 was not administered the 8:00am dose of Aspirin on 01/09 due to 'medication not available". On 01/09/24, s/he was to begin Atorvastatin 40 mg tablet, give one tablet by mouth once a day, at 8:00 am. - Resident 4 was not administered his/her scheduled doses on 01/24 and 01/27 due to "medication not available." During an interview on 04/02/24, Staff 15 (Regional Director of Nursing) stated the following: -During the timeframe of the January MAR, the community was using two medication carts for the entire facility. -The medication carts became "crowded" with medication. -Facility staff were documenting "Medication not available" if they could not locate the medication in their first attempt since the cart was so "crowded." It was confirmed the facility failed to carry out medication and treatments as prescribed. The findings were reviewed and acknowledged with Staff 1 (Assistant Executive Director), Staff 18 (Administrator), Staff 15, Staff 19 (RN), and Staff 20 (VP of Clinical Operations) on 04/02/24 via telephone. Plan of correction: The facility has since ordered two additional medication carts for the facility, one for each of the houses. The facility has implemented weekly medication cart audits and re-training their MTs on re-ordering medication. Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 residents (# 2). Findings include, but are not limited to: A review of Resident 2's September 2023 and October 2023 MARs indicated the following: · Rivastigmine, used for mood, one patch to be applied to skin daily. On 09/01/23, the administration of this medication was not recorded at the scheduled 12:00 pm. · On 10/04/23 and 10/05/23, the medication Acidophilus, used for supplement, to be given daily once by mouth, said "medication was unavailable." · On 10/14/23 and 10/15/23 treatment order for bandage change indicated "medication not available." · On 10/04/23 and 10/13/23, zinc oxide paste, used for skin protectant, to be applied twice daily. The 8:00 am doses were not administered due to "medication not available." Physician orders for the time period were not able to be located by Staff 1 (Assistant Executive Director). In an interview on 04/02/24 with Staff 1, Staff 18 (Executive Director), Staff 15 (Regional Director of Nursing), Staff 19 (RN), and Staff 20 (VP of Clinical Operations) it was stated that the expectation for staff when they are unable to document medications electronically, they should be documenting on a paper MAR, or it should be documented electronically in and noted in the exception report the reason for documenting late. When there are blank spaces in the MAR it means someone did not record if the medication was passed or not. The facility failed to carry out medication orders as prescribed. The findings were reviewed with and acknowledged by Staff 1, Staff 18, Staff 15, Staff 19 and Staff 20 on 04/02/24 via telephone call. Verbal Plan of Correction: The facility has ordered enough med carts to have 1 for each house to make medications easier to find. Weekly cart audits are being completed and retraining for all med techs. Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 27 of 27 sampled residents (#s 2, 3, 4, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 39 & 40). Findings include, but are not limited to: During separate interviews on 03/11/24, Staff 13 (Business Office Manager) and Staff 1 (Assistant Executive Director) stated the following: - A medication error had taken place on February 5th and multiple residents were affected. - Incident reports regarding the medication error on February 5th were completed. - Staff 13 and Staff 1 did not work at the time of incident and were unsure of the exact cause. A review of the facility's "Medication Exception Report", dated 02/05/24, indicated a total of 32 residents missed medications/treatments on 02/05/24. a. Resident 2: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 2 was not administered Acetaminophen 500 mg, Clotrimazole 1% cream, Docusate Sodium 100 mg, Midodrine 2.5 mg, Remedy AF 2% Miconazole Powder, Sennoside Oral tablet 8.6 mg, Sertraline HCI Oral tablet 100 mg, and Zinc Oxide Paste 16%. A review of Resident 2's MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am acetaminophen 500 mg missed dose; · 02/05/24 8:00 am aspirin 81 mg not recorded; · 02/05/24 8:00 am clotrimazole 1% cream missed dose; · 02/05/24 8:00 am docusate sodium 100 mg missed dose; · 02/05/24 8:00 am midodrine 2.5 mg missed dose; · 02/05/24 8:00 am remedy AF 2% miconazole powder missed dose; · 02/05/24 8:00 am sennosides oral tablet 8.6 mg missed dose; · 02/05/24 8:00 am sertraline HCI 100 mg missed dose; and · 02/05/24 8:00 am zinc oxide paste 16% missed dose. A review of physician orders, dated 02/20/24, indicated Resident 2 was prescribed the following: · Acetaminophen 500 mg with instructions to "GIVE 1 TABLET BY MOUTH TWICE DAILY" scheduled at 8:00 am and 5:00 pm, effective 04/10/23; · Aspirin 81 mg with instructions to  " GIVE 1 TAB BY MOUTH EVERY DAY "  scheduled at 8:00 am, effective 12/14/22; · Clotrimazole 1% cream with instructions to  " APPLY TOPICALLY A THIN FILM AS DIRECTED TO TOENAILS OF BOTH FEET AND GLUTEAL CLEFT TWICE DAILY "  scheduled at 8:00 am and 5:00 pm, effective 01/16/23; · Docusate Sodium 100 mg with instructions to  " GIVE 1 CAPSULE BY MOUTH ONCE A DAY "  scheduled at 8:00 am, effective 01/18/23; · Midodrine 2.5 mg with instructions to  " TAKE 1 TABLET BY MOUTH 2 TIMES DAILY "  scheduled at 8:00 am and 5:00 pm, effective 08/06/22; · Remedy AF 2% Miconazole Powder with instructions to  " APPLY TOPICALLY A SMALL AMOUNT TO HIS/HER FEET PRIOR TO PLAING HIS/HER SOCKS ON EACH MORNING "  scheduled at 8:00 am, effective 01/18/23; · Sennoside Oral tablet 8.6 mg with instructions to  " GIVE 1 TABLET BY MOUTH MONDAY, WEDNESDAY AND FRIDAY "  scheduled at 8:00 am, effective 11/20/23; · Sertraline HCI Oral tablet 100 mg with instructions to  " Take one tablet by mouth every morning, may crush and put into food "  scheduled at 8:00 am, effective 02/14/23; and · Zinc Oxide Paste 16% with instructions to  " Apply topically to gluteal cleft after applying Clotrimazole twice daily and after bathing on Wed and Sat evening "  scheduled at 8:00 am and 5:00 pm, effective 03/08/23. b. Resident 3: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 3 was not administered Amlodipine Besylate 10 mg, Eliquis Oral Tablet 5 mg, Furosemide 20 mg, Hydralazine 50 mg, Risperidone 0.25 mg, Senna-time 8.6 mg and Vitamin D3 25 mcg. A review of Resident 3's MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am Amlodipine Besylate 10 mg missed dose; · 02/05/24 8:00 am Eliquis Oral Tablet 5 mg missed dose; · 02/05/24 8:00 am Furosemide 20 mg missed dose; · 02/05/24 8:00 am Hydralazine 50 mg missed dose; · 02/05/24 8:00 am Risperidone 0.25 mg missed dose; · 02/05/24 8:00 am Senna-time 8.6 mg missed dose; and · 02/05/24 8:00 am Vitamin D3 25 mcg missed dose A review of physician orders, dated 10/06/23, indicated Resident 3 was prescribed the following: · Amlodipine Besylate 10 mg with instructions  " Take 1 table by mouth daily"; · Apixaban 5 mg (Commonly known as ELIQUIS) with instructions to  " Take 1 tablet by mouth 2 times daily"; · Furosemide 20 mg with instructions to  " Take 1 tablet by mouth Daily"; · Hydralazine 50 mg with instructions to  " Take 1 tablet by mouth 2 times daily"; · Senna 8.6 mg with instructions to  " Take 2 tablets by mouth 2 times daily (before meals)"; and · Cholecaliferol 25mcg (Commonly known as Vitamin D-3) with instructions to "take 2 tablet by mouth Daily". c. Resident 4: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 4 was not administered Aspirin 81 mg, Atorvastatin 40 mg, Fluticasone 50 mcg, Risperidone .25 mg, Spiriva Respimat 2.5 mcg and Wixela 100-50 inhub. A review of Resident 4's MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am Aspirin 81 mg missed dose; · 02/05/24 8:00 am Atorvastatin 40 mg missed dose; · 02/05/24 8:00 am Fluticasone 50 mcg missed dose; · 02/05/24 8:00 am Risperidone 0.25 mg missed dose; · 02/05/24 8:00 am Spiriva Respimat 2.5 mcg missed dose; and · 02/05/24 8:00 am Wixela 100-50 inhub missed dose A review of physician orders, dated 02/20/24, indicated Resident 4 was prescribed the following: · Aspirin 81 mg with instructions to "GIVE 1 TAB BY MOUTH ONCE A DAY "  scheduled at 8:00 am, effective 01/06/24; · Atorvastatin 40 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY "  scheduled at 8:00 am, effective 01/09/24; · Fluticasone 50 mcg with instructions to "GIVE 2 SPRAYS IN EACH NOSTRIL ONCE A DAY "  scheduled at 8:00 am, effective 01/08/24; · Risperidone .25 mg with instructions to "GIVE 1 TABLET BY MOUTH 3 TIMES A DAY "  scheduled at 8:00 am, 2:00 pm and 8:00 pm, effective 01/05/24; · Spiriva Respimat 2.5 mcg with instructions to "INHALE 2 PUFFS INTO THE LUNGS ONCE A DAY "  scheduled at 8:00 am, effective 01/08/24; and · Wixela 100-50 inhub with instructions to "INHALE 1 PUFF W/DEV INTO THE LUNGS TWICE DAILY "  scheduled at 8:00 am and 8:00 pm, effective 01/08/24. d. Resident 15: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 15 was not administered Acetaminophen 500 mg, Donepezil HCL 10 mg, Pravastatin Sodium 20 mg, Vitamin D3 50 mcg and Levothyroxine 25 mcg. A review of Resident 15's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Acetaminophen 500 mg missed dose; · 02/05/24 8:00 am Donepezil HCL 10 mg missed dose; · 02/05/24 8:00 am Pravastatin Sodium 20 mg missed dose; · 02/05/24 8:00 am Vitamin D3 50 mcg missed dose; and · 02/05/24 7:00 am Levothyroxine 25 mcg missed dose. A review of physician orders dated 02/20/24 indicated Resident 4 was prescribed the following: · Acetaminophen 500 mg with instructions to  " GIVE 2 TABLETS BY MOUTH ONCE A DAY ROUTINE FOR PAIN "  scheduled at 8:00 am, effective 01/31/24; · Donepezil HCL 10 mg with instructions to  " GIVE 1 TABLET BY MOUTH ONCE A DAY "  scheduled at 8:00 am, effective 11/28/23; · Pravastatin Sodium 20 mg with instructions to  " GIVE 1 TABLET BY MOUTH ONCE A DAY "  scheduled at 8:00 am, effective 11/28/23; · Vitamin D3 50 mcg with instructions to  " GIVE 1 CAPSULE BY MOUTH ONCE A DAY FOR BONE SUPPLEMENT "  scheduled at 8:00 am, effective 01/31/24; and · Levothyroxine 25 mcg with instructions to  " GIVE ONE TABLET BY MOUTH ONCE A DAY "  scheduled at 7:00 am, effective 11/28/23. e. Resident 16: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 16 was not administered Acetaminophen 325 mg, Citalopram 20 mg, Memantine 10 mg, Quetiapine Fumarate 50 mg, Vitamin B-12 500 mcg, and Vitamin D3 2000 IU. A review of Resident 16's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Acetaminophen 325 mg missed dose; · 02/05/24 8:00 am Citalopram 20 mg missed dose; · 02/05/24 8:00 am Memantine 10 mg missed dose; · 02/05/24 8:00 am Quetiapine Fumarate 50 mg missed dose; · 02/05/24 8:00 am Vitamin B-12 500 mcg missed dose; and · 02/05/24 8:00 am Vitamin D3 2000 IU missed dose. A review of physician orders dated 02/20/24 indicated Resident 16 was prescribed the following: · Acetaminophen 325 mg with instructions  " 2 TABLETS BY MOUTH 3 TIMES DAILY "  scheduled at 8:00 am, 12:00 pm and 5:00 pm, effective 01/04/23; · Citalopram 20 mg with instructions  " 1 TABLET BY MOUTH EVERY DAY "  scheduled at 8:00 am, effective 06/09/22; · Memantine 10 mg with instructions to  " GIVE 1 TABLET BY MOUTH 3 TUMES A DAY IN THE MORNING, AFTERNOON, EVENING FOR DEMENTIA/AGITATION "  scheduled at 8:00 am, 12:00 pm and 5:00 pm, effective 01/08/23; · Vitamin B-12 500 mcg with instructions to  " GIVE 1 TABLET BY MOUTH ONCE A DAY "  scheduled at 8:00 am, effective 01/08/23; and · Vitamin D3 2000 IU with instructions to  " GIVE 1 TABLET BY MOUTH ONCE A DAY "  scheduled at 8:00 am, effective 01/08/23. f. Resident 17: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 17 was not administered Divalproex Sod 125 mg, Losartan Potassium 25 mg, Multivitamin w/min, Olanzapine ODT 5 mg, Remedy Phytoplex Hydraguard, Sertraline HCL 25 mg, Acetaminophen 500 mg, Vitamin D3 2000 IU, Blood Pressure and Heart Rate Daily and Monthly Weights and Vitals. A review of Resident 17's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Divalproex Sod 125 mg missed dose; · 02/05/24 8:00 am Losartan Potassium 25 mg missed dose; · 02/05/24 8:00 am Multivitamin w/min missed dose; · 02/05/24 8:00 am Olanzapine ODT 5 mg missed dose; · 02/05/24 8:00 am Remedy Phytoplex Hydraguard missed dose; · 02/05/24 8:00 am Sertraline HCL 25 mg missed dose; · 02/05/24 7:00 am Acetaminophen 500 mg missed dose; · 02/05/24 7:00 am Vitamin D3 2000 IU missed dose; · 02/05/24 8:00 am Blood Pressure and Heart Rate Daily missed dose; and · 02/05/24 8:00 am Monthly Weights and Vitals missed dose. A review of physician orders dated 02/15/24 indicated Resident 17 was prescribed the following: · Divalproex Sod 125 mg with instructions to  " Take 4 capsules by mouth 2 times daily " ; · Losartan 25 mg with instructions to  " Take 1 tablet by mouth Daily " ; · Multiple Vitamins-Minerals with instructions to  " Take 1 tablet by mouth Daily " ; · Olanzapine Zydis 5 mg with instructions to  " Take 1 tablet by mouth 2 times daily " ; · Sertraline 50 mg with instructions to  " Take 1 tablet by mouth Daily " ; · Acetaminophen 500 mg with instructions to  " Take 2 tablets by mouth 3 times daily " ; and · Cholecalciferol (Vitamin D-3) 50 mcg with instructions to  " Take 1 capsule by mouth Daily " . g. Resident 18: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 18 was not administered Olanzapine 5 mg, Quetiapine Fumarate 50 mg, Sertraline HCL 50 mg, Vitamin B-1 100 mg, and Vitamin D3 25 mcg. A review of Resident 18's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Olanzapine 5 mg missed dose; · 02/05/24 8:00 am Quetiapine Fumarate 50 mg missed dose; · 02/05/24 8:00 am Sertraline HCL 50 mg missed dose; · 02/05/24 8:00 am Vitamin B-1 100 mg missed dose; and · 02/05/24 8:00 am Vitamin D3 25 mcg missed dose. A review of physician orders dated 02/07/24 indicated Resident 18 was prescribed the following: · Olanzapine 5 mg with instructions "1 tablet twice a day"; · Quetiapine 50 mg with instructions "1 tablet three times daily"; · Sertraline 50 mg with instructions "1 tablet daily"; · Thiamin HC (Vitamin B1) 100 mg with instructions "1 tablet daily"; and · Vitamin D3 25 mcg with instructions "1 tablet daily". h. Resident 19: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 19 was not administered Acetaminophen 325 mg, Amlodipine Besylate 5 mg, Aspirin 81 mg, compression stockings, Dorzolamide-Timolol eye drops, Furosemide 20 mg, Lisinopril 10 mg, Miconazole 2% topical cream, and Prednisolone AC 1% eye drop. A review of Resident 19's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Acetaminophen 325 mg missed dose; · 02/05/24 8:00 am Amlodipine Besylate 5 mg missed dose; · 02/05/24 8:00 am Aspirin 81 mg missed dose; · 02/05/24 8:00 am compression stockings missed dose; · 02/05/24 8:00 am Dorzolamide-Timolol eye drops missed dose; · 02/05/24 8:00 am Furosemide 20 mg missed dose; · 02/05/24 8:00 am Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ml held per doctor ' s orders; · 02/05/24 8:00 am Lisinopril 10 mg missed dose; · 02/05/24 8:00 am Miconazole 2% topical cream missed dose; and · 02/05/24 8:00 am Prednisolone AC 1% eye drop missed dose. A review of physician orders, dated 08/10/23, indicated Resident 19 was prescribed the following: · Aspirin 81 mg with instructions to  "Chew and swallow 1 tablet Daily"; · Compression stockings; · Dorzolamide-Timolol eye drops with instructions to "Place 1 drop into the right eye 2 times daily"; · Furosemide 20 mg with instructions to "Take 0.5 tablets by mouth Daily"; · Insulin Glargine 100 units/ml injection with instructions to "Inject 45 units under the skin every morning"; · Lisinopril 10 mg with instructions to "Take 1 tablet by mouth Daily Hold for SBP<110 "; · Miconazole 2% topical cream with instructions to  "Apply topically Twice daily as needed (for yeast rash in groin, pannus, and/or under breasts)"; and · Prednisolone AC 1% eye drop with instructions to  "Place 1 drop into the right eye 2 times daily". i. Resident 20: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 20 was not administered Levothyroxine 50 mcg, Acetaminophen 500mg, Carbidopa-Levodopa 25-100, Fluticasone 50 mcg, Furosemide 20 mg, Lisinopril 10 mg, montelukast sod 10 mg, Quetiapine Fumarate 25 mg and Vitamin B-12 1000 mcg. A review of Resident 20's MAR, dated 02/2024 indicated the following: · 02/05/24 6:00 am Levothyroxine 50 mcg missed dose; · 02/05/24 8:00 am Acetaminophen 500mg missed dose; · 02/05/24 8:00 am Carbidopa-Levodopa 25-100 missed dose; · 02/05/24 8:00 am Fluticasone 50 mcg missed dose; · 02/05/24 8:00 am Furosemide 20 mg missed dose; · 02/05/24 8:00 am Lisinopril 10 mg missed dose; · 02/05/24 8:00 am montelukast sod 10 mg missed dose; · 02/05/24 8:00 am Quetiapine Fumarate 25 mg missed dose; and · 02/05/24 8:00 am Vitamin B-12 1000 mcg missed dose. A review of physician orders dated 02/28/24 indicated Resident 20 was prescribed the following: · Levothyroxine 50 mcg with instructions to "Take 1 tablet by mouth every morning (before breakfast)"; · Acetaminophen 500mg with instructions to "Take 2 tablets by mouth every 8 hours"; · Carbidopa-Levodopa 25-100 mg with instructions to "Take 1 tablet by mouth 3 times daily"; · Fluticasone 50 mcg with instructions to "Use 1 spray in each nostril once daily"; · Lisinopril 10 mg with instructions to "Take 1 tablet by mouth Daily"; · montelukast 10 mg with instructions to "Take 1 tablet by mouth Daily"; · Quetiapine 25 mg with instructions to "Take 0.5 tablets by mouth 3 times daily"; and   · Cyanocobalamin (Vitamin B-12) 1000 mcg with instructions to "Take 1 tablet by mouth Daily". j. Resident 21: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 21 was not administered Alendronate 70 mg, Alendronate Sodium 70mg, Lamotrigine Oral 100 mg, Quetiapine Fumarate 25 mg and Vitamin D3 25 mcg. A review of Resident 21's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Alendronate 70 mg missed dose; · 02/05/24 8:00 am Alendronate Sodium 70mg missed dose; · 02/05/24 8:00 am Lamotrigine Oral 100 mg missed dose; · 02/05/24 8:00 am Quetiapine Fumarate 25 mg missed dose; and · 02/05/24 8:00 am Vitamin D3 25 mcg missed dose. A review of physician orders dated 02/12/24 indicated Resident 21 was prescribed the following: · Alendronate 70 mg with instructions "1 tablet every 7 days on Monday"; · Lamotrigine Oral 100 mg with instructions "2.5 tablet every morning; 3 tabs every evening"; · Quetiapine 25 mg with instructions "1 tablet three times daily"; and · Vitamin D3 25 mcg with instructions "1 capsule daily". k. Resident 22: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 22 was not administered Acetaminophen 500 mg, Diclofenac Sodium 1% gel, Quetiapine Fumarate 25 mg, Vitamin D3 2000IU and Vitamin D3 Oral capsule 50 mcg A review of Resident 22's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Acetaminophen 500 mg missed dose; · 02/05/24 8:00 am Diclofenac Sodium 1% gel missed dose; · 02/05/24 8:00 am Quetiapine Fumarate 25 mg missed dose; · 02/05/24 8:00 am Vitamin D3 2000IU missed dose; and · 02/05/24 8:00 am Vitamin D3 Oral capsule 50 mcg missed dose A review of physician orders dated 08/24/23 indicated Resident 22 was prescribed the following: · Diclofenac 1% topical gel with instructions "4 grams 2 times a day, topical route, to left hip, knee and ankle"; · Vitamin D3 2000IU "PO, qd am" [by mouth once a day in morning]; · Quetiapine 25 mg "PO, qd am" [by mouth once a day in morning]; · Quetiapine 25 mg "PO, qd pm- prn" [by mouth once a day in evening as needed ]; and · Acetaminophen 1000 mg "PO, tid" [by mouth three times a day]. l. Resident 23: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 23 was not administered Acetaminophen 650 mg, Atorvastatin 10 mg, Calcium Carbonate 600 mg, Deep Sea 0.65% nasal spray, Fiber-lax 625 mg, Fluticasone 50 mcg, Lidocaine 5% patch, Memantine HCL 5 mg, Refresh Classic Eye Drops, Risperidone 0.25 mg, Vitamin B-1 100 mg and Vitamin D3 50 mcg. A review of Resident 23's MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am Acetaminophen 650 mg missed dose; · 02/05/24 8:00 am Atorvastatin 10 mg missed dose; · 02/05/24 8:00 am Calcium Carbonate 600 mg missed dose; · 02/05/24 8:00 am Deep Sea 0.65% nasal spray missed dose; · 02/05/24 8:00 am Fiber-lax 625 mg missed dose · 02/05/24 8:00 am Fluticasone 50 mcg missed dose; · 02/05/24 8:00 am Lidocaine 5% patch missed dose; · 02/05/24 8:00 am Memantine HCL 5 mg missed dose; · 02/05/24 8:00 am Refresh Classic Eye Drops missed dose; · 02/05/24 8:00 am Risperidone 0.25 mg missed dose; · 02/05/24 8:00 am Vitamin B-1 100 mg missed dose; and · 02/05/24 8:00 am Vitamin D3 50 mcg missed dose. A review of physician orders, dated 02/14/24, indicated Resident 23 was prescribed the following: · Acetaminophen 650 mg with instructions to "Take 1 tablet by mouth 3 times daily"; · Atorvastatin 10 mg with instructions to "Take 1 tablet by mouth Daily"; · Calcium Carbonate 600 mg with instructions to "Take 1 tablet by mouth daily (with breakfast)"; · Deep Sea 0.65% nasal spray; · Calcium Polycarbophil (Fibercon) 625 mg with instructions to "Take 1 tablet by mouth Daily"; · Fluticasone (Flonase) 50mcg/nasal spray with instructions "2 sprays by Each Nare route Daily"; · Lidocaine 5% patch with instructions to "Place 1 patch on the skin Daily. Keep applied for 12 hours. Apply to low back before first transfer out of bed each day"; · Memantine HCL 5 mg with instructions to "Take 2 tablets by mouth 2 times daily in the morning, and at night"; · Polyvinyl Alcohol (Liquitears) 1.4% with instructions to "Place 1 drop into both eyes to times daily"; · Risperidone 0.25 mg with instructions to "Take 1 tablet by mouth 2 times daily"; · Thiamine (Vitamin B-1) 100 mg with instructions to "Take 1 tablet by mouth Daily"; · Cholecalciferol (Vitamin D-3) 2000 units with instructions to "Take 1 capsule by mouth Daily". m. Resident 24: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 24 was not administered Alpha Lipoic Acid 600 mg, Buspirone HCL 7.5 mg, Coenzyme Q-10 100 mg, Ginko Biloba 120 mg, Rivastigmine 1.5 mg, Vitamin D3 5000 unit and Zinc Sulfate 50 mg. A review of Resident 24's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Alpha Lipoic Acid 600 mg missed dose; · 02/05/24 8:00 am Buspirone HCL 7.5 mg missed dose; · 02/05/24 8:00 am Coenzyme Q-10 100 mg missed dose; · 02/05/24 8:00 am Ginko Biloba 120 mg missed dose; · 02/05/24 8:00 am Rivastigmine 1.5 mg missed dose; · 02/05/24 8:00 am Vitamin D3 5000 unit missed dose; and · 02/05/24 8:00 am Zinc Sulfate 50 mg missed dose. A review of physician orders dated 08/24/23 indicated Resident 24 was prescribed the following: · Alpha Lipoic Acid 600 with instructions to "GIVE 1 CAPSULES BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 05/10/23; · Buspirone HCL 7.5 mg with instructions to "GIVE 1 TABLET BY MOUTH 3 TIMES A DAY" scheduled at 8:00 am, 12:00 pm and 5:00 pm, effective 08/03/23; · Coenzyme Q-10 100 mg with instructions to "GIVE 1 CAPSULE BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 05/10/23; · Ginko Biloba 120 mg with instructions to "GIVE 1 CAPSULE BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 05/10/23; · Rivastigmine 1.5 mg with instructions to "GIVE 1 CAPSULE BY MOUTH TWICE DAILY" scheduled 8:00 am and 5:00 pm, effective 06/27/23; · Vitamin D3 5000 unit with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 05/10/23; and · Zinc Sulfate 50 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 05/10/23. n. Resident 25: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 25 was not administered Docusate Sodium 100 mg, Lorazepam 0.5 mg, Memantine HCL 10 mg, Multivitamin tab, Muscle rub cream 15%-10%, Risperidone 0.5 mg, Senna-time 8.6 mg, Triamcinolone 0.5% cream and Vitamin D3 50 mcg. A review of Resident 25's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Docusate Sodium 100 mg missed dose; · 02/05/24 8:00 am Lorazepam 0.5 mg missed dose. · 02/05/24 8:00 am Memantine HCL 10 missed dose. · 02/05/24 8:00 am Multivitamin tab missed dose. · 02/05/24 8:00 am Muscle rub cream 15%-10% missed dose. · 02/05/24 8:00 am Risperidone 0.5 mg missed dose. · 02/05/24 8:00 am Senna-time 8.6 mg missed dose. · 02/05/24 8:00 am Triamcinolone 0.5% cream missed dose; and · 02/05/24 8:00 am Vitamin D3 50 mcg missed dose. A review of physician orders dated 02/15/24 indicated Resident 25 was prescribed the following: · Docusate Sodium 100 mg with instructions to "Take 1 capsule by mouth 2 times daily. Hold for loose stool. " ; · Lorazepam 0.5 mg with instructions to "Take 0.25 mLs by mouth every hour as needed for Anxiety " ; · Memantine 10 mg with instructions to "Take 1 tablet by mouth 2 times daily"; · Multiple Vitamins-Minerals with instructions to "Take 1 tablet by mouth Daily"; · Menthol-methyl salicylate 10-15% cream with instructions to "Apply 1 Application topically 3 times daily to neck and bilateral shoulders"; · Risperidone 0.5 mg with instructions to "Take 1 tablet by mouth 2 times daily"; · Senna 8.6 mg with instructions to "Take 1 tablet by mouth Daily Hold for loose stool"; · Triamcinolone 0.5% cream with instructions to "Apply topically Daily as needed to affected areas of skin on buttocks. Wash areas, pat dry, then apply cream"; and · Cholecalciferol (Vitamin D3) 2000 units with instructions to "Take 1 capsule by mouth Daily. If unable to swallow dissolve in 15mg of warm water". o. Resident 26: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 26 was not administered Docusate Sodium 100 mg, Memantine HCL 10 mg, Sertraline HCI Oral Tablet 100 mg and buddy tape toe. A review of Resident 26's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Docusate Sodium 100 mg missed dose. · 02/05/24 8:00 am Memantine HCL 10 mg missed dose. · 02/05/24 8:00 am Sertraline HCI Oral Tablet 100 mg missed dose; and · 02/05/24 7:00 am Buddy tape toe missed dose. A review of physician orders dated 03/01/24 indicated Resident 26 was prescribed the following: · Docusate Sodium 100 mg with instructions to "GIVE 1 CAPSULE BY MOUTH ONCE A DAY IF PATIENT COMPLAINS OF CONSTIPATIONS "  scheduled at 8:00 am, effective 12/08/23; · Memantine HCL 10 mg with instructions to "GIVE 1 TABLET BY MOUTH TWICE DAILY "  scheduled at 8:00 am and 8:00 pm, effective 10/30/23; · Sertraline HCI Oral Tablet 100 mg with instructions to "Give 1 tablet by mouth daily "  scheduled at 8:00 am, effective 10/30/23; and · Buddy tape toe with instructions "Every morning, remove the tape from [Resident's] right 5th toe and clean [his/her] foot. After drying the foot thoroughly, "buddy tape" the 5th toe to the 4th toe using medical tape". p. Resident 27: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 27 was not administered Memantine HCL 10 mg, Multivitamin HP Tab, Polyethylene Glycol 3350, Tamsulosin HCL 0.4 mg, Vitamin B-12 1000 mcg and Vitamin D3 50 mcg. A review of Resident 27's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Memantine HCL 10 mg missed dose; · 02/05/24 8:00 am Multivitamin HP Tab missed dose; · 02/05/24 8:00 am Polyethylene Glycol 3350 missed dose; · 02/05/24 8:00 am Tamsulosin HCL 0.4 mg missed dose; · 02/05/24 8:00 am Vitamin B-12 1000 mcg missed dose; and · 02/05/24 8:00 am Vitamin D3 50 mcg missed dose. A review of physician orders dated 08/10/23 indicated Resident 27 was prescribed the following: · Memantine Tab 10 mg with instructions "2 TIMES A DAY", effective 07/13/23; · Polyethylene Glycol 3350 with instructions "DAILY, Hold for loose stools"  effective 07/22/23; · Tamsulosin capsule 0.4 mg with instructions "DAILY, Capsules should be swallowed whole. Do not chew or crush. Do NOT open capsules, sprinkle on food, or administer via NG." effective 08/05/23; · Cyanocobalamin (Vitamin B-12) 1000 mcg effective 08/10/23; and · Cholecalciferol, Vitamin D3 50 mcg effective 08/10/23. q. Resident 28: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 28 was not administered Donepezil HCL 10 mg. A review of Resident 28's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Donepezil HCL 10 mg missed dose. A review of physician orders, dated 02/20/24, indicated Resident 28 was prescribed the following: · Donepezil HCL 10 mg with instructions to  " GIVE 1 TABLET BY MOUTH ONCE A DAY FOR MILD TO MODERATE ALZHEIMER ' S TYPE DEMENTIA "  scheduled at 5:00 pm, effective 09/19/23. r. Resident 29: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 29 was not administered Memantine HCL 5 mg. A review of Resident 29's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Memantine HCL 5 mg missed dose. A review of physician orders dated 02/20/24 indicated Resident 29 was prescribed the following: · Memantine HCL 5 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 09/19/23. s. Resident 30: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 30 was not administered Divalproex 125 mg Sprinkle Cap, Quetiapine Fumarate 50 mg, Sertraline 50 mg, and Vitamin D3 2000IU (50 mcg). A review of Resident 30's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Divalproex 125 mg Sprinkle Cap missed dose; · 02/05/24 8:00 am Quetiapine Fumarate 50 mg missed dose; · 02/05/24 8:00 am Sertraline 50 mg missed dose; and · 02/05/24 8:00 am Vitamin D3 2000IU (50 mcg) missed dose. A review of physician orders dated 08/24/23 indicated Resident 30 was prescribed the following: · Divalproex 125 mg Sprinkle Cap with instructions "1 CAPSULE BY MOUTH TWICE DAILY" scheduled at 8:00 am and 8:00 pm, effective 03/17/22; · Quetiapine Fumarate 50 mg with instructions "Give 1 tab by mouth every morning and 2 tabs by mouth every evening" scheduled at 8:00 am and 5:00 pm, effective 02/26/23; · Sertraline 50 mg with instructions "1.5 TABLET (75MG) BY MOUTH EVERY DAY" scheduled at 8:00am, effective 02/05/22; and · Vitamin D3 2000IU (50 mcg) with instructions "1 TABLET BY MOUTH EVERY DAY" scheduled at 8:00 am, effective 09/28/22. t. Resident 31: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 31 was not administered Acetaminophen 500 mg, Polyethylene Glycol 3350, Sertraline 100 mg, Silvasorb Gel, Cavilon durable barrier cream and Minerin cream. A review of Resident 31's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Acetaminophen 500 mg missed dose; · 02/05/24 8:00 am Polyethylene Glycol 3350 missed dose; · 02/05/24 8:00 am Sertraline 100 mg missed dose; · 02/05/24 8:00 am Silvasorb Gel missed dose; · 02/05/24 7:00 am Cavilon durable barrier cream missed dose; and · 02/05/24 7:00 am Minerin cream missed dose. A review of physician orders dated 02/26/24 indicated Resident 31 was prescribed the following: · Acetaminophen 500 mg with instructions to "Take 1 tablet by mouth 2 times daily"; · Polyethylene Glycol with instructions to "Mix 1 packet and take orally once daily"; and · Sertraline HCI 100 mg with instructions to "Take 1 tablet by mouth once daily". u. Resident 32: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 32 was not administered Atorvastatin 40 mg, Budesonide EC 3 mg, Memantine HCL 10 mg, Metoprolol Succ ER 25 mg, Tamsulosin HCL 0.4 mg, and Venlafaxine HCL ER 150 mg. A review of Resident 32's MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am Atorvastatin 40 mg missed dose; · 02/05/24 8:00 am Budesonide EC 3 mg missed dose; · 02/05/24 8:00 am Memantine HCL 10 mg missed dose; · 02/05/24 8:00 am Metoprolol Succ ER 25 mg missed dose; · 02/05/24 8:00 am Tamsulosin HCL 0.4 mg missed dose; and · 02/05/24 8:00 am Venlafaxine HCL ER 150 mg missed dose. A review of physician orders, dated 02/08/24, indicated Resident 32 was prescribed the following: · Atorvastatin 40 mg with instructions to "TAKE 1 TABLET DAILY"; · Budesonide EC 3 mg with instructions to "TAKE ONE CAPSILE BY MOUTH DAILY"; · Memantine 10 mg with instructions to "Take 1 tablet (10 mg total) by mouth 2 times daily"; · Metoprolol Succinate 25 mg with instructions to "Take 1 tablet (25mg total) by mouth 2 times daily"; · Tamsulosin HCL 0.4 mg with instructions to "Take 1 capsule (0.4 mg 100 capsule total) by mouth at bedtime"; and · Venlafaxine 150 mg with instructions to "Take 1 capsule (150 mg total) by mouth 2 times daily". v. Resident 33: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 33 was not administered Celecoxib 200 mg, Clotrimazole 1% cream, Eliquis 5 mg, Escitalopram 10 mg, Ferrous Sulf 325 mg, Metoprolol Tartrate 25mg, Multivitamin tab, Risperidone 2 mg and Omeprazole DR 20 mg. A review of Resident 33's MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am Celecoxib 200 mg missed dose; · 02/05/24 8:00 am Clotrimazole 1% cream missed dose; · 02/05/24 8:00 am Eliquis 5 mg missed dose; · 02/05/24 8:00 am Escitalopram 10 mg missed dose; · 02/05/24 8:00 am Ferrous Sulf 325 mg missed dose; · 02/05/24 8:00 am Metoprolol Tartrate 25 mg missed dose; · 02/05/24 8:00 am Multivitamin tab missed dose; · 02/05/24 8:00 am Risperidone 2 mg missed dose; and · 02/05/24 7:30 am Omeprazole DR 20 mg missed dose. A review of physician orders, dated 07/03/23, indicated Resident 33 was prescribed the following: · Celecoxib 200 mg with instructions to "Take 200 mg by mouth 2 times daily"; · Apixaban (ELIQUIS) 5 mg with instructions to "Take 5 mg by mouth 2 times daily"; · Escitalopram 10 mg with instructions to "Take 1 tablet by mouth Daily"; · Metoprolol Tartrate 25 mg; · Multiple Vitamins-Minerals with instructions to  "Take 1 tablet by mouth Daily"; · Risperidone 1 mg tablet with instructions to  "Take 2 mg by mouth 2 times daily"; · Omeprazole 20 mg with instructions to  "Take 20 mg by mouth 2 times daily". w. Resident 34: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 34 was not administered Lisinopril 10 mg, Pantoprazole Sod DR 40 mg and Sertraline HCL 25 mg. A review of Resident 34's MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am Lisinopril 10 mg missed dose; · 02/05/24 8:00 am Pantoprazole Sod DR 40 mg missed dose; and · 02/05/24 8:00 am Sertraline HCL 25 mg missed dose. A review of physician orders, dated 02/20/24, indicated Resident 34 was prescribed the following: · Lisinopril 10 mg with instructions to "GIVE 1 TABLEY BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 10/30/23; · Pantoprazole Sod DR 40 mg with instructions to "GIVE 1 TABLET BY MOUTH EVERY MORNING (BEFORE BREAKFAST)" scheduled at 8:00 am. Effective 10/30/23; · Sertraline HCL 25 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 10/30/23. x. Resident 35: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 35 was not administered Acetaminophen 500 mg, Amlodipine Besylate 2.5 mg, Cetirizine HCL 10 mg, Cranberry 250 mg, Fluticasone 50 mcg, Metoprolol Succ ER 50 mg, Vitamin B-12 1000 mcg, Vitamin C 1000 mg and Vitamin D3 400 units. A review of Resident 35 ' s MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am Acetaminophen 500 mg missed dose; · 02/05/24 8:00 am Amlodipine Besylate 2.5 mg missed dose; · 02/05/24 8:00 am Cetirizine HCL 10 mg missed dose; · 02/05/24 8:00 am Cranberry 250 mg missed dose; · 02/05/24 8:00 am Fluticasone 50 mcg missed dose; · 02/05/24 8:00 am Metoprolol Succ ER 50 mg missed dose; · 02/05/24 8:00 am Vitamin B-12 1000 mcg missed dose; · 02/05/24 8:00 am Vitamin C 1000 mg missed dose; and · 02/05/24 8:00 am Vitamin D3 400 units missed dose. A review of physician orders, dated 02/20/24, indicated Resident 35 was prescribed the following: · Acetaminophen 500 mg with instructions to "GIVE 1-2 TABS (325-650 MG) BY MOUTH EVERY MORNING IF NEEDED" scheduled at 8:00 am, effective 01/31/24; · Amlodipine Besylate 2.5 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 02/01/24; · Cetirizine HCL 10 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 02/01/24; · Cranberry 250 mg with instructions to "GIVE 1 CAPSULE BY MOUTH 3 X DAILY WITH MEALS" scheduled at 8:00 am, effective 02/01/24; · Fluticasone 50 mcg with instructions to "GIVE 1 SPRAY IN EACH NOSTRIL ONCE A DAY" scheduled at 8:00 am, effective 01/31/24; · Metoprolol Succ ER 50 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 02/01/24; · Vitamin B-12 1000 mcg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 02/01/24; · Vitamin C 1000 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 02/01/24; and · Vitamin D3 400 units with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY" scheduled at 8:00 am, effective 01/31/24. y. Resident 36: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 36 was not administered Acetaminophen 325 mg, Eliquis 2.5 mg, Ferrous Sulf 325 mg, Prilosec OTC 20 mg and Quetiapine Fumarate 25 mg. A review of Resident 36's MAR, dated 02/2024, indicated the following: · 02/05/24 8:00 am Acetaminophen 325 mg missed dose; · 02/05/24 8:00 am Eliquis 2.5 mg missed dose; · 02/05/24 8:00 am Ferrous Sulf 325 mg missed dose; · 02/05/24 8:00 am Prilosec OTC 20 mg missed dose; and · 02/05/24 8:00 am Quetiapine Fumarate 25 mg missed dose. A review of physician orders dated 02/20/24 indicated Resident 36 was prescribed the following: · Acetaminophen 325 mg with instructions to discontinue order initiated on 01/04/24 to administer 2 tablets by mouth every 8 hours; · Eliquis 2.5 mg with instructions to "GIVE 1 TABLET BY MOUTH TWICE DAILY FOR AFIB"  scheduled at 8:00 am and 5:00 pm, effective 01/04/24; · Ferrous Sulf 325 mg with instructions to "GIVE 1 TABLET BY MOUTH ONCE A DAY WITH BREAKFAST" scheduled at 8:00 am, effective 01/04/24; · Prilosec OTC 20 mg with instructions to "GIVE 1 TABLET BY MOUTH EVERY MORNING BEFORE BREAKFAST" scheduled at 8:00 am, effective 01/11/24; and · Quetiapine Fumarate 25 mg with instructions to "GIVE 1 TABLET BY MOUTH TWICE DAILY AT 8AM AND 8PM" scheduled at 8:00 am and 5:00 pm, effective 01/04/24. z. Resident 39: A review of the facility's "Medication Exception Report" dated 02/05/24 indicated Resident 39 was not administered Acetaminophen 500 mg, Oxycodone immediate 5 mg and Senna-time 8.6 mg. A review of Resident 39's MAR, dated 02/2024 indicated the following: · 02/05/24 8:00 am Acetaminophen 500 mg missed dose; · 02/05/24 8:00 am Oxycodone immediate 5 mg missed dose; and · 02/05/24 8:00 am Senna-time 8.6 mg missed dose. aa. Resident 40: A review of the facility's "Medication Exception Report", dated 02/05/24, indicated Resident 40 was not administered Morphine Sulf ER 15 mg and Morphine Sulf 30 mg. A review of Resident 40's MAR, dated 02/2024, indicated the following: · 02/05/24 7:00 am Morphine Sulf ER 15 mg missed dose; · 02/05/24 7:00 am Morphine Sulf 30 mg missed dose; · 02/05/24 8:00 am Ammonium Lactate 12% LOT RX missed dose; · 02/05/24 8:00 am Baclofen 20 mg missed dose; · 02/05/24 8:00 am Haloperidol 0.5 mg missed dose; · 02/05/24 8:00 am Ketoconazole External Shampoo 2% missed dose; · 02/05/24 8:00 am Lidocaine 4% cream missed dose; · 02/05/24 8:00 am Olanzapine 2.5 mg missed dose; · 02/05/24 8:00 am Omeprazole DR 40 mg missed dose; · 02/05/24 8:00 am Polyethylene Glycol 3350 missed dose; · 02/05/24 8:00 am Prune juice missed dose; · 02/05/24 8:00 am Remedy Phytoplex Hydraguard missed dose; · 02/05/24 8:00 am Right foot care missed dose; · 02/05/24 8:00 am Ropinirole 3 mg missed dose; · 02/05/24 8:00 am Senexon-s 50-8.6 mg missed dose; and · 02/05/24 8:00 am Sertraline HCL 100 mg missed dose. A review of physician orders, dated 02/26/24, indicated Resident 40 was prescribed the following: · Morphine Sulf ER 15 mg with instructions to discontinue order initiated on 10/12/23 to administer 1 tab orally every 12 hours for pain; give at the same time as 30mg tablet, 45mg total dose; · Morphine Sulf ER 30 mg with instructions to discontinue order initiated on 10/12/23 to administer 1 tab orally every 12 hours for pain; give at the same time as 15mg tablet, 45mg total dose; · Omeprazole 40 mg with instructions to discontinue order initiated on 04/17/23 to take 1 cap(s) oral 2 times a day; take with breakfast and dinner; and · Ropinirole 3 mg with instructions to discontinue order initiated on 04/17/23 to take 3 tab(s) oral 2 times a day, effective date 02/26/24. A review of physician orders, dated 01/25/24, indicated Resident 40 was prescribed the following: · Lidocaine 4% topical ointment with instructions to "Apply 15 gm (s) topical 3 times a day for right lateral foot pain" effective 01/25/24; and · Sertraline 100 mg with instructions to "Take 1 tab (s) oral Daily for depression; OK to use two 50mg tablets based on pharmacy availability" effective 01/25/24. A review of physician orders, dated 12/21/23, indicated Resident 40 was prescribed the following: · MiraLax oral powder for reconstitution with instructions to "Administer 17 gm(s) orally once a day for bowel management; Administer in at least 8 oz of fluid. Hold one dose after episode of liquid stool" effective 12/21/23. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Via telephone call on 04/02/24, the findings were reviewed and acknowledged with Staff 1, Staff 18 (Administrator), Staff 15 (Regional Director of Nursing), Staff 19 (RN), and Staff 20 (VP of Clinical Operations) via telephone. Verbal Plan of Correction: The facility has ordered enough med carts to have 1 for each house to make medications easier to find. Weekly cart audits are being completed and retraining for all med techs. There is also now a manager on duty daily review of schedule and keeping all agency contracts open for more staffing options. Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 resident (# 2). The findings include, but are not limited to: A review of Resident 2's M

Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: In an interview on 03/11/24, Staff 1 (Assistant Executive Director) stated there had been a couple of instances where staff either did not show up for their shift or called out and there were not enough staff to pass medications. The last time was on 02/24/24. A review of the posted staff plan indicated the following: * Day shift: 8 caregiver and 2 med techs; * Evening shift: 8 caregiver and 2 med techs; and * Night shift: 4 caregivers and 1 med tech. A review of staff schedules from 01/01/24 through 03/31/24 indicated in February the facility was consistently staffed under the posted staffing plan . A review of facility self-reports dated 02/06/24 indicated on 02/05/24 med techs called out. Self-reports indicated 27 residents missed medications on the morning of 02/05/24. The facility failed to have sufficient staff to meet the 24-hour scheduled and unscheduled needs of each resident. The findings were reviewed and acknowledged with Staff 1, Staff 18 (Executive Director), Staff 15 (Regional Director of Nursing), Staff 19 (RN), and Staff 20 (VP of Clinical Operations) on 04/02/24. Verbal Plan of Correction: There is now a daily manager on duty who completes a review of schedule and the facility was keeping all agency contracts open for more staffing options.

Based on observation and interview, conducted during a site visit on 03/11/24, it was confirmed the facility failed to provide staff with an orientation to the resident, including the service plan. Findings include but are not limited to: In an interview on 03/11/24, Staff 22 (Caregiver) stated s/he had been shown resident service plans and reviewed them. When Staff 22 was asked where resident service plans were kept for review s/he was unable to indicate where to find service plans. In an interview on 03/11/24, Staff 1 (Assistant Executive Director) stated there were two staff members that no called, no showed and s/he had contacted agency to have two agency staff sent to the facility. At 3:48 pm an agency staff member was observed being shown into the facility and the section that s/he would be working in. Agency staff was not provided with any direction, checklists or service plans of residents in his/her area to review before beginning to interact with residents. The facility failed to provide staff with an orientation to the resident, including the service plan. The findings were reviewed with and acknowledged by Staff 1, Staff 18 (Executive Director), Staff 15 (Regional Director of Nursing), Staff 19 (RN), and Staff 20 (VP of Clinical Operations) on 04/02/24. Verbal Plan of Correction: Facility has since implemented an agency staff orientation checklist.

Based on observation and interview, conducted during a site visit on 10/16/23,  it was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include, but are not limited to: At 12:09 pm on 10/16/23, a brown sticky substance was observed on the floor of a shared resident bathroom in Flower House and a bowel movement was in the toilet. When the Compliance Specialist returned at 2:06 pm the substance was still on the floor and the bowel movement was in the toilet. During an interview on 10/16/23, Staff 1 (Executive Director) stated each house does not have housekeeping daily and caregivers are responsible for cleaning as needed. The findings were reviewed with Staff 1 on 10/16/23. It was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents Verbal plan of correction: Facility to review  daily housekeeping responsibilities with front line staff on 10/18/23. The facility implemented the Resident Care Connections (Manager Rounding Tool) and the daily house assignments for the management team on 10/17/23.

Based on interview and record review, conducted during a site visit on 10/16/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: In an interview on 10/16/23, Staff 1 (Executive Director) stated the facility used the ODHS tool. The facility's current census was 51 residents, and s/he was unaware four residents were not entered into the tool. A review of the facility's ODHS ABST on 10/16/23 indicated the facility had 47 residents entered in the ABST. A review of the current resident roster had the facility's census listed as 51. The facility failed to fully implement and update an Acuity Based Staffing Tool. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 10/16/23.

Based on observation, interview and record review, conducted during a site visit on 10/16/23, it was confirmed that the facility failed to provide an accessible outdoor recreation area. Findings include, but are not limited to: A review of the facility's "Inclement Weather Policy", dated 08/01/21, indicated exterior doors and courtyard doors will be locked in accordance with state regulations. The procedure defined inclement weather as: icy, stormy, extreme heat, snow, etc. at which point the courtyard doors are to remain locked for resident safety. The Inclement Weather policy and procedure for unlocking doors to the courtyard indicated the courtyard doors are to be unlocked upon arrival of day shift and locked at dusk. In an interview on 10/16/23, Staff 5 (Caregiver) stated if a resident wants to go outside s/he can ask a staff member to put the code in to the house doors and then to come back inside the resident must knock on a house door to be let back inside. Staff 5 also stated "the great-room's doors are usually unlocked." On 10/16/23, from 9:00 am - 4:00 pm, the Compliance Specialist observed the following: * The door in Mountain house that led to the main courtyard was locked. * The door in River house that led to the main courtyard was locked. * The door in Flower house that led to the main courtyard was locked. * The door in Lighthouse house that led to the main courtyard was locked. * The two sets of double doors that lead to the main courtyard and is connected to the common area of all the houses were locked. * The exit door across from the entry to River house that lead to the main courtyard was locked. * The exit door across from the entry to Mountain house that lead to the main courtyard was unlocked. *  When the CS attempted to re-enter the the facility through the courtyard, it was observed all doors to re-enter the facility were locked, except the door across from Mountain House. * At 12:35 pm, Resident 1 was observed in the outdoor courtyard trying to enter through locked doors, staff from Resident 1's house escorted resident inside from the outdoor courtyard to his/her appropriate dining area. On 10/16/23 from 9:00 am - 4:00 pm, residents were observed attempting to exit into the courtyard or asked aloud to go outside. CS observed staff did not assist residents with accessing the outdoor courtyards and did not unlocked the doors allowing for residents to come and go freely. On 10/16/23 throughout the site visit the weather was observed to be cool with some rain showers. The facility failed to provide an accessible outdoor recreation area. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) on 10/16/23. Verbal Plan of Correction: The Executive Director has reached out to the previous maintenance director for the instructions on how to set up the auto unlock/lock timing settings for the doors and they will get the doors set up to automatically unlock during daylight hours.

Based on interview and record review it was confirmed that the facility failed to provide assistance with bathing and washing hair. Findings include the following: During an unannounced site visit on 12/08/2022 Compliance Specialist (CS) reviewed a facility grievance form that states resident missed a shower on 11/26/2022. CS reviewed facility Caregiver Assignment Sheet and observed that a newly admitted resident was not listed. CS reviewed service plan for Resident #4 (R4) and found that they require shower assistance once per week. In separate interviews with Staff #4 and Staff #7 (S4 & S7) the following was stated: · If R4 gets shower assistance it would be on the assignment sheet. · I have worked in that house since R4 was admitted, but I have not helped them with a shower, if they get assistance with showers it should be on the assignment sheet. Facility Plan of Correction: Facility will update the assignment sheets to ensure they have all residents accounted for.

Based on record review and interview it was confirmed that the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include the following: During an unannounced site visit on 12/08/2022 Compliance Specialist (CS) reviewed the Department imposed licensing condition RCFCD22-00638 amended on 09/18/2022 for their required staffing plan which was listed as six caregivers, two med techs, and one float on day and swing shifts and for NOC shift, four caregivers, and one med tech. A review of facility staff schedules for October, November and December 2022 revealed two dates where facility was not compliant with staffing requirements. In an interview with Witness #1 (W1) it was stated that that the facility was short staffed one morning and it made it difficult to provide proper care for residents that needed two-person assistance. Findings were shared with Staff #1 (S1) who was in agreement. Facility Plan of Correction: Facility has implemented new systems to ensure that they will have proper staff levels moving forward since their alleged compliance date of 11/23/2022.

Based on record review and interview it was confirmed that the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include the following: During an unannounced site visit on 12/08/2022 Compliance Specialist (CS) reviewed facility ABST, resident specific ABST for Resident #1-#4 (R1-R4) and service plans for R1-R4. CS found that last edit date for one of four residents was 07/18/2022 when their last service plan update was 09/25/2022. CS found several other inconsistencies between resident service plans and ABSTs. In an interview with Staff #1-#3 (S1-S3) it was stated that they were not aware that when updating resident service plans quarterly they needed to open and save the questions in the ABST to reflect a correct LastEditDate. Facility Plan of Correction: Facility will have two nurses review all service plans and update ABST accordingly. Facility also has a meeting set with policy analyst and corrective action coordinators to review facility ABST.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 12/08/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and record review it was confirmed that the facility failed to carry out medication orders as prescribed. Findings include the following: During an unannounced site visit on 09/07/2022 Compliance Specialist (CS) reviewed August and September 2022 Medication Administration Records (MARs) for Residents #1- #3 (R1-R3) which revealed instances on 3 of 3 residents MARs where medications are not marked as given and no reason listed for medication not given. 3 of 3 residents had medications not given due to medication not onsite. R1 has a placement specific medication that has consistently been placed on an alternative site than as prescribed. According to Witness #1 (W1) a resident did not receive their morning insulin. The above findings were shared with Staff #1 and Staff #2 (S1 & S2) who were in agreement. Facility Plan of Correction: The facility is moving to cycle fill rather than on demand to establish a better process for maintain medication stock. The variance and exceptions reports are now being reviewed everyday and any variances are being addressed immediately.

Based on interview, record review and observation it was confirmed that the facility failed to provide sufficient care staff to meet the scheduled and unscheduled needs of the residents. Findings include the following: During an unannounced site visit on 09/07/2022 Compliance Specialist (CS) reviewed staff schedules for July, August and September 2022. The Department imposed licensing condition RCFCD22-00638, the facility Acuity Based Staffing Tool (ABST) and facility payroll for 07/12, 08/28 and 09/04/2022. The imposed licensing condition requires for Day and Swing shifts 9 caregivers and 2 med techs and for NOC shift 6 caregivers and 1 med tech. Facility staff schedules are not scheduling to required staffing levels. A review of facility payroll confirmed that has not been posting to required staffing levels. In separate interviews with Staff #1 and Staff #2 (S1 & S2) the following was stated: · The facility is running mostly 12-hour shifts, with a couple staff that work 8-hour shifts · The facility is utilizing agency staff · Even with agency staff the facility is still struggling to meet the requested updated staffing plan made to the Department of 6 Caregivers, 2 med techs and 1 float for Day and Swing and 4 caregivers and 1 med tech for NOC During separate unannounced site visits on 09/06/2022 and 09/07/2022 Compliance Specialist observed less staff onsite than what is required by the facilities condition.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 09/07/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview, record review and observation it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following: During an unannounced site visit on 02/25/2022 in separate interviews with Staff #7-11 (S7-S11) staff indicated that there were 16 2-person transfers and 2 additional situational 2-person transfers. Staff also stated the following: · We haven ' t had a med tech working NOC shift all week · This is the 3rd day there hasn ' t been a med tech working at night · NOC shift has been short a med tech last week and this week · I had a resident ask for a PRN for pain last night, but there wasn ' t a med tech working so no one could administer it.   · We can ' t lock the doors to the outdoor courtyard so we push the couches in from so residents can ' t go outside at night. · We ' ve had a resident we couldn ' t find for a few hours and found them wondering outside at night before. Compliance Specialist observed 5 staff members onsite at the time of entry. 1 staff member in 3 of the  ' neighborhoods '  and 2 staff in the 4th  ' neighborhood ' . There were no med techs and no one able to administer medications onsite. CS observed staff leaving locked  ' neighborhoods '  without staff to attend residents in order to provide support in another neighborhood. Staff had pushed couches in front of doors to courtyard to prevent residents from going outside at night because they can ' t keep an eye on residents that go outside as well as residents in the neighborhoods. CS observed a resident come inside into the common area from the outdoor courtyard and no staff were present in the common area and all the neighborhood doors were locked via key code. CS reviewed February Medication Administration Records (MARs) for Residents #1-10 (R1-R10) and found instances of medications being administered late due to short staffing, meal monitoring not being completed due to short staffing and an indication of medications not being administered due to no NOC med tech working. Based on interview, record review and observation it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following: During an unannounced site visit on 02/25/2022 in separate interviews with Staff #7-11 (S7-S11) staff indicated that there were 16 2-person transfers and 2 additional situational 2-person transfers. Staff also stated the following: · We haven ' t had a med tech working NOC shift all week · This is the 3rd day there hasn ' t been a med tech working at night · NOC shift has been short a med tech last week and this week · I had a resident ask for a PRN for pain last night, but there wasn ' t a med tech working so no one could administer it.   · We can ' t lock the doors to the outdoor courtyard so we push the couches in from so residents can ' t go outside at night. · We ' ve had a resident we couldn ' t find for a few hours and found them wondering outside at night before. Compliance Specialist observed 5 staff members onsite at the time of entry. 1 staff member in 3 of the  ' neighborhoods '  and 2 staff in the 4th  ' neighborhood ' . There were no med techs and no one able to administer medications onsite. CS observed staff leaving locked  ' neighborhoods '  without staff to attend residents in order to provide support in another neighborhood. Staff had pushed couches in front of doors to courtyard to prevent residents from going outside at night because they can ' t keep an eye on residents that go outside as well as residents in the neighborhoods. CS observed a resident come inside into the common area from the outdoor courtyard and no staff were present in the common area and all the neighborhood doors were locked via key code. CS reviewed February Medication Administration Records (MARs) for Residents #1-10 (R1-R10) and found instances of medications being administered late due to short staffing, meal monitoring not being completed due to short staffing and an indication of medications not being administered due to no NOC med tech working.