Wildflower Lodge

Based on interview and record review, it was determined the facility failed to conduct investigations of injuries of unknown cause to rule-out abuse or report the injuries as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 1 of 2 sampled residents (#2) with injuries of unknown cause. Findings include, but are not limited to:

Resident 2 was admitted to the Memory Care Facility in 2021 with diagnoses which included dementia and required staff assistance with ADL care needs.

Facility Observation Notes, reviewed from 07/01/25 through 09/09/25, revealed the following:

* On 07/30/25, staff documented that the resident had “slight bruising/swelling to the corner of brow of the right eye…"; and

* On 08/28/25, the resident was found with a "small cut on the right middle knuckle of the right hand…"

There was no documented evidence the facility immediately investigated and documented that the injuries were not the result of abuse or neglect, or evidence the facility reported the injuries to the local protective services office as suspected abuse/neglect.

Additional information was requested from Staff 1 (MCC Administrator) on 09/10/25 at 10:15 am.

On 09/10/25, Staff 1 informed the surveyor that the injuries had not been investigated to rule out abuse or neglect. The need to ensure injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1. She stated she would investigate the incidents and report the injuries to the local protective services office. Verification that the facility had reported the incidents to the local SPD office was received during the survey.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 2022 with diagnoses which included dementia and was receiving hospice services as of the survey.

Physician orders and MARs, reviewed from 08/01/25 through 09/09/25, revealed the following orders were not followed:



* Knee immobilizer, to be placed on the left knee during the day, was not applied on nine occasions; and
* Haldol (for agitation) 1 mg one tablet at noon and bedtime was not administered at noon on 08/01/25, 08/02/25 and 08/03/25 because it was unavailable. However, the bedtime dose was administered during the same time frame.

In an interview with Staff 2 (MCC RCC) and Staff 4 (LPN Wellness Director) on 09/10/25 at 3:00 pm, they acknowledged that staff failed to administer the noon dose of Haldol as ordered.

The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (MCC Administrator) and Staff 5 (Campus Administrator) on 09/11/25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained and PRN parameters were followed for all facility administered medications for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted in 2021 with diagnosis which included dementia and was receiving hospice services as of the survey.

Resident 1 had orders for:

* Sertraline HCL 25 mg one tablet twice a day for dementia.

According to the MARs, reviewed from 08/01/25 through 09/09/25, staff documented on multiple occasions between 08/29/25 through 09/02/25, that the medications were not available. However, there were also two occasions that staff initialed the medications were administered during the same time frame.

The discrepancies on the MAR were reviewed with Staff 1 (MCC Administrator) on 09/10/25 at 11:25 am. She confirmed that staff initialed that the medications had been administered when they were unavailable. She acknowledged the MAR was inaccurate.

2. Resident 2 moved into the MCC in 2022 with diagnoses which included dementia and was receiving hospice services as of the survey.

Resident 2 had orders for the following:

* Lorazepam 0.5 mg one tablet every two hours as needed for anxiety. Staff were instructed to call Hospice prior to administration;
* Haloperidol 2 mg one tablet every two hours as needed for uncontrolled agitation, nausea, or vomiting. Staff were instructed to call Hospice prior to administration; and
* Morphine Sulfate 20mg/1ml, give o.5 ml every hour as needed for severe pain or shortness of breath. Staff were instructed to call Hospice prior to administration.

The residents MARs and clinical record were reviewed from 08/01/25 through 09/09/25. According to the MARs, the PRN Lorazepam, Haloperidol and Morphine was administered by staff on several occasions without documentation that hospice was called before the medications were given to the resident.

Additional information was requested during the survey.

In an interview on 09/11/25 at 10:15 am, Staff 2 (MCC RCC) and Staff 4 (LPN Wellness Director) stated they were unable to find documentation that staff consistently called hospice prior to administering the PRN medications. They acknowledged the parameters were not followed.

The need to ensure PRN parameters were followed was reviewed with Staff 1 (MCC Administrator) and Staff 5 (Campus Administrator) on 09/11/25. They acknowledged the findings.

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

Refer to C231, C303, and C310.

Based on observation, interview, and record review, conducted during a site visit on 05/07/25, the facility's failure to update and implement an acuity-based staffing tool (ABST) was substantiated for 2 or 3 sampled residents (#s 1 and 2). Findings include, but are not limited to: A review of the ABST Facility Entrance Questionnaire dated 05/07/25 indicated the facility used ODHS ABST. The facility had a resident census of 22.a. Resident 1's service plan dated 01/22/25 and 05/07/25 was reviewed and compared to his/her ABST profile last updated on 04/11/25. Resident 1's ABST profile did not accurately reflect Resident 1's care needs in the following areas: · In the area of transfers, the service plan indicated Resident 1 required full assistance with moving from bed to wheelchair and required two-person assistance. Resident 1's ABST indicated zero minutes of staff time was allotted to complete task. · In the area of eating, the service plan indicated Resident 1 required daily assistance and "will occasionally start crying and telling staff [s/he] can't feed [himself/herself] ". Resident 1's ABST indicated zero minutes of staff time was allotted to complete task. · In the area of ambulation and escorts, the service plan indicated Resident 1 will be escorted in their wheelchair to and from meals, activities, toileting, and other common areas by staff. Resident 1's ABST indicated zero minutes of staff time was allotted to complete task. b. Resident 2's service plan dated 04/03/25 was reviewed and compared to his/her ABST profile last updated on 04/03/25. Resident 2's ABST profile did not accurately reflect Resident 2's care needs in the following areas: · In the area of bathing, the service plan indicated Resident 2 required full assistance. Resident 2 ' s ABST indicated zero minutes of staff time was allotted to complete task. · In the area of personal hygiene, staff to provide support with all hygiene routines daily. Resident 2 ' s ABST profile indicated that ADL was provided 70 times per week. In separate interviews, Staff 1 (MC Administrator) Staff 4 (CG), Staff 6 (CG), and Staff 11 (MT) stated Resident 1 and Resident 2 required total assistance with ADLs, except meal assistance and when hospice provided services. If hospice does not provide the service, staff are to provide assistance with bathing. Compliance Specialists (CS) observed the following: · Resident 1 and Resident 2 required assistance of two-staff persons for transfers and toileting. · Resident 1 required cuing throughout his/her lunch meal and on occasion staff provided hand-over-hand assistance. The facility failed to accurately capture care time and care elements that staff are providing to each resident.On 05/07/25, those findings were reviewed with and acknowledged by Staff 1, Staff 2 (Wellness Director/LPN), and Staff 3 (Executive Director).

Based on record review and interview, it was determined the facility failed to ensure 1 of 2 sampled newly hired direct care staff (#6) completed abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 04/22/25.

Staff 6 (Care Partner) hired 01/21/25, did not have documented evidence abdominal thrust training had been completed within 30 days of hire.

The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (Memory Care Administrator) and Staff 5 (Business Office Manager) on 04/23/25. They acknowledged the findings.

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

Refer to C 372.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 6 and 7) completed additional pre-service dementia training prior to beginning their job responsibilities and 1 of 1 long term, non-direct care staff (#5) completed required annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 04/22/25. The following was identified:

a. There was no documented evidence Staff 6 (Care Partner), hired 01/21/25, and Staff 7 (MT), hired 12/23/24, completed the following additional pre-service dementia training topics:

* Environmental factors that are important to a resident’s well-being (e.g. staff interactions, lightening, room temperature, noise, etc.);

* Family support and the role the family may have in the care of the resident; and

* Use of supportive devices with restraining qualities in memory care communities.

b. Staff 5 (Dining Services Director), hired 06/22/21 lacked documented evidence of completion of annual infectious disease training.

The need to ensure all staff completed the additional pre-service dementia training, and completed required infectious disease training annually, was discussed with Staff 1 (Memory Care Administrator), and Staff 4 (Business Office Manager) on 04/23/25. They acknowledged the findings.

The findings of the Change of Ownership combined with the Facility Enhanced Oversight and Supervision surveys, conducted 05/13/24 through 05/15/24, are documented in this report. The surveys were 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the Change of Ownership combined with the Facility Enhanced Oversight and Supervision survey of 05/15/24, conducted 09/23/24 through 09/25/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

2. Resident 1 was admitted to the facility in 02/2024 with diagnoses including Alzheimer's disease.During the acuity interview, Resident 1 was identified as being in an intimate relationship with Resident 2. The resident's 02/05/24 to 05/13/24 progress notes and temporary service plans (TSPs), current service plan dated 03/04/24, and facility policy titled "Intimacy Among Residents with Dementia" were reviewed, observations of the residents were made, and interviews with staff, the family, and the resident were conducted. The following was identified:* The facility policy, "Intimacy Among Residents with Dementia" listed several procedures, including "[f]ill out an Incident Report and Administrator or designee to complete the investigation and document in electronic computer program what was observed and reported," and "[u]pdate the Growth and Wellness Plans for both residents involved to reflect the relations or relationship including any pertinent details team members should know."* A 04/22/24 progress note stated, "[r]esident was engaged in a sexual encounter with another resident this afternoon."* An incident report regarding the encounter was requested from Staff 2 (Health Wellness Director) at 10:30 am on 05/14/24. She stated no incident report had been completed.* The current service plan provided some information and instructions for staff, but failed to provide identifying information regarding the other resident, or other pertinent information to support the health and safety of the resident.During an interview at 3:50 pm on 5/14/24, Staff 1 (Memory Care Director), Staff 2, and Staff 3 (Community Nurse) acknowledged the policy had not been implemented.The need to implement written policies to promote high quality services, health, and safety for residents was discussed with Staff 1, Staff 2, Staff 3, Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to implement written policies to promote high quality services, health, and safety for 2 of 2 sampled residents (#s 1 and 2) who were in an intimate relationship. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.During the acuity interview, Resident 2 was identified as being in an intimate relationship with Resident 1. The resident's 02/13/24 to 05/13/24 progress notes and temporary service plans (TSPs), current service plan dated 05/02/24, and facility policy titled "Intimacy Among Residents with Dementia" were reviewed, observations of the residents were made, and interviews with staff, the family, and the resident were conducted. The following was identified:* The facility policy, "Intimacy Among Residents with Dementia" listed several procedures, including "[f]ill out an Incident Report and Administrator or designee to complete the investigation and document in electric computer program what was observed and reported," and "[u]pdate the Growth and Wellness Plans for both residents involved to reflect the relations or relationship including any pertinent details team members should know."* A 04/22/24 progress note stated, "[r]esident was engaged in a sexual encounter with another resident this afternoon."* An incident report regarding the encounter was requested from Staff 1 (Memory Care Director) at 8:00 am on 05/14/24. She stated no incident report had been completed.* The current service plan provided some information and instructions for staff, but failed to provide identifying information regarding the other resident, or other pertinent information to support the health and safety of the resident.During an interview at 4:02 pm on 5/14/24, Staff 1, Staff 2 (Health Wellness Director), and Staff 3 (Community Nurse) acknowledged the policy had not been implemented.The need to implement written policies to promote high quality services, health, and safety for residents was discussed with Staff 1, Staff 2, Staff 3, Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 05/13/24 through 05/15/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcomes and satisfaction was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse) and Staff 25 (Regional Director). No additional information was provided.Refer to the deficiencies in the report.

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that promoted privacy, respect, and dignity in a homelike environment for 1 of 3 sampled residents (#3) and multiple unsampled resident. Findings include, but are not limited to:1. The Memory Care Community was toured on 05/13/24 through 05/15/24.Resident-occupied rooms 101, 104, 106, 107, 110, 114, 115, and 117 lacked the lenses for the peephole, creating a hole with visibility directly into the residents' living area.The missing peephole lenses creating lack of privacy were observed and discussed with Staff 1 (Memory Care Director) and Staff 10 (Maintenance Director) on 05/14/24. They acknowledged the findings.
2. During the acuity interview on 05/13/24 at approximately 1:00 pm, the following apartments were noted to have double occupancy:104;107;110; and115.Additionally, one of the residents that resided in each of the above-mentioned apartments was identified to require ADL assistance from staff.During a tour of the memory care community on 05/15/24 at 8:10 am, apartments 104, 107, 110 and 115 were observed and noted to be without a privacy curtain or screen of any kind. The lack of privacy for residents residing in shared apartments was reviewed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). Staff acknowledged the lack of privacy.3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.Resident 3's service plan dated 04/03/24 noted the resident required assistance with ADL care. A tour of Resident 3's room revealed a window without blinds or curtains and a view to the parking lot used by staff and visitors. Resident 3's bed and reclining chair were within view of the window and there was no opportunity to provide privacy if requested.The lack of privacy for Resident 3 was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). Staff acknowledged the lack of privacy.
4. Meal observations were conducted 05/13/24 and 05/14/24. Multiple caregiving staff were observed assisting unsampled residents with eating. The staff were standing over the residents instead of sitting next to them.The need to ensure residents' right to be treated with dignity and respect was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.Resident 3's service plan dated 04/03/24 and clinical and observation notes dated 02/05/24 through 05/11/24 were reviewed. Resident 3 was noted to require standby to full assistance with ADL care. On 02/05/24 Resident 3 was noted to be found on the floor with a skin tear to the left "cheek/jaw" area. On 04/01/24 the resident was noted to have a bruised and swollen left pinky finger.Although both incidents were monitored and subsequently resolved, there was no documented evidence the injuries of unknown cause were investigated promptly to rule out abuse and/or reported to the local SPD office if abuse could not be ruled out. During an interview on 05/15/24 at 12:30 pm, Staff 1 (Memory Care Director) was directed to report the injuries of unknown cause to the local SPD office if the investigation could not be located. No additional information was provided by the facility.The need to ensure injuries of unknown cause were investigated promptly to rule out abuse and to report the injuries of unknown cause to the local SPD office when abuse or suspected abuse could not be ruled out was discussed on 05/15/24 at approximately 12:30 pm with Staff 1, Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). No additional information was provided.
Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local Seniors and People with Disabilities (SPD) office unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse for 2 of 2 sampled residents (#s 1 and 3) reviewed with injuries of unknown cause. Findings include, but are not limited to:1. Resident 1 was admitted to facility 02/2024 with diagnoses including dementia. Review of Resident 1's progress notes noted an alert on 04/12/24 regarding a swollen hand. There was no documented evidence how the facility determined that was not the result of neglect or abuse. The incident was not reported to the local SPD office at the time of the incident. In an interview on 05/15/24 at 11:30 am, Staff 1 (Memory Care Director) stated Resident 1 injured his/her hand when he/she punched a window. The need to thoroughly investigate all incidents to rule out suspected abuse and/or neglect and report to the local SPD office if abuse/neglect could not be ruled out, was discussed with Staff 1 and Staff 2 (Health Wellness Director) on 05/16/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and failed to indicate who was involved in the evaluation process for 1 of 1 sampled resident (#1) whose evaluation was reviewed. Findings include, but are not limited to:Resident 1's move-in evaluation, dated 01/25/24, lacked information regarding the following required elements:* Mental health issues including history of treatment and effective non-drug interventions;* Cognition including confusion and decision making abilities; * Personality: including how the person copes with change or challenging situations;* Eating; and* Ability to manage medications.There was no indication regarding who was involved in the evaluation process.In an interview on 05/15/24 at 11:30 am, Staff 1 (Memory Care Director) stated that she did not normally complete the new move-in evaluation for residents and acknowledged she missed the above noted areas.The move-in evaluation including an indication of who was involved in the evaluation process and the required elements was reviewed with Staff 1, Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Medication room supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the RN for an assessment and service plan updated as needed and/or failed to determine and document what action or intervention was needed for residents, communicate actions to staff on each shift and document weekly progress through resolution for 3 of 3 sampled residents (#s 1, 2, and 3) reviewed with changes of condition. Resident 3 experienced ongoing weight loss. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.During the acuity interview on 05/13/24 at 1:00 pm, Resident 3 was identified to have experienced weight loss.A physician order dated 07/07/23 directed staff to weigh the resident monthly. The only documented weights available in the resident record were recorded on an After Visit Summary and noted the following weights:*09/05/23 - 215 pounds; and*02/13/24 - 187 pounds.During the six-month period between 09/2023 and 02/2024, Resident 3 lost 28 pounds or 13.02% of his/her body weight resulting in a severe weight loss and significant change of condition. There was no documented evidence the significant change of condition had been evaluated or referred to the facility RN for assessment. The resident's current service plan dated 04/03/24 noted the resident needed food to be cut up into bite-sized pieces, encouraged to take small bites, and would not eat if s/he felt like staff was "nagging" him/her. On 05/13/24 at 3:40 pm, Resident 3's lunch plate consisting of a sandwich, roll, chips and pink liquid was removed by staff from the resident's apartment and nothing had been eaten. The resident was given crab salad and water for a snack.On 05/14/24 at 9:20 am, staff delivered a breakfast tray to Resident 3 in his/her apartment. Staff removed the uneaten crab salad from the previous day and served the resident eggs, bacon, toast, juice, water and hot chocolate. The food was not cut up into bite-sized pieces. During an interview at 9:50 am Staff 22 Personal Care Associate reported the resident ate toast and hot chocolate for breakfast.Resident 3's lunch plate on 05/14/24 at 3:30 pm was removed from his/her apartment. Lunch consisted of meat balls, mashed potatoes, and gravy, all of which remained untouched on the resident's plate. Resident 3 ate a piece of cake for lunch.On 05/15/24 at 8:50 am, Resident 3 was noted to have eaten 100% of breakfast in his/her apartment and at 11:38 am, ate approximately 50% of lunch in the dining room.During interviews with caregiving staff on 05/13/24 through 05/15/24 the following was noted:*Resident ate in his/her apartment and at times came out to the dining room;*Refused food, "a lot";*S/he was worried about gaining weight;*Was picky about food;*Often requested ham and cheese sandwich or a cheeseburger; and*Resident had lost weight related to pants fitting loosely.Resident 3 was weighed during the survey and noted to be 176 pounds, an additional 11 pounds or 5.8% of his/her body weight since the previously documented weight in 02/2024, over a three month period of time.Resident 3 was noted to have a severe weight loss without documented evidence the significant change of condition was evaluated or referred to the facility RN for assessment. The resident continued to lose weight. Resident 3's weight loss was discussed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.
2. Resident 1 was admitted to the facility in 02/2024 with diagnoses including dementia. A review of the resident's clinical records, 02/05/24 through 05/13/24, indicated the following changes of condition had not been reviewed by the facility and/or monitored to resolution: * 03/16/24 - Alert for spouse moving into the ALF; * 03/30/24 - Behaviors with staff;* 04/10/24 - Swollen hand; and * 04/26/24 - Start new prescription of Citalopram. There was no documented evidence the facility had determined actions or interventions specific to each change of condition, and/or monitored the above documented changes of condition to resolution. The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and monitored until resolution was updated was discussed with Staff 1 (memory Care Director), Staff 2 (Health Wellness Director) and Staff 3 (Community Nurse) on 05/15/24. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.The resident's 02/13/24 to 05/13/24 progress notes and temporary service plans (TSPs) and service plan dated 05/02/24 were reviewed, observations of the resident were made, and interviews with staff were conducted. The following was identified:a. There was no documented evidence the facility determined actions or interventions and provided written communication to staff on each shift for the following short term changes of condition:04/29/24 - Sexually inappropriate comments to staff in front of other residents;05/01/24 - Sexually inappropriate activity in community living room;05/01/24 - Injury fall; and05/02/24 - Non-injury fall.b. There was no documented evidence the facility monitored the following short-term changes of condition with weekly progress noted to resolution:02/15/24 - Resident-to-resident altercation;02/20/24 - New medication, cephalexin (an antibiotic); and03/18/24 - Urinary tract infection;04/29/24 - Sexually inappropriate comments to staff in front of other residents; and05/01/24 - Sexually inappropriate activity in community living room.The need to ensure actions or interventions were determined, documented, and communicated to staff on each shift and monitoring was completed at least weekly with progress noted to resolution for short-term changes of condition was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). They acknowledged the findings, and no further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment, including findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced significant changes of condition. Resident 3 experienced on going weight loss. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.During the acuity interview on 05/13/24 at 1:00 pm, Resident 3 was identified to have experienced weight loss.During the six-month period between 09/2023 and 02/2024, Resident 3 lost 28 pounds or 13.02% of his/her body weight resulting in a severe weight loss and significant change of condition. There was no documented evidence the significant change of condition had been evaluated or referred to the facility RN for an assessment which included findings, resident status, and interventions made as a result. Resident 3 continued to lose weight.Refer to C 270, example 1.
2. Resident 1 was admitted to the facility 02/2024 with a diagnosis of dementia.The resident's clinical records including progress notes, evaluation, service plan and temporary plans of care were reviewed during the survey. A progress note dated 04/22/24 reported the resident had a sexual encounter with another resident. There was no documented evidence of previous sexual encounters. This was a new behavior for the resident and constituted a significant change of condition. There was no documented evidence an RN assessed Resident 1's significant change of condition.The need to ensure an RN assessment was completed for Resident 1's significant change of condition was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC), and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.During the acuity interview, the resident was identified as being in an intimate relationship with Resident 1. The resident's 02/13/24 to 05/13/24 progress notes and temporary service plans (TSPs) and service plan dated 05/02/24 were reviewed, observations of the resident were made, and interviews with staff were conducted. The following was identified:* A 04/22/24 progress note stated, "resident was engaged in a sexual encounter with another resident."* During an interview at 11:50 am on 05/14/24, Staff 12 (MT) stated the resident did not have a history of sexual activity since admitting to the facility.* Review of the clinical record did not reveal any recent history of sexual activity for Resident 2.* Subsequent progress notes indicated the sexual activity continued.The resident's new onset of sexual activity constituted a significant change of condition which required an RN assessment including findings, resident status, and interventions made as a result of the assessment. During an interview at 4:02 pm on 05/14/24, Staff 3 (Community Nurse) stated no RN assessment had been completed.The need to ensure an RN assessment was completed for significant changes of condition that included findings, resident status, and interventions was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director).

Based on observation, interview, and record review, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist and to maintain infection prevention and control protocols during dining service and for 1 of 1 sampled resident (#3) who received ADL care. Findings include, but are not limited to:1. During an interview on 05/13/24 Staff 1 (Memory Care Director) stated Staff 3 (Community Nurse) was designated as the facility's Infection Control Specialist. During a subsequent interview on 05/14/24 at 11:30 am, Staff 1 verified there was no documented evidence Staff 1 had completed specialized training in infection prevention and control protocols.The requirement to have a designated Infection Control Specialist with documented evidence of specialized training in infection prevention and control was discussed on 05/15/24 at approximately 12:30 pm with Staff 1, Staff 2 (Health Wellness Director), Staff 3, Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia.The resident's current service plan dated 04/03/24 noted the resident required standby assistance with ADL care, including incontinence care.Staff 19, Personal Care Associate, (PCA) and Staff 22 (PCA) were observed to provide incontinence care for Resident 3 on 05/14/24 from approximately 9:20 to 9:50 am. The following was noted:*Gloves were donned to provide incontinent care to the resident in the bathroom;*Soiled briefs and clothing were removed and placed on the floor;*Staff grabbed the door handle to to come out of the bathroom and grabbed clean clothing for the resident while wearing the same gloves;*The resident's hair was combed while using the same gloves; *Staff removed soiled clothing from a recliner chair to the floor while wearing the same gloves;*Staff doffed gloves after care was completed without washing hands.The need to ensure the facility maintained infection prevention and control protocols was discussed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). No additional information was provided.
3. Observations of meal service and snack delivery service were conducted from 05/13/24 to 05/15/24. The following was identified: a. Caregiving staff were observed feeding residents and delivering food to residents' rooms without wearing a protective covering over their potentially contaminated clothing. b. Food and beverages were delivered around the community to residents in their rooms and in common areas without a covering to protect from contamination.The need to ensure the facility maintained infection prevention and control protocols was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.The resident's 05/01/24 to 05/13/24 MAR and current prescriber orders were reviewed and the following was identified:a. The following medications lacked a reason for use:* Calcium;* Clotrimazole 1%;* Diclofenac Sodium 1%;* Docusate Sodium;* Levothyroxine;* Melatonin;* Metformin;* Nystop;* One-A-Day 50+;* Propranolol;* Resperidone;* Sertraline; and* Vitamin D3.b. Resident 3 was prescribed routine Clotrimazole, apply to affected area twice a day, Diclofenac Sodium, apply topically to affected area four times a day and Nystop, apply to affected area twice a day. There was no medication-specific instructions related to where the medication was to be applied. The need to ensure residents' MARs included documented reasons for use and resident specific instructions for administration was discussed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). No additional information was provided.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, contained reasons for use, had resident-specific parameters for PRN medications and clear instructions to staff for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1's 05/01/24 through 05/13/24 MAR was reviewed and revealed the following: Resident 1's MAR revealed multiple medications that lacked reasons for use for the following medications;* Aspirin;* Lisinopril;* Donepezil;* Quetiapine;* Lorazepam; and* Citalopram. In an interview with Staff 1 (Memory Care Director) at 11:30 am on 05/15/24, she acknowledged the lack of reasons for use on Resident 1's medications.The need to ensure medications had reasons for use was reviewed with Staff 1, Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the MARs were not accurate.
3. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease. The resident's 05/01/24 to 05/13/24 MAR and current prescriber orders were reviewed and the following medications lacked a reason for use:* Cephalexin; and* Quetiapine.The need to ensure the MAR included medication reasons for use was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented as ineffective prior to PRN psychotropic medications being administered for 2 of 2 sampled residents (#s 1 and 3) who were prescribed as-needed psychotropic medications. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression and a history of schizophrenia.The resident's 04/01/24 through 05/13/24 MAR and prescriber orders were reviewed.Resident 3 had a physician order for lorazepam, 0.5 mg tabs one tab per day as needed for anxiety, insomnia or agitation. The MAR indicated the resident received the PRN medication nine times between 04/01/24 and 05/12/24. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication. During an interview, Staff 12 (MT) verified there was no documented evidence non-pharmacological interventions had been attempted and documented as ineffective prior to administering PRN medication.The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.
2. Resident 1 was admitted to the facility in 02/2024 with diagnoses including dementia and mood disorder.The resident's 05/01/24 through 05/13/24 MAR and prescriber orders were reviewed.Resident 1 had a physician order for lorazepam, 0.5 mg tabs one tab every eight hours as needed for anxiety or agitation. The MAR indicated the resident received the PRN medication three times between 05/07/24 and 05/09/24. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication. During an interview, with Staff 3 (Community Nurse) verified there was no documented evidence non-pharmacological interventions had been attempted and documented as ineffective prior to administering PRN medication.The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed on 05/15/24 at approximately 11:30 am with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3, Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to employ an administrator that obtained a full Residential Care Facility Administrator license. Findings include, but are not limited to:Staff 1 (Memory Care Director) was acting as the administrator of the Residential Care Facility, Endorsed Memory Care Facility. During an interview on 05/14/24 at 11:30 am, Staff 1 stated she had not yet obtained her Residential Care Facility Administrator license.In an interview on 05/15/24 at 12:30 pm, Staff 1 verified the finding.

Based on interview and record review, it was determined the facility failed to review and update an Acuity-Based Staffing Tool (ABST) at least quarterly and to accurately reflect all the ADLs for 2 of 3 sampled residents (#s 2 and 3) and multiple unsampled residents. Findings include, but are not limited to:The ABST must address all the required activities of daily living for each resident and the amount of staff time per resident needed to provide care. The ABST must be reviewed and updated at least quarterly.a. The facility staffing tool was reviewed with Staff 1 (Memory Care Director) on 05/15/24. Ten residents' ABSTs lacked evidence they were reviewed at least quarterly.b. Interviews with staff, observations of the residents, review of current service plans and progress notes were completed. The facility ABST showed numerous ADL care areas which were not reflective of Resident 2 and 3's current care needs. The number of staffing minutes noted on the ABST tool did not accurately reflect the amount of time staff spent with residents providing care in the areas including:* Safety checks;* Time spent ensuring non-drug interventions for behaviors;* Monitoring behavioral conditions and symptoms; and* Dressing and undressing.The need to accurately address the amount of staff time needed to provide care for residents and to ensure all resident ABST entries were reviewed quarterly was reviewed with Staff 1 on 05/15/24. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to maintain documentation regarding each direct care staff's demonstrated competency and maintain written documentation of all training completed by each employee. Findings include, but are not limited to:During a review of staff training records on 05/14/24 and 05/15/24, Staff 4 (Business Office Manager) was unable to provide documented evidence sampled staff administering medications and providing personal care had completed pre-service orientation, pre-service dementia training, and demonstrated competency in all duties they were assigned before working independently with residents, and that sampled long term staff had completed annual training including infectious disease preventionThe requirement to maintain written documentation of training completed by each employee was discussed with Staff 1 (Memory Care Director), Staff 7 (Med Room Supervisor/RCC) and Staff 24 (RCC) on 05/15/24. They acknowledged the findings. Refer to C 372 and Z 155.

Based on record review and interview, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 19 and 20) completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 05/14/24 and 05/15/24. Staff 19 Personal Care Associate (PCA) hired 02/04/24, and Staff 20 (PCA), hired on 04/03/24, did not have documented evidence First Aid and abdominal thrust training had been completed within 30 days of hire.The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (Memory Care Director) and Staff 24 (RCC) on 05/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety training at least every other month. Findings include, but are not limited to:Fire and life safety records, reviewed between 10/2023 and 04/2024, revealed fire and life safety training was not documented as completed every other month alternating with fire drills.In an interview on 05/14/24, Staff 10 (Maintenance Director) acknowledged there was no documented fire and life safety training.On 05/14/24, the need provide fire and life safety training was reviewed with Staff 1 (Memory Care Director). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material, accessible and maintained in good repair and measures were taken to prevent pests. Findings include, but are not limited to:The exterior of the facility was toured on 05/13/24 through 05/15/24. The following was identified:* Exterior concrete pathways and patios contained multiple drop-offs measuring from two to four inches from the concrete to the planting bed surface. These drop-offs created potential hazards for residents that frequently walked the pathway; and* Wasps and wasp nests were noted in eves of the north patio in the interior courtyard. The building's exterior was toured with Staff 1 (Memory Care Director) and Staff 10 (Maintenance Director) on 05/14/24 and 05/15/24 . They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and resident equipment were kept clean and in good repair. Findings include, but are not limited to:The facility was toured on 05/13/24 through 05/14/24. The following areas in disrepair and in need of cleaning were observed:* The baseboards in dining room had spills and splatters;* The handrails outside the dining room were damaged and un-cleanable;* The counter in the dining room was damaged, gouged, and un-cleanable;* The flooring in laundry room was damaged and un-cleanable;* The wall behind the toilet in the common bathroom at the back of the facility was damaged;* The toilet paper holder in back common bathroom was broken; * The door jamb of the bathroom in 107 was damaged; and* The ceiling vents in the hall and resident rooms had a build up of dust and debris.The areas were reviewed and toured with Staff 1 (Memory Care Director) and Staff 10 (Maintenance Director) who acknowledged the areas needed to be repaired and/or cleaned.

Based on observation and interview, it was determined the facility failed to ensure a manually operated emergency call system was provided in each toilet and that exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:The facility was toured on 05/13/24 through 05/15/24. Observations and interviews with staff during the survey confirmed the doors by which residents could exit the facility to the inner courtyard did not have a working alarm or other acceptable system to alert staff when residents exited the building.The emergency call system in the common bathroom at the front of the Memory Care Community had a pull string approximately six inches long and three feet above the ground. The need to ensure the emergency call system in common bathrooms were accessible and exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (Memory Care Director) and Staff 10 (Maintenance Director) on 05/14/24. They acknowledged the findings.

Concerns were identified and the facility was provided with technical assistance in the following areas:H 1517: OAR411-004-0020 (1)(c): Individual Rights Settings: Privacy, Dignity(1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Concerns were identified and the facility was provided with technical assistance in the following area:(2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Concerns were identified and the facility was provided with technical assistance in the following area:(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.Refer to H 1518.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 154, C 156, C 200, C 231, C 350, C 361, C 365, C 372, C 420, C 510, C 513, and C 555.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 13, 19, and 20) completed pre-service orientation and dementia training prior to beginning their job responsibilities and had documented evidence of demonstrated competency in all required areas within 30 days of hire, and 2 of 2 long term, non-direct care staff (#s 8 and 11) completed required annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed with Staff 4 (Business Office Manager) on 05/14/24. The following was identified:a. There was no documented evidence Staff 13 (MT), hired 04/08/24, Staff 19 Personal Care Associate (PCA), hired 02/04/24, and Staff 20 (PCA), hired 04/03/24, completed all required pre-service orientation topics and pre-service dementia training prior to beginning job duties. b. Staff 13, Staff 19, and Staff 20 lacked documented evidence they had completed all of the required training and demonstrated competency in all job duties within 30 days of hire. In an interview on 05/15/24, Staff 7 (Med Room Supervisor/RCC) acknowledged Staff 13 had not demonstrated competence in medication pass prior to working independently as a MA. Staff 7 agreed to ensure Staff 13 demonstrated competence prior to independently passing medications.c. Staff 8 (Dietary Services Director), hired 06/22/21, and Staff 11 (Housekeeper/Bus Driver), hired 09/06/22, lacked documented evidence of completion of annual infectious disease training.The need to ensure all staff completed pre-service orientation and dementia training, demonstrated competence in job duties within 30 days, and completed required infectious disease training annually, was discussed with Staff 2 (Health Wellness Director), Staff 1 (Memory Care Director), Staff 7, and Staff 24 (RCC) on 05/15/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules of the facility. Findings include, but are not limited to:Refer to C 252, C 270, C 280, C 295, C 310 and C 330.

Based on observation, interview, and record review, it was determined the facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents for multiple sampled and unsampled residents, and to evaluate residents for activities and develop an individualized activity plan based on the evaluation for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:a. Observations of the community were conducted from 05/13/24 to 05/15/24. A bowling activity was completed with one resident at 3:15 pm on 05/13/24. No other activities were observed. During an interview at 3:25 pm on 05/13/24, Staff 22 Personal Care Associate stated the facility Activities Director was on leave and "we try to do them if we have time."b. Residents 1, 2, and 3's most recent evaluations and service plans were reviewed. The records did not address one or more of the required elements:* Past and current interests;* Current abilities and skills;* Emotional and social needs and patterns;* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interventions.There was no individualized activity plan developed based on the evaluation that reflected the resident's activity preferences and needs for Residents 1, 2 and 3.The need to ensure the facility provided meaningful activities, evaluated each resident for activities, and developed an individualized activity plan based on the evaluation was discussed with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director) on 05/15/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and included on the service or care plan for 1 of 3 sampled residents (#3) who had documented behaviors. Findings include, but are not limited to:Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia, depression, and a history of schizophrenia.The resident's clinical record including progress notes dated 02/05/24 through 05/11/24, physician orders, evaluation and service plan dated 04/03/24 were reviewed, interviews were conducted, and observations made between 05/13/24 through 05/15/24. The following was noted:* Behaviors including screaming and yelling were noted on multiple occasions;* The MARs noted multiple refusals of medications including psychotropic medications;* Changes with psychotropic medications;* Staff reported the resident often screamed and yelled for help, felt like s/he didn't get enough attention, didn't like people looking at him/her, would get overwhelmed by lots of people and noise, was destructive to personal property at times; and* One-on-on attention, going outside, compliments, and praise helped diffuse the behaviors.Although the service planned identified the resident had behaviors and offered some interventions to attempt there was no documented evidence the behaviors were evaluated to include what agitation and anxiety looked like for the resident, triggers to behaviors, review of medications and interventions most frequently used by staff. Resident 3's behaviors were discussed on 05/15/24 at approximately 12:30 pm with Staff 1 (Memory Care Director), Staff 2 (Health Wellness Director), Staff 3 (Community Nurse), Staff 7 (Med Room Supervisor/RCC) and Staff 25 (Regional Director). The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:The facility was toured on 05/13/24 through 05/15/24. Occupied resident rooms 101, 102, 106a, 108a, 109b, and 116a lacked any individually specific means of identifying the room for the residents. Shadow boxes outside each room were empty.The need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 1 (Memory Care Director) on 05/13/24. She acknowledged the findings.

The findings of the on-site investigation, conducted 09/19/23 though 09/20/23 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. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on record review and interview, conducted during a site visit on 09/19/23 and 09/20/23 it was confirmed the facility failed to fully implement and update an ABST for 1 of 1 sampled residents (# 1). Findings include, but are not limited to: Resident 1 moved into the facility on 09/18/23 but was not yet included in the facility's ABST on 09/19/23.In an electronic communication on 09/22/23, Staff 1 (Executive Director) stated "[Resident 1] did not show on the original ABST tool in Memory Care due to being a respite and the report had to be run differently. S/he was our first respite since having the ABST tool. "The findings were reviewed with and acknowledged by Staff 1 on 09/19/23. The facility failed to update their 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 11/02/2022. 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on record review and interview it was confirmed that the facility failed to update care plan quarterly. Findings include but not limited to:A review of the facility's service plan binder revealed that two of the three sampled residents had not had their care plans updated in the previous quarter. These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/02/2022 who were in agreement.Plan of correction: Nurse consultant will review binder 11/02/2022 and put updated service plans in the binder or schedule appropriate assessments and meetings.

Based on observation, interview and record review, it was confirmed that the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment including protocols to prevent the development and transmission of communicable diseases. Findings include but not limited to:During an unannounced site visit on 11/02/2022, Compliance Specialist (CS) observed a staff member enter the dining room wearing only a surgical mask during an active COVID outbreak. CS also observed Staff #6 (S6) enter a room identified as an isolation room with a COVID + resident inside without donning proper personal protective equipment (PPE) including a gown or gloves. S6 did not perform hand hygiene when exiting the room. CS observed signage outside of this room with isolation precautions and a PPE station that was well-stocked.During interview, S6 stated they didn't know it they needed additional PPE upon entrance and that they had not yet returned to their cart to perform hand hygiene upon exiting. A review of the facility's Community Infection Control Policy revised on 12/21/2021 revealed staff are to utilize contact precautions for known or suspected infections that represent an increased risk for contact transmissions.These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/02/2022 who were in agreement.Plan of Correction: CS alerted RN and regional team who immediately educated S6. Facility will educate the rest of their shift to shift meeting at 2pm today, and 2pm tomorrow. Nursing to verified signs, products, etc at stations. Spot check and audit 2x/day, every day for first week, and 3x/week for 4 weeks.

Based on record review and interview it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:A review of a report dated 10/12/2022 from Red Cross Drug Store revealed 55 medications administrations being missed in the month prior due to "meds not available." During an interview conducted 10/31/2022 Witness #1 (W1) stated that this facility's medication practices are unsafe and disorganized.A review of Resident' #1- Resident #3 (R1-R3) MARs conducted onsite on 11/02/2022 for October 2022 revealed at least 13 occasions when a medication was not administered due to not being available in-house.These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/02/2022 who were in agreement.Plan of Correction: Facility has another pharmacy audit and RN consultant beginning 11/02/2022. RN consultant to work on Med Tech competencies.

Based on observation, record review and interview, it was confirmed that the facility has failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents During an unannounced site visit on 11/03/2022 Compliance Specialist observed three caregivers and one med tech working on the floor during day shift. The facility's posted staffing plan stated need for two caregivers and one med tech on day shift.A review of the facility's ABST revealed a need for 36 hours of care that day shift. A review of the facility's schedule for November 2022 revealed only one med tech and three caregivers were scheduled. During interview, Staff #2 (S2) stated that the facility needs four caregivers on day shift.These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/03/2022.

Based on observation, record review and interview, it was confirmed that the facility has failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include but not limited to:During an unannounced site visit on 11/03/2022 Compliance Specialist observed three caregivers and one med tech working on the floor during day shift. The facility's posted staffing plan stated need for two caregivers and one med tech on day shift.A review of the facility's ABST revealed a need for 36 hours of care that day shift. A review of the facility's schedule for November 2022 revealed only one med tech and three caregivers scheduled. The facility's ABST also revealed that it is not being updated quarterly as required by rule as 20 of 22 residents included had not been updated since 07/07/2022.During interview, Staff #2 (S2) stated that the facility needs four caregivers on day shift.These findings were reviewed with and acknowledged by Staff #2-Staff #5 and Staff #7 on 11/03/2022.

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 09/08/2022. 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on observation, interview and record review it was confirmed that the facility failed to assist the resident in performing all activities of daily living, on a 24-hour basis with toileting assistance. Findings include but not limited to:During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) heard Resident #4 (R4) screaming from behind a closed door in their room. CS was unable to locate a staff member for some time. CS checked on resident to verify safety and resident was yelling and requesting a brief change stating that they were messy and wanted to get up. CS found Staff #5 (S5) and requested assistance for resident. During separate interviews, Staff #4 (S4) and S5 stated that staff are very busy and do not have time to help with hygiene, showers, or toileting as much as residents need. Neither could say if R4 had assistance with brushing their teeth.A review of R4's service plan dated 08/12/2022 revealed resident requires physical assitance with grooming/personal hygiene.A review of Resident #1 (R1's) shower sheets revealed that resident did not receive a shower between 08/11/2022 and 08/22/2022.A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers and 1 Med Aid for a total of 24 hours of care on day shift.These findings were reviewed with and acknowledged by Staff #1-Staff #3 (S1-S3) on 09/08/2022 who were in agreement.Facility Plan of Correction: Facility continue attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.

Based on record review and interview it was confirmed that the facility failed to ensure the implementation of services. Findings include but not limited to:A review of Resident #1 (R1)'s service plan dated 08/12/2022 revealed that R1 is to be weighed every Monday. Compliance Specialist requested documentation of weights from Staff #1-Staff #3 (S1-S3) who were unable to produce these records.During interview, S1-S3 indicated that the weights had not been entered.Facility Plan of Correction: Facility to resume daily standup meeting which has not occurred in several weeks. Clinical meeting to occur immediately following standup. MAR Audit to occur daily, verify weight put into vitals each Monday.

Based on record review and interview it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to:A review of Resident #2's MAR, progress notes and narcotic log for September 2022 revealed that resident missed a dose of a psychotropic medication on 09/02/2022 and that no exceptions or refusals were documented. These findings were reviewed with and acknowledged by Staff #1-Staff #3 on 09/08/2022 who were in agreement.Facility Plan of Correction: Inservice to occur on documenting refusals and missed-medications on 09/09/2022. Administrative team to resume clinical meeting on a daily basis and conduct MAR/charting audits.

Based on record review and interview it was confirmed that the facility failed to keep an accurate MAR. Findings include but not limited to:A review of Resident #2 (R2)'s MAR for September 2022 revealed that resident missed multiple doses of a medication on 09/01/2022 and 09/02/2022 however the narcotic log revealed that those doses were given. These findings were reviewed with and acknowledged by Staff #1-Staff #3 on 09/08/2022 who stated that the staff member likely signed them out from the narcotic book and forgot to document they were given on paper MAR.Facility Plan of Correction: Inservice to occur on documenting refusals and missed-medications on 09/09/2022.

Based on record review and interview it was confirmed that the facility failed to offer non-pharmacological interventions prior to administration of PRN psychotropic medications. Findings include but not limited to:A review of Resident #2 (R2) MAR for August and September 2022 revealed that R2 is utilizing PRN psychotropic medications for which there are no interventions in place. These findings were reviewed with and acknowledged by Staff #1-Staff #3 on 09/08/2022 who were in agreement. Facility Plan of Correction: RN to add interventions by end of day 09/08/2022. PRN psychotropic audit to occur by end of the following week.

Based on observation, interview and record review it was confirmed that the facility failed to assist the resident in performing all activities of daily living, on a 24-hour basis with toileting assistance. Findings include but not limited to:During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) heard Resident #4 (R4) screaming from behind a closed door in their room. CS was unable to locate a staff member for some time. CS checked on resident to verify safety and resident was yelling and requesting a brief change stating that they were messy and wanted to get up. CS found Staff #5 (S5) and requested assistance for resident. During separate interviews, Staff #4 (S4) and S5 stated that staff are very busy and do not have time to help with hygiene, showers, or toileting as much as residents need. Neither could say if R4 had assistance with brushing their teeth.A review of R4's service plan dated 08/12/2022 revealed resident needs physical assistance with grooming/personal hygiene.A review of Resident #1 (R1's) shower sheets revealed that resident did not receive a shower between 08/11/2022 and 08/22/2022.A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers and 1 Med Aid for a total of 24 hours of care on day shift.These findings were reviewed with and acknowledged by Staff #1-Staff #3 (S1-S3) on 09/08/2022 who were in agreement.Facility Plan of Correction: Facility continue attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.

Based on record review, observation and interview it was confirmed that the facility failed to adopt and implement an ABST.Findings include but not limited to:A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers (CGs) and 1 Med Aid (MA) for a total of 24 hours of care on day shift. During an unannounced site visit on 09/08/2022, Compliance Specialist (CS) observed two caregivers and one MA working during the day shift. These findings were reviewed with Staff #1-Staff #3 on 09/08/2022 who were in agreement.Facility Plan of Correction: Facility continue attempts to hire new staff. Job postings currently on Indeed, Company website and community reader-board on main road in La Grande. They had a booth at a job fair and are offering referral bonuses.

Based on observation and interview it was confirmed that the facility failed to keep all equipment in good repair. Findings include but not limited to:During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) observed the facility scale in an activity room, dismantled and tucked into a corner. Staff #1 and Staff #2 were unable to make the scale work at that time and were in agreement that scale was not working.Facility Plan of Correction: Scale was fixed prior to exit on 09/08/2022.

The findings of the kitchen inspection, conducted 07/11/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 07/11/22, conducted 10/04/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 07/11/22 revealed:* Splatters, spills, drips, and debris noted on: - Shelving throughout kitchen; - Sides of steam table; - Exterior of the range; - Stand mixer; - Underneath shelving and equipment; - Floor of the walk in refrigerator; and - Dishwashing area. * Dish washing racks were stored on the floor.* Bottle of opened salsa noted to require refrigeration left in an un-refrigerated food storage area; and * Undated food items and food items with dates older than seven days were noted in the refrigerators.* Multiple dented or damaged cans in the dry storage area;* Damage to the door jambs creating an un-cleanable surface.* Missing laminate on the shelving below the beverage station and the steam table creating an un-cleanable surface.* Staff were observed to not change gloves between tasks or sanitize hands upon entering the kitchen; and* Caregiving staff assisting with meal service and delivery were not using aprons.Staff 3 (Dining Services Director) and the Surveyor toured the kitchen. Staff 3 acknowledged the above findings.The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) and Staff 2 (Memory Care Administrator). They acknowledged the findings.

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

The findings of the re-licensure survey, conducted 10/04/21 through 10/06/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:OAR 411-054-0055 (1)(a) Systems: Medications and TreatmentsThe facility put an immediate plan of correction in place during the survey and the situation was abated.
The findings of the first re-visit to the re-licensure survey of 10/06/21, conducted 03/02/22 through 03/04/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second re-visit to the re-licensure survey of 10/06/21, conducted 05/18/22 through 05/19/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:During the survey, conducted 10/04/21 through 10/06/21, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.Refer to the deficiencies in the report.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:1. During the survey, conducted 10/04/21 through 10/06/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19, and made available to all facilities, were not being followed by the facility. a. Facility staff were observed without face masks in place while preparing food for residents.b. Staff were observed to enter through the back door of the memory care unit to begin their shift. They were not screened prior to entering the facility. c. The screening process conducted at the front entrance of the building was not comprehensive or completed consistently. 2. Caregiving staff were observed on 10/04/21, 10/05/21 and 10/06/21, while serving meals, assisting residents to eat, and in the common areas. a. Staff donned gloves during the meal service. Staff touched doors, tables, resident clothing and wheelchairs. There was no removal of gloves or hand hygiene practiced.b. Staff were observed with gloves on in common areas, entering and exiting resident rooms without removing gloves or practicing hand hygiene. 3. The morning medication pass was observed on 10/06/21. The Medication Aide failed to practice hand hygiene between residents. Infection control practices were reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director) on 10/06/21. They acknowledged the need for increased oversight of infection control practices in the building.

Based on interview and record review, it was determined the facility failed to immediately notify the local SPD office, or the local AAA, of any incident of abuse or injury of unknown cause, for 2 of 2 sampled residents (#s 1 and 3) who had reportable incidents. Findings include, but are not limited to:1. Resident 3 was admitted to the MCC in 2019 with diagnoses which included dementia.Progress notes, incident investigations, temporary service plans and physician visit summaries reviewed between 07/01/21 and 10/04/21, revealed the following:* Resident 3 fell on 08/15/21 and complained of pain in his/her left ankle. On 08/31/21, the resident was seen by the physician and was diagnosed with a "displaced fracture of the fifth metatarsal bone of the left foot" and a sprain of a "ligament of the left ankle." * Progress notes, dated 09/09/21, indicated the resident had been placed on alert charting for an altercation with another resident that had occurred on 09/08/21. There was no documented evidence the facility had conducted an immediate investigation of the incidents to include the time, date, description of the event, response of staff at the time of the event, follow up action, or administrator review. Additionally, there was no evidence the facility had ruled out abuse. On 10/05/21, the surveyor requested the facility report the incidents to the local SPD. A fax confirmation of the report was received prior to survey exit. The need ensure injuries of unknown cause or incidents of abuse or suspected abuse were immediately investigated, contained all required areas of documentation including administrator review, was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director) during the survey. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease. Review of the resident's 05/11/21 through 10/04/21 progress notes revealed the following:On 08/27/21, a facility progress note showed the resident had a bruise to his/her right hip. There was no documentation as to how the injury occurred. There was no documented evidence the facility immediately investigated the injury and documented it was not the result of abuse or neglect. The facility failed to report the injury to the local SPD office as suspected abuse/neglect.The lack of a documented investigation and failure to report the injury to the local SPD office was discussed with Staff 2 (RN) and Staff 3 (Regional Director) on 10/05/21. They acknowledged the findings.The surveyor directed Staff 2 and Staff 3 to report the injury of unknown cause to the local SPD office. Confirmation the report was received by the SPD office was received during the survey. The need to ensure injuries of unknown cause were investigated promptly to rule out abuse and neglect or reported to the local SPD office as suspected abuse was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 on 10/6/21. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to promptly investigate incidents and document the required information to rule out abuse or neglect for 1 of 3 sampled residents (#12) who had falls and was involved in incidents with other residents. This is a repeat citation. Findings include, but are not limited to:1. Resident 12 was admitted to the MCC in February 2022 with diagnoses including dementia.Progress notes, incident investigations, temporary service plans and physician visit summaries reviewed between 02/17/22 and 03/04/22, revealed the following:a. Resident 12 had an unwitnessed fall on 02/21/22 and sustained an abrasion to the spine. The abrasion was documented in progress notes on 02/22/22.* An incident report, dated 02/28/22, indicated the investigation was "in process". There was no documented evidence the facility had conducted an immediate investigation of the incident to include the time, a full description of the event, response of staff at the time of the event, or follow up action. The administrator review indicated abuse or neglect could not be ruled out.On 03/04/22, the surveyor requested the facility report the incident to the local SPD. A fax confirmation of the report was received prior to survey exit. b. Resident 12 was involved in an incident on 02/19/22 when s/he was being yelled at by another resident. * Progress notes, dated 02/19/22, documented that staff responded to the common area where yelling was heard and found Resident 12 had been sleeping on a couch and was being yelled at by another resident. There was no documented evidence the facility had conducted an immediate investigation of the incident to include the time, a full description of the event, response of staff at the time of the event, or follow up action. The record lacked evidence that abuse had been ruled out.In an interview on 03/04/21, Staff 21 (Executive Director) stated no adverse effects were evident with either resident involved in the incident following the occurrence.The need to ensure incidents of abuse or suspected abuse were promptly investigated and contained all required areas of documentation was discussed with Staff 1 (Administrator) and Staff 21 during the survey. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the MCC kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 10/05/21 at 3:20 pm, the MCC kitchen was observed to need cleaning and repair in the following areas:a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:* Tops of wall base boards;* Walls;* Interior of several drawers and cupboards;* Underneath the sink; * Interior of the refrigerator; and * Back and side of peninsula.b. The following areas needed repair:* Faucet nozzle and handle was not secured to sink;* Base boards were scraped and gouged; and* Several towels were observed in a cabinet underneath the sink. The towels were wet and catching water from a leak.The areas that required cleaning and repair were observed and discussed with Staff 1 (Administrator) on 10/6/21 at 11:15 am. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were were accurate, used as the foundation to develop service plans, and updated each time a resident had a significant change in condition for 1 of 3 sampled residents (#1) whose evaluations were reviewed. Findings include, but are not limited to:Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease. The resident's 08/16/21 quarterly evaluation was reviewed and was identified as not reflective of the resident's status and needs in the following areas:* Meal assistance;* Emergency room visits;* Skin issues;* Assistive devices;* Unexplained weight loss; and* History of dehydration.Resident 1 experienced the following significant changes of condition in July 2021:* Severe weight loss; and* A decline in ADL's.The facility lacked documented evidence the evaluation was updated each time the resident experienced a significant change in condition. On 10/05/21 the failure to ensure the evaluation was reflective of the resident's needs and updated after significant changes of condition was reviewed with Staff 2 (RN). She acknowledged the finding. No further information was provided. The need to ensure quarterly evaluations were reflective of resident's current status, used as the basis for the service plan and were updated when residents experienced significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the service plan dated 06/23/21, showed the care plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Transfer assistance;* Bathing assistance;* Incontinence and toileting needs;* Eating assistance;* Falls and safety interventions; and* Outside provider services. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services, for 2 of 3 sampled residents (#s 1 and 2), whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease. Observations of the resident and interviews with staff were conducted throughout the survey. The resident's 08/16/21 service plan, temporary service plans, and 05/11/21 through 10/04/21 progress notes were reviewed.The resident's current service plan was not reflective and did not include clear instruction for staff in the following areas:* Meals - regarding the need to assist the resident with meal intake;* Transfers - regarding when staff should use the Hoyer lift for transfers;* Toileting - regarding the resident's incontinence and toileting schedule; * Outside provider services - regarding who was providing services, what services were provided, and how often services were provided; and* Emergency evacuation - regarding clear instructions detailing how staff should assist the resident during an emergency evacuation.The need to ensure service plans were reflective of the resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

2. Resident 3 moved into the facility in 2019 and had diagnoses which included dementia.Resident 3's clinical record, reviewed from 07/01/21 through 10/04/21, revealed s/he fell on 09/25/21 and sustained an abrasion to his/her right knee. No further documentation about the injury, including treatment and wound monitoring, was documented. During an interview with Staff 2 (RN) on 10/05/21, she stated she looked at the wound yesterday (10/04/21) and it had healed. She provided the surveyor with a wound update, documented in progress notes on 10/05/21. Failure to document the progress of short-term changes of condition at least weekly until resolution was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the facility RN as needed, determine and document interventions needed and monitored weekly through resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 01/2021. The resident's progress notes, incident reports, 08/16/21 service plan, temporary service plans (TSP's), and incident reports were reviewed. a. The resident experienced multiple short term changes in condition without documented monitoring of each condition at least weekly through resolution and interventions monitored for effectiveness in the following areas:* Multiple injury falls within the community;* Multiple non injury falls within the community; and* Bruising to the skin, and an open wound.b. The resident experienced the following significant changes in condition that lacked documented evidence staff evaluated the resident and made a referral to the facility RN regarding the resident's condition:* Severe weight loss; and * Decline in ADL'sThe need to ensure short term changes in condition were monitored weekly through resolution, interventions monitored for effectiveness, and significant changes in condition evaluated and referred to the facility RN when necessary was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings. Refer to C 280, Example 2.


2. Resident 12 moved into the facility in 2022 with diagnoses including dementia and Parkinson's.a. Resident 12's clinical record, reviewed from 02/17/22 through 03/04/22, revealed staff found bruising to his/her buttock area on 02/19/22. The record lacked any additional documentation of the bruising until 03/02/22 during the survey.An interview with Staff 22 (RN) on 03/04/22 confirmed there had not been weekly documented monitoring of the bruises. b. Resident 12 sustained an abrasion to the spine following a fall on 02/21/22. The record lacked documentation that the abrasion was monitored at least weekly, until resolved.c. Resident 12 sustained a bump to the back of his/her head with redness following a fall on 02/22/22. The record lacked documentation that the bump and redness was monitored, at least weekly, until resolved. d. Between 02/18/22 and 02/26/22, Resident 12 experienced five falls. Review of the resident's service plan, temporary service plans and incident reports revealed fall interventions had not been identified and monitored for effectiveness. Failure to document the status of skin injuries at least weekly until resolution and the effectiveness of fall interventions was discussed with Staff 1 (Administrator), Staff 21 (Executive Director) and Staff 22 (RN) on 03/03/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident, communicate the interventions to staff, ensure interventions were resident-specific and monitor interventions for effectiveness, for 2 of 3 sampled residents (#s 3 and 12) who experienced changes of condition requiring monitoring. This is a repeat citation. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 8/2019 with diagnoses including dementia.A review of the resident's clinical records, 02/04/22 through 03/02/22, indicated the following changes of condition:* 02/07/22 Resident had swelling in the knee and went to the local hospital; * 02/14/22 Resident had a follow up appointment with primary physician; and* Physician ordered daily monitoring of resident's knee for "worsening of infection, increasing pain, redness, warmth or swelling". There was no documented evidence the facility had provided written instructions to staff and/or monitored the above documented changes of condition to resolution. The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and monitored until resolution was updated was discussed with Staff 1 (Administrator) and Staff 21 (Executive Director) on 03/04/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 2 of 3 sampled residents (#s 1 and 2) who experienced significant changes in condition. Residents 1 and 2 experienced ongoing severe weight loss. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia. On all days of the survey, Resident 2 was assisted to eat meals and was provided a dietary supplement between meals.It was documented Resident 2 weighed 107.4 lbs in 05/2021 and 06/2021.In 07/2021 Resident 2 was noted to weigh 101.4 lbs, a 6 lb, or 5.6%, body weight loss in one month. This constituted a severe weight loss.In 08/2021 Resident 2 was noted to weigh 95 lbs, an additional 6.4 lb, or 6.3 %, severe weight loss in one month.Resident 2 had no documented weight for 09/2021.Between 05/2021 and 08/2021, Resident 2 lost 12.4 lbs, 11.5% of his/her body weight in three months. A current weight for Resident 2 was requested during the survey. Resident 2's weight on 10/05/21 was noted to be 95.5 lbs. There was no documented RN assessment of Resident 2's ongoing severe weight loss.The need for facility RN assessments of significant changes in condition was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director). They acknowledged the findings.
2. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease. The resident's 2021 weight records, 05/11/21 through 10/04/21 progress notes, incident reports, 08/16/21 service plan, and temporary service plans (TSP's) were reviewed.a. Resident 1's April 2021 weight was recorded as 219.2 pounds. His/her July 2021 weight was recorded as 183 pounds, a loss of 36.2 pounds, or 16.51% of his/her body weight in three months. This represented a severe loss and was a significant change of condition which required an RN assessment. There was no evidence a facility RN assessment had been completed. The resident's August 2021 weight was recorded as 161.1 pounds, a additional loss of 21.9 pounds or 12.79% of his/her total body weight in one month, which constituted a severe loss. There was no RN assessment documented. The surveyor made a request for staff to obtain Resident 1's weight during the survey. Staff reported the resident's weight as 179.8 on 10/6/21. The lack of an RN assessment for Resident 1's severe weight loss was discussed with Staff 2 (RN) on 10/06/21. No further information was provided.b. In 07/2021, Resident 1 experienced a significant change of condition related to a decline in ADL's in the following areas:* Mobility;* Transfers; and* Eating.The facility lacked documented evidence the RN assessed Resident 1 for the significant changes in condition.The lack of an RN assessment for Resident 1's decline in ADL's was discussed with Staff 2 on 10/05/21. No further information was provided.The requirement for the facility to ensure an RN assessed residents experiencing significant changes of condition, documented findings, resident status, interventions made as a result of the assessment, and communicated the actions or interventions to staff was discussed with Staff 1(Memory Care Director), Staff 2 and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.
2. On 02/28/22, Resident 12 experienced a significant change of condition related to overall decline in the following areas:* Mobility;* Behaviors; and* Ability to eat independently and meal intake.The resident was admitted to Hospice services on 02/28/22.The facility RN documented a progress note and completed an "evaluation" form on 02/28/22. The assessment lacked the required information including findings, the overall status of the resident, and interventions identified as a result of the assessment.The requirement for the facility to ensure an RN assessment of residents with significant changes including documented findings, resident status, interventions made as a result of the assessment, and communicated the actions or interventions to staff was discussed with Staff 1 (Administrator) and Staff 21 (Executive Director) on 03/04/22. They acknowledged the findings.


Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed in accordance with residents' condition for significant changes of condition for 2 of 2 sampled residents reviewed (#s 3 and 12). This is a repeat citation. Findings include, but are not limited to:1. Resident 3 was admitted in 2019 with diagnoses which included dementia. During the entrance conference on 3/10/21, Staff 1 (Administrator) stated the resident had a recent significant decline in health and returned from the emergency department on 02/07/22. The decline in health constituted a significant change in condition for which an assessment by the facility RN was required. The facility RN's assessment on 02/08/22, lacked information on findings, overall status of the resident and interventions as a result of the assessment.The need to ensure the facility RN assessments included resident findings, overall status of resident and interventions was discussed with Staff 1 and Staff 21 (Executive Director) on 03/04/22 at 10:50 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 1 sampled resident (#1), who received home health services. Findings include, but are not limited to:Resident 1 was re-admitted to the Memory Care Community on 07/12/21 following a hospital stay and treatment for a urinary tract infection (UTI) and decline in ADL's. The resident's 05/11/21 through 10/04/21 progress notes, 07/12/21 hospital discharge records, and home health records were reviewed. The records indicated Resident 1 received home health PT services from an outside provider to monitor the resident's UTI and ADL decline and later, home health RN services to monitor and manage a wound to the resident's right second toe.a. Review of the "Collaboration of Care" forms indicated home health providers left the following instructions for the facility:* 07/14/21 - "Change [his/her] pants regularly, if incontinent"; and* "Clean [his/her perineal area] to prevent another UTI. Keep clean and dry to keep skin from breaking down."There was no documented evidence the facility updated the resident's service plan with these instructions or communicated the new instructions to staff.The failure to update the service plan and communicate instructions to staff was discussed with Staff 1 (Administrator) on 10/06/21. She confirmed the findings. b. The record indicated Resident 1 received an order for home health RN services to treat and monitor a wound to the resident's right second toe on 09/9/21. There was no documented evidence facility management, or a licensed nurse was notified of the services provided by the outside provider, staff informed of new interventions, necessary service plans adjustments were made, or reporting protocols put in place.The failure to review Resident 1's on-site health services, inform staff of new interventions, update the service plan, and implement reporting protocols was discussed with Staff 1 on 10/6/21. She confirmed the findings. The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1, Staff 2 (RN) and Staff 3 (Regional Director) on 10/6/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 2 sampled residents (#12), who received outside services. This is a repeat citation. Findings include, but are not limited to:Resident 12 was admitted to the Memory Care Community in 02/2022.The resident's clinical records were reviewed. The records indicated Resident 12 went to the emergency department on 02/25/22 and was receiving Hospice services since 02/28/22.a. The "after visit summary", dated 02/25/22 obtained by the facility instructed staff to "hold magnesium until restarted by provider". Staff 23 (RN) wrote "noted 3/3/22" on the report. A review of the MAR showed the magnesium was administered on 02/25 though 02/28/22. On 03/04/22, Staff 2 (Regional RN) verified the recommendation to "hold" the magnesium should have been clarified and an order received from the prescriber.b. On 03/02/22, a request was made for provider notes from Hospice services for Resident 12. Staff 25 (RCC) stated she would request Hospice fax the notes and that the Hospice service provider had not left notes with the facility upon recent visits on 02/28 and 03/02/22.During an interview with Staff 21 (Executive Director) and Staff 25, staff reported the facility was working on a process to ensure outside providers would leave notes when they visited the facility, including any recommendations for staff to follow.The need to ensure the facility had a process to obtain information from outside providers and ensure recommendation were followed was discussed with Staff 1 (Administrator), Staff 21 and Staff 25 on 03/04/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system, failed to have medication and treatment systems that were approved by a pharmacist consultant, registered nurse or a physician, and failed to ensure adequate professional oversight of the medication and treatment administration system. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:1. During the survey, MARs for Residents 1, 2 and 3 were reviewed from 09/01/21 - 10/04/21. Initials for Staff 5 (MA) were present for numerous medications and administration times, including insulin administration. In an interview with Staff 2 (RN) on 10/05/21 at 3:30 pm, she stated Staff 5 was not delegated to give insulin and was unsure why her initials were on the MAR. Staff 9 (MA) was interviewed on 10/05/21 at 3:45 pm. She explained that her electronic MAR account and password "stopped working" several days ago so she logged into the system using Staff 5's password and gave medications and insulin using Staff 5's initials. She added that Staff 5's electronic MAR password was posted in the medication room in case passwords for other staff did not work. Staff 9 said she informed Staff 1 (Administrator) and the support system for the electronic MAR program of the issue. The above information was shared with Staff 2 and Staff 3 (Regional Director) on 10/05/21 at 4:00 pm. They were unaware staff were not using their own passwords or initials when administering medications. Both stated they would investigate, contact the Electronic MAR Company to get the issue corrected, and provide additional education to the MAs regarding accurate MAR documentation. On 10/06/21, Staff 3 informed the survey team that new pass codes had been assigned to medication staff and the issue had been resolved.2. On 10/06/21 at 7:30 am, the survey team was informed the scheduled MA had called off work, Staff 5 (MA) would be staying from the overnight shift and covering as the MA. On 10/06/21 between 8:10 am and 9:40 am, the RN surveyor observed Staff 5 administer medications. During the pass, the following was observed:* Staff 5 gave pills to Resident 6 in the dining room. The pills had already been punched and the surveyor joined the medication pass in process. During the pass, Staff 5 dropped two pills onto the floor. She picked them up and returned to the cart. Staff 5 proceeded to prepare pills for another resident. The surveyor intervened and asked why replacement pills would not be given. Staff 5 replied "I don't know, I guess I should" and proceeded to re-punch the dropped pills. As the observation continued, the surveyor learned the following:Resident 6 had an order for donepezil (medication for Alzheimer's) 10 mg two tablets at bedtime. In error, Staff 5 gave the resident one of the two tablets in the dining room at breakfast. She proceeded to give the second tablet when the surveyor intervened and asked Staff 5 to recheck the medication, administration time and MAR. Staff 5 acknowledged she gave the donepezil at breakfast when it should have been given at bedtime. * Resident 7 had an order for Glipizide (diabetic medication) 5 mg 1.5 tablets before breakfast. As Staff 5 prepared the medication, she punched 1 tablet versus 1.5 as ordered. The surveyor brought the error to her attention and asked that the correct dose be administered. Additionally, the medication was administered after the resident had finished breakfast versus before as ordered. * Resident 8 had an order for metoprolol (medication for hypertension 50 mg 1.5 tablets twice a day. As Staff 5 prepared the medication, she punched 1 tablet versus 1.5 as ordered. Before administering the medication, the surveyor asked Staff 5 to check the order with the medication dose. Staff 5 acknowledged the error, and the correct dose of metoprolol was administered. * Resident 9 had an order for Synthroid (medication for hypothyroidism) 150 mcg one tablet daily before breakfast. Staff administered Resident 9 his/her Synthroid after s/he had eaten breakfast. * Resident 10 had an order for Senexon-S 8.6-50 mg one tablet twice daily for constipation. As Staff 5 prepared Resident 10's medication, she stated she could not find the Senexon so could not give it. The surveyor asked her to double check the medication cards. Staff 5 rechecked the cards and found the medication. * Two times during the medication pass observation, Staff 5 left medication cards and pill bottles on top of the cart and proceeded to leave. The surveyor intervened and asked her to secure the medications. * During the medication pass, Staff 5 dropped a pill into a drawer that contained numerous medication cards. As Staff 5 pulled out the cards to retrieve the dropped pill, several random loose pills were discovered at the bottom of the drawer. Staff 5 stated she did not pass medications on this shift or in the MCC unit and was therefore unsure why there would be loose medications in the drawer. During the pass, the surveyor asked Staff 5 about her medication training and experience. Staff 5 stated:* She normally worked night shift on the ALF side;* She had only passed medications on day shift "one other time";* She had worked the night shift in the ALF "last night" and had to stay and pass medications in the MCC to cover a shift; and * She had not passed medications in the MCC and was unfamiliar with the process. "I don't give medications on this side."Between 8:10 am and 9:30 am, the RN surveyor observed Staff 5. During that time frame, Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director), and Staff 20 (ALF Executive Director) were informed that Staff 5 had made multiple medication errors, was unfamiliar with the medication administration system in the MCC, and needed to either be supervised for duration of pass or pulled from the task. At 9:40 am, no assistance or oversight had been provided to Staff 5. The RN surveyor immediately informed Staff 2 and Staff 3 that Staff 5 was unsafe giving medications independently and oversight was necessary. At that time, Staff 2 assisted Staff 5 with the remainder of the medication pass. On 10/06/21 at 10:00 am, the survey team stopped survey activities and discussed the unsafe medication administration system and lack of oversight. After a telephone consultation with the Community Based Care Supervisor, the survey team informed Staff 2 and Staff 3 on 10/06/21 at 10:30 am that the facility's failure to have safe medication administration system in place and lack of adequate professional oversight constituted a situation that required an immediate plan of correction. Staff 3 presented a plan of correction on 10/06/21 at 6:00 pm. The plan indicated corrections in the following areas:* "Oversight and monitoring of staff administering medication";* "Medication administration records not being accurate and not following physician orders for medication"; and * "Facility Administration."The survey team directed Staff 3 to contact her assigned Policy Analyst and Corrective Action Coordinator. The plan was accepted by the survey team and the immediate jeopardy was abated at 6:00 pm.3. During an interview on 10/06/21 at 10:30 am, Staff 2 (RN) and Staff 3 (Regional Director) were asked to provide documentation that their medication system was approved by pharmacist consultant, registered nurse, or physician. Neither was aware of an approval. In an interview at 6:00 pm the same day, Staff 3 verified the facility did not have medication and treatment systems in place that were approved by a consultant pharmacist, registered nurse or physician. 4. Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:C 303: Systems: Medication and Treatment Orders; C 304: Systems: Medication and Treatment Review; and C 310: Systems: Medication Administration.The requirement to ensure a safe medication system and adequate professional oversight of the medication administration system was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3), and 5 unsampled residents (#s 6, 7, 8, 9 and 10) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia and depression.Resident 2's 09/2021 and 10/01-04/21 MARs and current physician's orders were reviewed.There was no documented evidence Resident 2 was administered his/her am medications on 09/17/21 including:* Aspirin 81 mg for chronic pain at 7:00 am;* Ensure Nutritional supplement for weight loss at 8:30 am and 11:30 am;* Levothyroxine Sodium 100 mcg for high blood pressure at 7:00 am; and* Sertraline 25 mg for depression at 7:00 am.The need to ensure medications were administered as ordered was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Regional Director). They acknowledged the findings.
2. Resident 3 moved into the facility in 2019. As of the survey, s/he had diagnoses which included dementia and insulin dependent diabetes.MARs for Resident 3, reviewed from 09/01/21 - 10/04/21, and observation of the morning medication administration pass on 10/06/21 revealed the following orders were not followed:* Lantus insulin 10 units once a day at 7:00 am. - Resident 3 did not receive the insulin from 09/03/21 to 09/07/21 (five days). - On 10/06/21, Resident 3 ate breakfast at 8:00 am. However, staff did not administer the insulin until after 9:00 am.* Resident 3 had an order for Metformin 500 mg 1 tablet twice a day with meals for diabetes. According to the MAR, staff gave the second dose at 8:00 pm, not with a meal as ordered. In interviews on 10/05/21 and 10/06/21, the surveyor and Staff 2 (RN) reviewed the MARs and orders. She acknowledged the insulin and Metformin had not been administered as ordered. She stated she would notify the PCP of the errors and change the administration time for the Metformin. The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director) on 10/06/21 at 4:15 pm. They acknowledged the findings.3. On 10/06/21 between 8:10 am and 9:40 am, the RN surveyor observed Staff 5 (MA) administer medications to unsampled residents #s 6, 7, 8, 9, and 10 . During the pass, Staff 5 failed to administer medications as ordered. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director) on 10/6/21. They acknowledged the findings.Refer to C 300, Example 2.


Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (# 12), whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 12 was admitted to the facility in 02/2022 with diagnoses including dementia and Parkinson's.Resident 12's 02/17/2022 though 03/04/22 MARs and current physician's orders were reviewed.The following physician ordered medications were missing from the MAR:* Rivastigmine 1.5 mg, 1 capsule two times daily; and* Simvastatin 10 mg, 1 tablet by mouth daily .During an interview on 03/03/22 with Staff 25 (RCC), the orders were reviewed and facility staff were unable to locate any orders to discontinue the medications, but were unable to determine why the current MAR was missing these medications. Staff 25 stated she would follow up with the physician to determine whether the medications should be re-started.The need to ensure medications were administered as ordered was reviewed with Staff 1 (Administrator), Staff 21 (Executive Director), and Staff 25. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment recommendations made by the registered pharmacist were reviewed or implemented. Findings include, but are not limited to:On 10/06/21, the facility provided copies of pharmacist medication reviews completed on 06/10/21 for numerous residents. The pharmacist requested further clarifications and/or made recommendations. As of the survey, there was no documented evidence the facility had reviewed and/or notified the residents' prescriber of the pharmacist recommendations.The failure to follow up on pharmacy recommendations was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director) on 10/06/21. During the interview they stated the facility failed to submit the recommendations to the prescriber for clarification and/or implementation. No further information was provided.

2. Resident 3 moved into the facility in 2019 and diagnoses which included diabetes and esophageal reflux.Resident 3's MARs, reviewed from 09/01/21 - 10/04/21, revealed the following inaccuracies:a. Resident 3 had an order for staff to check CBGs (blood sugars) "two times per day every week on Monday, Wednesday, and Friday." According to a physician's order, dated 12/16/20, staff were instructed to "notify PCP for CBGs less than 70 or greater than 400." The MARs lacked information about the CBG parameters.b. The MARs instructed staff to administer Mintox Regular Strength Oral Suspension 30 ml PRN for esophageal reflux. The MARs lacked a frequency for how often the Mintox could be administered each day. c. Between 09/01/21 and 10/04/21, staff initialed on the MARs the resident received Vitamin D3 (supplement) 50 mcg (2000 units) each day. However, there was no order for the medication in the resident's record. During an interview on 10/06/21 at 1:20 pm, Staff 1 (Administrator) and Staff 6 (MA) compared the MAR, PCP orders and medication cards. They stated the resident was not receiving the medication and staff were initialing for a medication that was not being administered. d. Resident 3 had an order for CBGs (blood sugars) twice a day every week on Monday, Wednesday, and Friday, and Lantus insulin 10 units daily. According the to MARs, staff were administering the insulin at 7:00 am, but not checking the morning CBG until 8:00 am, one hour after the insulin had been given. Staff 9 (MA) was interviewed on 10/05/21 at 3:45 pm. During the interview she stated the CBGs were checked before the insulin was given, not after as noted on the MAR. She acknowledged the MAR was inaccurate. The need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed in interviews on 10/05/21 and 10/06/21 with Staff 1, Staff 2 (RN) and Staff 3 (Regional Director). Staff 2 stated she would review the MAR and make corrections to ensure it was accurate and provided clear instruction to staff. 3. During the survey, MARs for Residents 1, 2 and 3, reviewed from 09/01/21 - 10/04/21, revealed MAs were not consistently using their own initials when administering medications.Refer to C 300, Example 1.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included specific instructions for PRN medications for 3 of 3 sampled residents (#s 1, 2 and 3) whose medications were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 01/2021 with diagnoses including hypertension and Alzheimer's disease. Review of Resident 1's 09/01/21 through 10/04/21 MAR's and physician orders revealed the following:* An order for daily blood pressure monitoring lacked parameters and instructions for staff as to when they should contact the provider or licensed nurse for readings outside of parameters; and* An order for Olanzapine 2.5 mg (to treat dementia with behavioral disturbances and hallucinations) one tablet by mouth or two tablets by mouth two times daily, lacked clear parameters as to when staff should administer one tablet versus two tablets.The lack of medication specific instructions and directions regarding when staff should contact the provider or nurse was discussed with Staff 2 (RN) on 10/06/21. She acknowledged the findings. The need to ensure Resident 1's MAR's were accurate and included clear parameters and direction to staff for medication and treatment administration was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs included all medications and treatments ordered by the provider, resident-specific parameters for PRN medications and initials of the person administering the medications for 2 of 3 sampled residents (#s 7 and 12) whose medication records were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 2015 with diagnoses including constipation. The resident's 02/2022 and 03/01 through 03/02/22 MARs and physicians orders dated 12/29/21 were reviewed and revealed the following:* There were blanks on 02/11/22 and 02/12/22 for the pm doses of Ciproloxacin eye drops with no explanation of what happened; and* There were blanks on 18 occasions between 02/04/22 and 02/28/22 for bowel tracking with no explanation of what happened. The need to ensure MARS were accurate and included the initials of the person administering the medication or tracking the required information was discussed with Staff 1 (Administrator) and Staff 3 (Regional RN) on 03/04/22. They acknowledged the findings.
2. Resident 12 moved into the facility in 02/2022 with diagnoses including dementia.Resident 12's MARs, reviewed from 02/17/22 - 03/04/22, revealed the following inaccuracies:* A physician's order on 02/23/22 for Hydroxizine, 25 mg every 6 hours, included instructions to administer it, as needed, for anxiety and at hs (hour of sleep) to assist with sleep. The February and March MARs instructed staff to offer the medication if the resident was "itching" or having a hard time falling asleep.During an interview on 03/04/22, Staff 2 (Regional RN) acknowledged the parameters and reason for use were not transcribed accurately. The need for the facility to ensure MARs were accurate was discussed with Staff 1 (Administrator), Staff 2 and Staff 21 (Executive Director) on 03/04/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:During the acuity interview on 10/04/21, the facility was home to 25 residents. Six residents were identified to require the assistance of two staff for transfer assistance. Three residents were observed to require assistance with eating during the survey. In addition to caregiving and medication duties, staff were observed to serve all meals.Review of the schedule and time cards for 09/01/21 through 10/05/21 revealed the facility had two staff scheduled for the swing shift, one MA and one caregiver, and one staff scheduled for the overnight shift, on multiple occasions. MT's were reported to not generally help with caregiving due to being busy with medication pass duties.The failure to adjust staffing levels, based on caregiving staff duties including meal service, and meeting the needs of multiple residents requiring the assistance of two staff, was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (Regional Director). They acknowledged the findings and reported the facility was attempting to hire more staff.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 16 and 18) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 10/06/21 and revealed Staff 16 (MA) and Staff 18 (MA), hired on 08/02/21 and 08/16/21 respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training.The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director) on 10/06/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month at different times of the day, evening and night shifts, and failed to include required components on fire drill records. Findings include, but are not limited to:Fire and life safety records, reviewed between 04/2021 - 09/2021, revealed the following:* Fire drills were not consistently conducted every other month at different times of the day, evening and night shifts; and * Fire drill records lacked the following components:- Location of simulated fire;- Escape route used;- Problems encountered and comments relating to residents who resisted or failed to participate in the drills; - Evacuation time-period needed; and- Number of occupants evacuated.In an interview on 10/06/21 at 3:00 pm, Staff 1 (Administrator) acknowledged the facility failed to consistently conduct fire drills on alternating months at different times of the day, evening and night shifts, and fire drill records lacked the required components.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation that fire and life safety training was provided to residents within 24 hours of move-in; * Documentation that annual fire and life safety training was provided to residents, including all required training topics; and * Alternate exit routes were used during fire drills.Additionally, staff interviewed during the survey were not aware of the designated point of safety.The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, alternate exit routes were used during fire drills, and all staff were aware of the designated point of safety was discussed with Staff 1 (Administrator) on 10/06/21 at 3:00 pm. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C231, C270, C280, C290, C303, C310, Z142 and Z162.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair, and free from unpleasant odors. Findings include, but are not limited to:Observations of the facility on 10/04/20 through 10/06/20 revealed the following areas were in need of cleaning and/or repair:* Multiple handrails, walls, window frames, doors and door frames throughout the facility were dinged, chipped, gouged, scrapped and had spills and splatters.* The common bathroom in the back of the facility was observed with damage to the wall and fecal matter on the base of the toilet and the floor on 10/04/21 and 10/05/21; * The front common bathroom lacked a doorknob, this was repaired on 10/06/21;* The carpet throughout the facility was damaged, stained, and warping in areas;* Square tables in the dining room were damaged with bare areas, chips and dings out of the table surfaces;* Multiple chairs in the dining room and living room had scraped legs, arms and/or spills and food debris; * There was a pervasive unpleasant odor throughout the unit and in Room 116 on all days of the survey; and* Multiple resident room garbage cans were observed filled with soiled incontinent products.The need to ensure the environment was kept clean and in good repair, and free from unpleasant odors was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director). They acknowledged the findings and reported the facility was scheduled for a remodel.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:During a walk-through of the facility on 10/04/21 at 1:45 pm, multiple exit doors were found to have no working audible alarm or system in place to alert staff when a resident exited the building.The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited was discussed with Staff 1 (Administrator) on 10/04/21. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:The licensee is responsible for the operation of the Memory Care Community and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision, training, and overall conduct of the staff.During the re-licensure survey, conducted 10/04/21 through 10/06/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the citations issued during the survey. 1. A situation was identified which constituted an immediate plan of correction to residents' health and safety in the following areas:OAR 411-054-0055 (1)(a) Systems: Medications and Treatments.The facility put immediate plans of correction in place during the survey and the situation was abated. 2. Refer to deficiencies in the report.

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, C 231, C 240, C 360, C 372, C 420, C 422, C 513, and C 555.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C231 and C455.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 16, and 18) completed all required pre-service dementia training and 30-day competency demonstration. Findings include, but are not limited to:A review of staff training records revealed:1. Staff 8 (CG) and Staff 18 (MA), were hired 08/02/21 and 08/16/21. Staff 8 and 18 completed the required six hours of department approved pre-service dementia training on 08/10/21 and 09/14/21, not prior to providing care or services to residents.There was no documented evidence they had completed the following elements of the required dementia training prior to performing any job duties: * Family support and the role the family may have in the care of the resident;* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and* Use of supportive devices with restraining qualities in memory care communities.2. There was no documented evidence that Staff 16 (MA), hired 08/20/21, signed a written job description and completed the required pre-service dementia training. 3. There was no documented evidence Staff 8, Staff 16, and Staff 18, demonstrated competency in their job duties within 30 days of hire in the following areas:* The role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting;and* General food safety, serving and sanitation.The facility's failure to ensure staff completed all required training in a timely manner was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director) on 10/06/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. An unsafe medication system requiring immediate correction was identified during the survey. Findings include, but are not limited to:Refer to C 252, C 260, C270, C 280, C 290, C 300, C 303, C 304, and C 310.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C270, C280, C290, C303 and C310.