Pacific Grove Senior Living Community

Based on observation, interview, and record review, conducted during a site visit on 02/07/24 through 02/15/24, it was confirmed the facility failed to ensure a safe medication system for a resident who was evaluated as unable to self-administer his/her own insulin for 1 of 1 sampled resident (# 1). Resident 1 was unable to administer his/her own insulin and was hospitalized on 02/10/24 for high blood sugars. Resident 1 was diagnosed with Type 1 diabetes and had experienced a decline in his/her vision. Resident 1 returned the facility on 02/07/24 from a skilled nursing facility. On 02/09/24, Resident 1 was observed getting instruction from Staff 4 (RN) on insulin administration. Resident 1 was able to administer his/her own insulin with the instructions of the RN providing visual assistance. An interim service plan, dated 02/07/24, indicated Resident 1 " Returned from skilled nursing today without [his/her] insulin pump and is unable to administer [his/her] own insulin safely. " A self-medication administration evaluation, completed by the facility RN on 02/09/24, indicated Resident 1 was unable to safely administer his/her own insulin. Resident 1 continued to administer his/her own insulin after s/he had been evaluated as unable to do so. The facility failed to follow up with the nursing evaluation and obtain an order for staff to administer his/her insulin. On 02/10/24, at approximately 10:10 am, Resident 1 was found by Compliance Specialists in his/her wheelchair, slouched facing the wall. Resident 1 was unresponsive and difficult to rouse. Compliance Specialists witnessed Resident 1 attempt unsuccessfully to check his/her own blood sugar. Compliance Specialists notified staff. Staff 7 (MT) was able to check Resident 1 ' s blood sugar level at approximately 10:47 am. Resident 1 ' s blood sugar was 537, above normal parameters.Resident 1 was sent to the emergency department, admitted to the hospital, and had not returned to the facility as of 02/15/24. On 02/14/24, at approximately 4:03 pm, 5:03 pm, and 6:54 pm, the Compliance Specialists requested an immediate plan of correction in the event Resident 1 returned to the facility. On 02/14/24 at approximately 8:54 pm, Compliance Specialists received a plan of correction. The plan of correction related to Resident 1 ' s insulin administration was accepted at 9:17 pm. It was determined the facility failed to ensure a safe medication system when Resident 1 was unable to self-administer his/her own insulin. Resident 1 was found unresponsive and hospitalized on 02/10/24 for high blood sugars. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Campus Director), Staff 2 (Memory Care Director), and Staff 3 (Regional Operations Director) on 02/15/24.

Based on observation, interview, and record review, conducted during a site visit on 02/07/24 through 02/15/24, it was confirmed the facility failed to ensure a safe medication system for a resident who was evaluated as unable to self-administer his/her own insulin for 1 of 1 sampled resident (# 1). Resident 1 was unable to administer his/her own insulin and was hospitalized on 02/10/24 for high blood sugars. Resident 1 was diagnosed with Type 1 diabetes and had experienced a decline in his/her vision. Resident 1 returned the facility on 02/07/24 from a skilled nursing facility. On 02/09/24, Resident 1 was observed getting instruction from Staff 4 (RN) on insulin administration. Resident 1 was able to administer his/her own insulin with the instructions of the RN providing visual assistance. An interim service plan, dated 02/07/24, indicated Resident 1 " Returned from skilled nursing today without [his/her] insulin pump and is unable to administer [his/her] own insulin safely. " A self-medication administration evaluation, completed by the facility RN on 02/09/24, indicated Resident 1 was unable to safely administer his/her own insulin. Resident 1 continued to administer his/her own insulin after s/he had been evaluated as unable to do so. The facility failed to follow up with the nursing evaluation and obtain an order for staff to administer his/her insulin. On 02/10/24, at approximately 10:10 am, Resident 1 was found by Compliance Specialists in his/her wheelchair, slouched facing the wall. Resident 1 was unresponsive and difficult to rouse. Compliance Specialists witnessed Resident 1 attempt unsuccessfully to check his/her own blood sugar. Compliance Specialists notified staff. Staff 7 (MT) was able to check Resident 1 ' s blood sugar level at approximately 10:47 am. Resident 1 ' s blood sugar was 537, above normal parameters.Resident 1 was sent to the emergency department, admitted to the hospital, and had not returned to the facility as of 02/15/24. On 02/14/24, at approximately 4:03 pm, 5:03 pm, and 6:54 pm, the Compliance Specialists requested an immediate plan of correction in the event Resident 1 returned to the facility. On 02/14/24 at approximately 8:54 pm, Compliance Specialists received a plan of correction. The plan of correction related to Resident 1 ' s insulin administration was accepted at 9:17 pm. It was determined the facility failed to ensure a safe medication system when Resident 1 was unable to self-administer his/her own insulin. Resident 1 was found unresponsive and hospitalized on 02/10/24 for high blood sugars. The findings of the investigation were reviewed with and acknowledged by Staff 1 (Campus Director), Staff 2 (Memory Care Director), and Staff 3 (Regional Operations Director) on 02/15/24.

The findings of the re-licensure survey, conducted 05/08/23 through 05/11/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.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 revisit to the re-licensure survey of 05/11/23, conducted 11/06/23 through 11/09/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.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 revisit to the re-licensure survey of 05/11/23, conducted 12/28/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.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 third revisit to the re-licensure survey of 05/11/23, conducted on 08/26/24, 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 and OARs 411 Division 004 for Home and Community Based Services Regulation.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the re-licensure survey conducted 05/08/23 through 05/11/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.Refer to deficiencies in report.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to: On 05/09/23 the survey team conducted a group interview with facility residents. During the interview multiple residents expressed complaints about the facility including experiencing long call light response times, residents feeling unsafe in the facility due to facility doors being unlocked or propped open after business hours and lack of resolution from administration. In an interview on 05/10/23, Staff 1 (ED) confirmed knowledge of resident complaints regarding long call light response times. When asked how the facility resolved the grievances, Staff 1 reported she conducted audits of the facility's call system periodically. During an interview, Staff 1 was unaware of how the facility's call system reported wait times.In an interview on 05/11/23, Staff 1 confirmed knowledge of resident complaints of feeling unsafe in the facility in the evenings, when the entrance doors to the facility were unlocked or propped open and there was no one assigned to the front desk including welcoming visitors. When asked how the facility resolved resident grievances regarding this issue Staff 1 responded, "we talked about it in our town hall meetings...I've provided education to the residents" and "to me this issue is resolved." "Manager, Family and Resident Townhall Meeting Minutes" dated 02/17/23, 03/17/23 and 04/20/23 were reviewed. The meeting minutes lacked documentation of resolution to agenda topics for previous months. The facility lacked documented evidence that resident complaints were responded to and resolution was reached related to long call light response times and safety in the facility.The need to ensure the facility implemented effective methods of responding to and resolving resident complaints was discussed with Staff 1 on 05/11/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents had a safe and homelike environment, were kept free from verbal abuse, were treated with dignity and respect and were able to voice grievances and suggest changes in policies and services to staff and outside representation without the fear of retaliation. Multiple residents expressed concerns and distress related to dignity and safety concerns and poor treatment from facility staff. Findings include, but are not limited to:1. In a group interview conducted on 05/09/23 at 11:00 am, and in various one on one interviews, facility residents made the following statements:* "[Staff 1 (ED)] has humiliated me in front of other residents many times.";* "I am scared to say anything.";* "[Staff 1] called me a druggie.";* "[Staff 1] yells at us, she has yelled at me.";* "[Staff 1] told me 'I'm tired of you, I want you to leave.'";* "He [Dietary Staff] called me a mother-f....r.";* "[Staff 1] pointed her finger in my face.";* "[Staff 1] is a bully.";* "[Staff 1] disrespects me.";* "I am too scared to ask again."; * "I feel unsafe around [Staff 1]";* "[Staff 1] said 'I can tell your caseworker that you want to move.'"* "[Staff 1] treats us like we don't matter.";* "[Staff 1] goes out of her way to ignore requests to meet and to get any kind of problem actually addressed.";* "[Staff 1] just wants me gone and tells me I am liar anytime I bring up a concern."* "I'm scared that she will know I said anything."; and* "The staff have tried to stand up for residents and they are treated just as bad."During a 05/11/23 interview, Staff 1 stated "there are a group of residents who are out to get me" and "this has happened before." 2. During the group interview, multiple residents expressed concern regarding the facility's laundry service and security at the front entrance. a. During an interview on 05/09/23, Witness 13 [Resident] was observed to have piles of soiled laundry on the bedroom and bathroom floors and the persuasive odor of urine throughout the unit. Witness 13 reported facility staff had not laundered his/her clothing and linens within a period of two weeks. During an interview on 05/09/23, Witness 9 [Resident] was observed to have a large pile of soiled laundry on the bathroom floor and a pervasive unpleasant odor in the room. Witness 9 reported facility staff had not laundered his/her clothing and linens within a period of one month.In an 05/10/23 interview, Staff 12 (CG) stated she was unaware of where to locate the laundry schedule which indicated when staff should launder specific resident's clothing and linens.b. Throughout the survey, multiple residents expressed concerns regarding the facility's front entrance being unlocked and open to the public in the evening without anyone assigned to consistently monitor the area.During interviews with non-sampled residents, residents made the following statements:* "I do not feel safe.";* "They found a homeless man sleeping in the stairwell.";* "I brought it to Staff 1 several times, she doesn't do anything.";* "Anyone could come in here, staff are busy working and don't know when people come in"; and* "This is the most unsafe I've felt in years."In an 05/11/23 interview Staff 1 relayed the facility policy was to lock the facility to the public at 9:00 pm nightly. When asked to confirm the resolution to the resident's safety concerns Staff 1 stated "I've provided education to the residents" and "To me this issue is resolved." The facility's failure to ensure residents were treated with dignity and respect, were free from verbal abuse, had a safe and home-like environment and were free to voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation negatively affected residents causing undue stress and fearfulness and was in violation of resident rights. The facility's failure to ensure resident's rights were protected was discussed with Staff 1 and Staff 26 (Corporate Director of Operations) on 05/11/23. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure nutritious and palatable meals were provided and failed to maintain infection prevention and control protocols to provide a safe and sanitary environment in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:During a group interview on 05/09/23 and in multiple one on one interviews throughout the survey, residents voiced the following concerns regarding the facility's dietary services:* "The food is always cold";* "The food is terrible";* "I get meal trays, they run out of food in the dining room, so we get very little on our trays"; and* "Caregivers do not wear aprons when they serve our food, what if someone vomited all over their shirt? I do not want that near my food."During meal observations on 05/08/23 and 05/10/23 of the lunch meals, direct care staff were observed walking in and out of the facility kitchen and serving meals to residents seated in the dining room. The direct care staff, who also provided ADL cares such as bathing, toileting and incontinent care to residents prior to the meal service, did not wear aprons or other protective barriers over their clothing during the meal service.In a 05/10/23 interview, Staff 8 (Dietary Services Manager) confirmed there were no clean aprons available for the direct-care staff to wear while serving the meal. Staff 8 stated he was unaware of the facility's procedure for laundering the aprons. On 05/10/23 lunch consisted of chicken and dumplings and a salad and a sample tray was requested. The meal was served in a plastic clamshell food container and was retrieved from the delivery cart directly after the last room tray was delivered. The serving portion of the chicken and dumplings appeared to be less than one quarter of a cup. The chicken and dumplings were cool with a temperature of 97.6 degrees and had a gelatinous texture. The need to ensure the facility served nutritious and palatable meals and maintained infection control practices to provide a safe and sanitary environment in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED) on 05/11/23. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure nutritious and palatable meals were provided and failed to maintain infection prevention and control protocols to provide a safe and sanitary environment in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:a. Observation of lunch on 11/07/23 in the dining room revealed the following:* Three cooks and/or servers with beards lacked coverings for their facial hair; and* Resident 9's clinical record was reviewed and s/he had a signed physician's order, dated 11/18/21, for a mechanical soft diet. Resident 9 was served cut up pieces of lemon pepper chicken, cooked spinach, a roll and Jello with whipped cream. Upon inspection by a surveyor (Speech Pathologist) of a sample tray with the same food (excluding the rice and Jello), it was determined the chicken and spinach were not considered mechanical soft. An interview on 11/09/23 at 1:40 pm with Staff 35 confirmed that he provided Resident 9 with his meal that day and acknowledged the chicken was not mechanical soft and the spinach needed to be chopped up.b. Observation of meal tray delivery and the process revealed the following: * On 11/07/23 two servers participated in delivering meals to residents eating in their apartments. At 1:20 pm a meal tray was left in a resident's apartment with the server noting that the resident was not there and the meal tray was left on the counter. The surveyor asked what the process was for delivering food to residents who were not present at time of delivery. S/he stated, "It depends on the preferences of the resident." This surveyor requested the food either be put in the resident's fridge or returned to the kitchen to avoid a potential for foodborne illnesses. The server complied.* A sample tray was retrieved from the delivery cart directly after the last room tray was delivered and was served in a plastic clamshell food container with plastic cutlery. The serving portion of the lemon pepper chicken was rubbery, dry, pale, tough and cool, with a temperature of 93.4 degrees Fahrenheit. The spinach was stringy and greyish-green in color, with a temperature of 99.1 degrees Fahrenheit.* On 11/08/23 this surveyor observed the process for residents who eat in their apartments. Observations identified that, with the exception of one resident who was offered broth because s/he was not feeling well, residents eating in their apartments were not offered an alternative menu and were only asked if they wanted to eat what was being served as the special for that meal. In an interview on 11/08/23 at 1:20 pm with Staff 36 (Dietary Manager), he confirmed the current process for meal delivery did not allow for residents to choose an alternate food option if they didn't like the food of the day. He stated, "The new process is to planned to order new domes for the plates that will be served to residents who eat in their apartments but "they have not been ordered yet."* On 11/08/23 the dessert for lunch was ice cream. An interview on 11/08/23, Staff 23 (CG) revealed the facility frequently did not have enough desserts for the residents who ate in their room "so they don't get a dessert. I also don't know how you would deliver ice cream." An interview on 11/09/23 with Staff 35 (Cook) confirmed they often do not have enough dessert for the residents who receive meals in their apartments.The need to ensure meals were nutritious and palatable, modified special diets were appropriate for residents' needs and choices, menus were available to all residents, and infection control practices were followed and maintained in accordance with the Food Sanitation Rules was discussed with Staff 29 (Interim ED) on 11/09/23. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to provide assistance with activities of daily living for 1 of 4 sampled residents (#2) who required ADL care. Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2021 with diagnoses including chronic pain.The service plan dated 02/16/23, indicated the following:* The resident "has frequent falls where (s/he) is unable to get (himself/herself) up. Staff are to call non-emergency for lift assistance." * The resident was noted to be alert and oriented to person, place, time and situation. The resident was able to direct his/her own care, understand others and make himself/herself understood. * The resident sporadically refused assistance offered by staff with ADL care and room clean up.Observations and interviews of the resident and interviews with staff from 05/08/23 through 05/11/23 showed:* The resident was independent with most ADL care, could utilize the call light for assistance and make his/her needs known. The resident had chronic significant pain, moved slowly when using his/her walker and utilized an electric wheelchair as his/her primary transportation. * Resident 2 indicated there were several occasions when s/he had fallen and could not get off the floor. S/he called the fire department for help once on his/her own, because no staff responded to the call light. The resident stated there were other falls in which the facility called the fire department for help to get him/her up.* Staff 10 and 11 (CGs) and Staff 15 and 25 (MTs) indicated when Resident 2 experienced a fall they were to call the paramedics/fire department to get the resident off the floor. The staff were unsure how many facility staff it would take to get the resident up, as it had not been attempted. In interview on 05/11/23, Staff 1 (ED) indicated the facility provided only one person assistance for residents. Staff were to call for assistance from outside the facility to help Resident 2 in the event of a fall. Staff 1 acknowledged an evaluation of the specific transfer assistance the resident required after a fall had not been completed. The need to ensure resident transfer assistance was provided as needed by facility staff was discussed with Staff 1, Staff 2 (LPN), Staff 4 (RN) and Staff 16 (Operation Specialist) on 05/11/23. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and were followed by staff for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 02/2021 with diagnoses including chronic pain and depression. Observations of the resident, interviews with staff, review of interim service plans for the last 60 days and review of the service plan, dated 02/16/23, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Transfer assistance;* Wounds and skin issues;* Self administration of medications and location of insulin;* Emotional distress and outbursts;* Falls;* Side rails and what to watch for;* Cleaning of the resident's apartment;* Behaviors including manipulation, accusations, yelling and refusal of care/assistance; and* Incontinent care, toileting assistance related to refusals and behaviors.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 3 (RN) and Staff 16 (Operations Specialist) on 05/11/23. The staff acknowledged the findings.2. Resident 4 was admitted to the facility on 03/2023 with diagnoses including dementia and weakness.Observations of the resident, interviews with staff, review of 60 days of interim service plans and review of the service plan, dated 04/21/23, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Bedbound incontinent care;* Bed mobility and repositioning;* Fluctuation in resident ability to assist with ADL care;* Side rails and what to watch for; and* One vs two staff assistance for ADL care and bed mobility;The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 3 (RN) and Staff 16 (Operations Specialist) on 05/11/23. The staff acknowledged the findings.
3. Resident 3 was admitted to the facility in 02/2021 with diagnoses including dementia. During the acuity interview on 05/08/23, Resident 3 was identified to have weight loss. Observations, interviews, and review of the current service plan, dated 02/10/23, and interim service plans showed the service plan had not been updated as needed when the resident experienced a significant change of condition and did not provide clear direction to staff in the following areas: * Weight loss and interventions.The need to ensure Resident 3's service plan was updated and provided clear direction to staff was discussed with Staff 1 (ED), Staff 4 (RN) and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings. 4. Resident 5 was admitted to the facility in 09/2021 with diagnoses including major depressive disorder.Observations and interviews with the resident, and a review of the resident's 03/07/23 service plan and interim service plans, indicated the service plan failed to reflect the resident's current care needs and lacked clear directions to staff in the following areas: * Behavioral safety plan instructions, including how often staff need to check on the resident. The need to ensure service plans were reflective of the resident's current needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 4 (RN) and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings.
5. Resident 1 was admitted to the facility in 8/2022 with diagnoses including chronic heart failure.Observations of the resident, interviews with staff, review of interim service plans for the last 90 days and review of the service plan, dated 02/08/23, revealed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Memory status;* Sensory/Communication status, including hearing aid and glasses use;* Ambulation/Mobility status;* Fall interventions;* Dietary/Eating, including food likes and dislikes, chewing ability, fluctuating appetite, and fluctuating self-feeding ability; and* Assistive devices, including use of walker, wheelchair and a hospital bed.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (RN), and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings.


Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care, and/or services were implemented for 1 of 4 sampled residents (# 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 9 was admitted to the facility in 02/2021 with diagnoses including epilepsy and traumatic brain injury.Resident 9's service plan, updated 10/01/23, interim service plans, and facility charting notes dated 08/19/23 through 11/02/23 were reviewed. Interviews with care staff, the resident, and the resident's family were conducted, and observations were made. The service plan was not reflective of the resident's care needs and lacked specific instruction to staff in the following areas:* Use of a CPAP machine (air pressure to keep breathing airways open while sleeping);* Escort assistance in manual wheelchair;* Transfer pole and it's position in relation to the recliner; and * Lighting in the bathroom.The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 29 (Interim ED) and Staff 2 (LPN) on 11/09/23. They acknowledged the findings.



Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care, and/or services were implemented for 1 of 2 sampled residents (# 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 9 was admitted to the facility in 02/2021 with diagnoses including epilepsy and traumatic brain injury.Resident 9's service plan, updated 10/01/23, interim service plans, and facility charting notes dated 12/24/23 through 12/27/23 were reviewed. Interviews with care staff, the resident, and the resident's family were conducted, and observations were made. The service plan was not reflective of the resident's care needs, lacked specific instruction to staff and was not implemented in the following areas: * Use of a CPAP machine (air pressure to keep breathing airways open while sleeping);* Escort assistance in manual wheelchair;* Transfer pole and it's position in relation to the recliner; and * Lighting in the bathroom.The need to ensure service plans were reflective of current care needs, implemented and provided clear direction to staff was discussed with Staff 39 (Campus Director) on 12/28/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition had resident-specific instructions or interventions developed, and that weekly progress on the condition was documented for 1 of 5 sampled residents (#2) who experienced changes of condition. Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2021 with diagnoses including chronic pain and depression. The resident's 02/16/23 service plan, 02/08/23 through 05/08/23 progress notes, interim service plans and physician communications were reviewed. The resident experienced multiple short-term changes without weekly progress noted until resolution and/or lacked resident-specific directions for staff in the following areas:* Leg cramps and leg pain;* Abrasions, scabbed areas and rashes;* ER trips, genital bleeding and significant pain;* Medication and treatment changes; and* Multiple behaviors and accusations towards the facility.The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 3 (RN) and Staff 16 (Operations Specialist) on 05/11/23. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 02/2021 with diagnoses including chronic obstructive pulmonary disease.During the survey, Resident 3's records were reviewed and staff were interviewed about his/her care needs. During the acuity interview on 05/08/23, the resident was identified as receiving outside services from hospice. There was no documentation regarding what care the resident was receiving from hospice, if there were any new recommendations, if the service plan required adjustment, and no documented evidence the facility had coordinated care regarding any supplemental care that needed to be provided.The need to ensure the facility had a system to ensure outside providers left documentation regarding the services being provided was discussed with Staff 1 (ED), Staff 4 (RN) and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 09/2021 with diagnoses including major depressive disorder. During the acuity interview on 05/08/23, Resident 5 was identified to receive mental health services from an outside provider. The facility was unable to provide evidence of the outside provider visits and any documentation of recommendations that were made. The need to coordinate care with outside providers and ensure visit notes were maintained onsite and reviewed by staff was discussed with Staff 1 (ED), Staff 4 (RN) and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure coordination of on-site health services with outside providers, facility management or licensed nurse was notified of the services provided by the outside provider, facility nurse reviewed the resident's health related service plan changes made as a result of the provision of on-site health services and outside service providers left written information in the facility that addressed the on-site service being provided to the resident and any clinical information necessary for staff to provide supplemental care for 3 of 6 sampled residents (#s 1, 3 and 5) who were identified as receiving outside services. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 8/2022 with diagnoses including heart attack, hypertension, and chronic heart failure. S/he was identified during the acuity interview as receiving outside services since 12/2022 related to palliative care.a. Review of the resident's clinical record revealed one outside provider note from palliative care between 2/1/23 and 5/8/23. During an interview on 05/09/23 at 10:20 am, Staff 2 (LPN) stated Resident 1 was visited by palliative care "one to two times a week," and that the facility did not have any additional notes or other information from those visits.b. Review of the resident's 04/2023 MAR revealed s/he was started on quetiapine (for behavioral disorders associated with dementia) by the palliative care physician on 04/25/23. During interviews on 05/09/23 at 10:00 am and 10:20 am, respectively, Staff 4 (RN) and Staff 2 stated they were unaware the resident was started on this medication.c. A progress note regarding a visit from the palliative care RN on 05/03/23 was requested by survey. During an interview on 05/09/23 at 10:20 am, Staff 2 stated there was no note in the facility for this visit. Staff 2 requested the visit note and provided it to survey. Recommendations from that note included: "one to one feeding assistance and assistance with hygiene ...more assistance with [his/her] meals, hygiene, and comfort level bases." There was no documented evidence the facility management or licensed nurse had been notified by the outside provider to ensure staff were informed of new interventions and that the service plan was adjusted if necessary.The need to ensure coordination of on-site health services with outside providers and that staff received pertinent information regarding changes in care was reviewed with Staff 1 (ED), Staff 2, Staff 4 and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:During the relicensure survey, conducted 05/08/23 through 05/11/23, the facility failed to ensure a safe medication and treatment system and administrative oversight was found to be ineffective based on deficiencies in the following areas:C 290 (1b): Resident Health Services: On- and Off-Site Health Services;C 302: Systems: Tracking Controlled Substances; andC 303: Systems: Medication and Treatment Orders.Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 05/11/23.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility in 02/2021 with diagnoses including chronic pain and depression. Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 04/04/23 included the following order:* Hydrocodone-acetaminophen 5-325, give ½ - 1 tablet by mouth every four hours PRN for pain, maximum of two tablets per day. The order did not include instructions on when to use ½ tab vs a full tab, nor did it indicate the resident could self-direct administration. The April 2023 MAR reflected the order and indicated a ½ tablet was for pain between 4 and 6. The resident's Controlled Substance Disposition logs and MARS, reviewed from 04/01/23 through 05/09/23 showed the following:* On 04/01/23 two doses were signed as administered on the MAR, but only one was documented on the disposition logs;* On 04/02/23 the resident received two doses of a half tab within four minutes of each other without information as to pain level or what occurred;* On 04/04/23 two doses were signed as administered on the MAR, but only one was documented on the disposition log;* On 04/09/23 a full tablet was administered but no information was noted related to pain level or why a full tab was given instead of a half tablet;* On 04/14/23, two doses were signed as administered on the disposition log, but only one was noted on the MAR;* On 04/20/23 a full tablet was administered but no information was noted on the resident's pain level or why a full tablet was given vs a half tablet;* On 04/22/23 one dose was signed as administered on the MAR, but was not on the disposition log;* On 04/23/23, two doses were signed as administered on the MAR, but was not on the disposition log;* On 04/25/23, one dose was signed as administered on the MAR, but was not on the disposition log;* On 04/27/23, one dose was signed as administered on the MAR, but was not on the disposition log;* On 04/28/23, two doses were signed as administered on the MAR, but were not noted on the disposition log;* On 04/29/23, one dose was signed as administered on the MAR, but was not on the disposition log;* On 04/30/23, one dose was signed as administered on the MAR, but was not on the disposition log; and * On 05/01/23, one dose was signed as administered on the MAR, but was not on the disposition log.Comparison of the medication bubble packs to the disposition logs, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (ED) and Staff 4 (RN) on 05/11/23. The staff acknowledged the findings.

3. Resident 2 was admitted to the facility in 04/2022 with diagnoses including chronic pain and rheumatoid arthritis. The resident's 02/08/23 through 05/08/23 progress notes, 04/04/23 physician orders, 04/04/23 through 05/10/23 physician communications, and the 04/01/23 through 05/08/23 MAR/TAR were reviewed.During the acuity interview on 05/08/23, the resident was identified to self-administer only his/her insulin. In subsequent interviews with Staff 15 (MT) and Staff 25 (MT), they indicated the resident self-administered his/her own insulin and facility staff did the rest.In interviews on 05/08/23 and 05/09/23, Resident 2 indicated s/he self-administered only his/her Nystatin cream and both insulins. The resident showed the surveyor where s/he kept these items and the extra supplies. The resident denied s/he had any additional medications or treatments in his/her room.The 04/04/23 physician orders and 04/01/23 through 05/08/23 MARs/TARs showed the following:* An order for Omeprazole 40 mg, give two tablets by mouth every morning before breakfast for heartburn. The MARs reflected staff were to administer Omeprazole 40 mg, give one tablet every morning.* Glucose Gel 40%, administer PRN for blood sugars less than 70 and resident awake. The MARs did not reflect the order for staff to administer this medication.* Hydroxyzine HCL 25 mg, give one tablet by mouth three times a day PRN for anxiety or itching. The order indicated the resident self-administered the medication. The MARs did not reflect an order for staff to administer this medication. * Rizatriptan Benzoate 10 mg tablet, give one tablet by mouth PRN for migraines. The order indicated the resident could self-administer and keep at bedside. The MARs did not reflect an order for staff to administer this medication.* Loperamide, give two capsules by mouth once a day PRN for first loose stool and one capsule PRN for additional loose stools. The MARs did not reflect an order for staff to administer this medication.* Calazime Skin Protectant Paste, apply Calazime three times daily PRN to sacral area. The order indicated the resident could self-administer and keep at bedside. The MARs did not reflect an order for staff to administer this treatment.The need to ensure the facility administered all medications and treatments as ordered by the physician was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (RN) and Staff 16 (Operations Specialist) on 05/11/23. The staff acknowledged the findings.4. Resident 4 was admitted to the facility in 03/2023 with diagnoses including chronic pain. The resident's 03/18/23 through 05/08/23 progress notes, 03/16/23 physician orders, 03/16/23 through 05/10/23 physician communications, and the 04/01/23 through 05/08/23 MAR/TAR were reviewed.The 04/04/23 physician orders and 04/01/23 through 05/08/23 MARs/TARs showed the following:* Lyrica 100 mg caplets, give twice a day for chronic pain.* The MARs showed the resident received the Lyrica 100 mg caplets, three times a day from 03/18/23 to 04/05/23.* The resident only one dose of the Lyrica on 04/07/23, 04/08/23 and 04/11/23.* The resident received zero doses of the prescribed Lyrica on 04/09/23 and 04/10/23.A fax to the physician was sent on 04/07/23 which indicated the resident was out of his/her Lyrica due to the wrong dosage being given at the facility. Staff requested a refill as soon as possible for the resident. The medication was noted as twice a day beginning on 04/12/23. The need to ensure the facility administered all medications and treatments as ordered by the physician was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (RN) and Staff 16 (Operations Specialist) on 05/11/23. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose orders were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted in 02/2021 with diagnoses including chronic obstructive pulmonary disease and high cholesterol. Resident 3's MARs from 04/01/23 through 05/08/23 and physician orders were reviewed and showed the following:* An order for acetaminophen (for pain) 325 mg, two tablets at 8 am, 2 pm and 8 pm. There was no documented evidence on the MAR the medication was administered on 04/12/23, 04/13/23 and 04/18/23 at 2pm;* Atorvastatin (for high cholesterol) 20 mg, one tablet at bedtime. The order transcribed onto the MARs instructed staff to administer the medication at 8 am; * Divalproex (for panic disorder) 250 mg, one tablet at 8 am, 12 pm and 8 pm. There was no documented evidence on the MAR the medication was administered on 04/02/23 and 04/12/23 at 12 pm; and* Gabapentin (for back pain) 300 mg, one capsule at 8 am, 12 pm and 8 pm. There was no documented evidence on the MAR the medication was administered on 04/02/23 and 04/12/23 at 12 pm. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 4 (RN) and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 09/2021 with diagnoses including major depressive disorder. Resident 5's MARs from 04/01/23 through 05/08/23 and physician orders were reviewed and showed the following:*An order for acetaminophen (for pain) 500 mg one tablet every six hours as needed for pain. The order transcribed onto the MARs instructed staff to administer two tablets every six hours as needed for pain. During an interview on 05/11/23, Staff 4 (RN) confirmed the medication order was transcribed incorrectly.The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 4 and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings.
5. Resident 1 was admitted to the facility in 08/2022 with diagnoses including hypertension. Resident 1's 04/01/23 through 05/08/23 MARs and signed physician orders dated 03/08/23 were reviewed and identified the following:* The physician's order for hydralazine (for high blood pressure) three times per day included parameters to hold the medication if the resident's systolic blood pressure was less than 120. On 04/07/23, 04/12/23, 04/13/23, 04/14/23, and 04/18/23, the resident had a systolic blood pressure reading below 120, and staff administered the medication when it should have been held; and* The physician's order for losartan (for high blood pressure) one time per day included parameters to hold the medication if the resident's systolic blood pressure was less than 120. On 04/02/23, 04/23/23, and 05/12/23, the resident had a systolic blood pressure reading below 120 and staff administered the medication when it should have been held.The need to ensure the facility administered all medications and treatments as ordered by the physician was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (RN) and Staff 26 (Director of Operations) on 05/11/23. The staff acknowledged the findings.


Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in residents' records for all medications and treatments provided by the facility, that residents' MARs reflected these orders, and the orders were carried out as prescribed for 4 of 5 sampled residents (#s 2, 7, 9 and 10) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility 02/2021 with diagnoses including epilepsy, hypertension, and congestive heart failure. Review of Resident 7's MAR, dated 10/01/23 through 11/06/23, and current physician orders identified the following deficiencies:There were no written, signed orders for the following medications on the resident's MAR:* Acetaminophen 325 mg PRN (for pain or fever);* Hydrocodone 5 mg/ acetaminophen 325 mg PRN (for pain);* Lyrica 50 mg (for symptomatic epilepsy); and* ZEASORB AF (anti-fungal)There was no documentation on the resident's MAR for the following ordered medications:* Apixaban 5 mg (anticoagulant);* Cyclobenzaprine 10 mg PRN (for muscle spasm);* Dextromethorphan 10 mL PRN (for cough);* Diclofenac gel 1% PRN (for moderate pain);* Docusate sodium 100 mg (bowel health);* Geri-kot tab 8.6 mg (bowel health);* Lactulose 10 gm/15mL PRN (for constipation); and* Polyethylene glycol 3350 PRN (for constipation)In an interview on 11/08/23, Staff 5 (Med Room Manager) confirmed the orders provided were the most current signed set, and there were no other subsequent individual medication orders.On 11/09/23, the need to ensure written, signed orders were documented for all medications and treatments provided by the facility, that residents' MARs reflected these orders was discussed with Staff 2 (LPN) and Staff 29 (Interim ED). They acknowledged the findings.
3. Resident 9 was admitted to the facility in 02/2021 with diagnoses including epilepsy and traumatic brain injury.Resident 9's 10/01/23 through 11/06/23 MARs and physician orders were reviewed. The following was identified:*An order for acetaminophen (for pain) 325 mg two tablets every four hours as needed for pain. The order transcribed onto the MARs labeled acetaminophen as "650 mg" tablets and instructed staff to administer two tablets (650mg) every four hours as needed for pain 1-4/10; *An order for selenium sulfide (for dry scalp) apply up to three times per week during showers as needed for dandruff and dry scalp. The order transcribed onto the MARs instructed staff to apply up to three times per week and one time during showers as needed; and *Divalproex sodium (for epilepsy) 500 mg, two tablets at 8:00 am and 8:00 pm. There was no evidence that the medication was given on 10/14/23 at 8:00 pm. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 29 (Interim ED) and Staff 2 (LPN) on 11/09/23. They acknowledged the findings.4. Resident 10 was admitted to the facility on 02/2021 with diagnoses including hypertension.Resident 10's 11/01/23 through 11/08/23 MAR was reviewed and showed the following:* An order for metoprolol tartrate (for abnormal heart rhythm) 25 mg two tablets at 8:00 am and one tablet at 8:00 pm. Records indicated Resident 10 missed his/her 8:00 pm dose on 11/06/23 and the 8:00 am doses on 11/07/23 and 11/08/23 because "medication unavailable." The resident did receive his/her 8:00 pm dose on 11/07/23. The MAR indicated the medication was unavailable.In an interview on 11/08/23 at 2:40 pm with Staff 38 (MT), she stated that Resident 10 received his/her 8:00 pm dose on 11/07/23 but not on 11/06/23 because the medication cart was "so full" on 11/06/23 from a cycle fill delivery that the medication could not be located. After the cart was organized the medication was found and Resident 10 received the medication for the 8:00 pm dose on 11/07/23. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 29 (Interim ED) and Staff 2 on 11/09/23. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 06/2014 with diagnoses including depression, anxiety, and diabetes.A review of the resident's clinical record, including progress notes dated 08/10/23 through 11/06/23, 10/01/23 through 11/06/23 MARs, and current physician orders was completed, and staff were interviewed. The following deficiencies were identified:a. Resident 2 had an order for cephalexin (an antibiotic) 500 mg, two capsules two times a day for 10 days. The 10/2023 MAR indicated the following:* The medication was entered on the MAR for one capsule two times daily, and the resident was administered only one capsule on 10/19/23 and once on 10/20/23. At that time the order was entered on the MAR again and the resident received the evening dose of the medication on 10/20/23; and* The MAR indicated the resident did not receive the medication at all on 10/28/23 and 10/29/23 and only one administration on 10/30/23.In an interview on 11/07/23, Staff 5 (Med Room Manager) reported the "home office" had audited the MAR and made a change staff were not aware of. A progress note on 11/01/23 written by Staff 5 indicates when the home office made the change "the days were not transferred over." She stated the resident did receive the remainder of the antibiotic.b. The resident had a physician order for cyclobenzaprine (a muscle relaxer) 5 mg once a day as needed for muscle spasms. The MAR indicated the resident received the PRN twice on 10/04/23 and 10/06/23 and three times on 10/17/23.In an interview on 11/07/23, Staff 2 (LPN) acknowledged the PRN had been administered more frequently than the physician had prescribed. c. The resident had an order for diclofenac sodium external gel 1% (a topical pain reliever) to be administered four times per day. The MAR indicated the resident did not receive the treatment on one of four administration times on 10/06/23 and on three of four administration times on 10/07/23.In an interview on 11/07/23, Staff 2 acknowledged the finding.d. The MAR indicated the resident should be treated with Nystatin External Ointment every other day "on rotation" with clobetasol 0.5% (both medications for itching). There was no physician order for the Nystatin to be administered every other day.A current order reflecting the documentation on the MAR for the Nystatin was requested on 11/07/23, and a physician order for Nystatin to be applied once daily was provided 11/07/23. An order to apply Nystatin every other day "on rotation" with clobetasol was requested again on 11/08/23. No further documentation was provided.The need to follow physician orders as written and to have orders for all medications the facility was responsible for administering to the resident was discuss with Staff 29 (Interim Director), Staff 2 (LPN), Staff 16 (Operation Specialist (Corporate)), and Staff 37 (Operational Specialist) on 11/09/23. No additional information was provided.

Based on observation, interview, and record review, it was determined the facility failed to provide a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of the residents. Findings include, but are not limited to:The facility was home to 64 residents at the time of the re-licensure survey. During the acuity interview on 05/08/23, the facility identified multiple residents with behavior concerns and high ADL care needs, four of whom required a minimum of two direct care staff to assist with transfers/mobility and ADL care. During the re-licensure survey, interview and record reviewed noted Resident 2 required more than two staff to assist with transfers from the floor after a fall. On 05/11/23, Staff 1 (ED) stated the posted staffing plan was as follows:* Day shift: two MTs and three CGs;* Swing shift: two MTs and three CGs; and* Night shift: one MTs and two CGs.Review of the facility's staffing schedules dated 03/01/23 through 05/10/23 revealed multiple occasions when the number of staff working was less than the posted staffing plan.Call light logs were reviewed from 04/01/23 through 05/10/23 for two sampled residents and three non-sampled residents and showed the following:* Resident 2's call light logs showed 94 occasions when wait times were over 20 minutes; of those there were 57 occasions when the wait times were over 30 minutes and 13 that were over one hour.* Resident 4's call light logs showed 64 occasions when wait times were over 20 minutes; of those there were 37 times when the wait times were over 30 minutes and 10 that were over one hour.* Non-sampled room 114 call light logs showed 17 occasions when wait times were over 20 minutes; of those there were four occasions when the wait times were over 30 minutes and three over an hour.* Non-sampled room 126 call light logs showed seven occasions when wait times were over 20 minutes and two wait times over three hours.* Non-sampled room 110 call light logs showed one occasion when the wait time was over 20 minutes and three wait times over 30 minutes. This resident used the call light infrequently during the time period reviewed. Interviews with staff and residents between 05/08/23 and 05/11/23 revealed the following:Staff 10 and 11 (CGs) and Staff 15 and 25 (MTs) indicated when Resident 2 experienced a fall they were to call the paramedics/fire department to get the resident off the floor. The staff were unsure how many facility staff it would take to get the resident up, as it had not been attempted. The staff indicated they thought three to four staff would be needed to assist the resident off the floor. Staff 9, 10, 11, 18, 21, 23 and 24 (CGs) indicated there were multiple occasions when only one caregiver was working on the floor. The staff indicated there were usually one to two MTs working but they were often busy passing medications. The staff indicated resident call lights took a long time to answer when there weren't enough caregivers working. Staff indicated wait times could be 45 minutes to an hour, but lights were answered as quickly as they could get to them. The staff further indicated they were responsible for all clean-up/set up of the dining room for meals, taking resident orders, delivering meals to the dining room and to resident rooms as well. Two sampled residents and eight non-sampled residents indicated they experienced extended call light wait times of up to an hour. The residents indicated day shift, night shift, weekends and mealtimes were some of the more difficult times to get assistance. Sampled and non-sampled residents reported the following: * "They don't have enough staff";* "Staff in the dining room get pulled away to help elsewhere or answer call lights";* "Staff are working very hard but need more help";* "Caregivers are delivering meals too; by the time it's delivered meals are cold";* "Call lights can take up to an hour to answer when staff are slow";* "Residents aren't given information and included in decisions; we don't know what is going on most of the time";* "All the staff are expected to do too many jobs and are spread too thin."* "I have PRN pain medication, sometimes it's 30 minutes before the CG answers my light, then I have to wait longer for the MT";* "There are times when no one responds at all...I don't know what happens...no one comes."The need to ensure the facility provided a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of residents was discussed with Staff 1 (ED) on 05/11/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to develop a staffing plan to meet the scheduled and unscheduled needs of the residents based on care minutes calculated by their ABST tool. Findings include, but are not limited to:The facility's ABST tool calculations, resident ABST data entries and the facility's staffing plan were reviewed on 05/10/23 and 05/11/23 and showed the following:a. The facility was using an ABST that generated daily staff hours, but was not consistently staffing to the levels identified. The ABST staffing calculations noted 3.0 staff were needed on day shift and swing shift. The ABST staffing calculations noted 2.0 staff were needed on the overnight shift. On 05/11/23, Staff 1 (ED) stated the staffing plan was as follows:* Day shift: two MTs and three CGs;* Swing shift: two MTs and three CGs; and* Night shift: one MTs and two CGs.Review of the caregiver and medication technician schedules showed numerous occasions when less than the ABST calculated number of staff were scheduled. b. Review of sampled resident ABST entries showed multiple ADL areas which reflected zero minutes when the resident required limited to extensive staff assistance with those activities. Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (ED) and Staff 4 (RN). The staff acknowledged the findings. Staff 1 (ED) indicated they typically had three caregivers and two medication technicians on day shift and evening shift. The overnight shift had two caregivers and one medication technician. Interviews with multiple staff indicated frequently there was only one caregiver on the floor and one to two medication technicians. The staff indicated day shift and the weekends were the most problematic. The staff indicated there were several residents who required extensive to full assistance with their care. The caregiving staff were also responsible for all the resident laundry and all the dining room set up, order taking, meal serving, clean up and room tray delivery. Staff and numerous resident interviews indicated the staffing levels observed during survey were not how the facility usually was staffed.Observations of the facility from 05/08/23 through 05/11/23 during day shift and swing shift showed three caregivers and two medication technicians assigned to the two story building. The need to ensure ABST resident entries were accurate, reflective of resident care needs and staffing calculations were used to develop and implement a staffing plan to meet resident needs was discussed with Staff 1 on 05/11/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure updated information was added to their Acuity-Based Staffing Tool (ABST) for 2 of 4 sampled residents (#s 2 and 9). This is a repeat citation. Findings include:During the revisit survey, the ABST information for Residents 2 and 9 was not reflective of the residents' current status and care needs.The need to implement an ABST based on accurate and updated information was discussed with Staff 29 (Interim ED) and Staff 2 (LPN) on 11/09/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed prior to staff providing direct care to residents for 1 of 2 newly hired staff (#14). Findings include, but are not limited to:The facility's training records were reviewed with Staff 3 (Business Office Manager) on 05/10/23. The following was noted:Staff 14 (CG) hired 11/02/2022 lacked documented evidence pre-service dementia care training was completed prior to providing care to residents.Requirements for pre-service dementia care training were reviewed with Staff 1 (ED) on 05/11/2023. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including at least six hours of dementia care training, for 3 of 3 long-term staff (#s 13, 20 and 22). Findings include, but are not limited to:Annual in-service training records were reviewed with Staff 3 (Business Office Manager) on 05/10/23. The following was noted:Staff 13 (MT) hired 02/01/2021, Staff 20 (MT) hired 02/22/2021 and Staff 22 (MT) hired 02/01/2021, lacked documented evidence of 12 hours of annual in-service training including at least six hour of dementia care training.The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (ED) on 05/11/2023.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire and to keep a written record of fire safety training, including content of the training sessions and the residents attending. Findings include, but are not limited to:On 05/11/23, Staff 7 (Maintenance) was asked to explain the facility's process and to provide documentation for instructing residents in fire and life safety procedures upon admission and annually. Staff 7 stated it was the facility's policy to instruct residents in fire and life safety procedures within 72 hours of admission, and documentation provided reflected this. Staff 7 also stated the last annual instruction in fire and life safety procedures for residents was completed in 08/2022; however the documentation lacked the content of the training session and the residents attending.The need to instruct residents in fire and life safety procedures within 24 hours of admission and re-instructed at least annually and to keep a written record of the content of the training sessions and the residents attending was discussed with Staff 1 (ED), Staff 2 (LPN), Staff 4 (RN), and Staff 26 (Director of Operations) on 05/11/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240, C 260, C 303 and C 361.
Based on observation, interview and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C260.

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 failed to ensure the grounds were orderly and free of litter and refuse. Findings include, but are not limited to:The grounds of the facility were toured on 05/11/2023. The following were identified: * Exterior pathways contained multiple drop offs measuring up to 2.5 inches along pathway edges;* Sidewalk leading from front of building to the courtyard patio had areas with uneven concrete; * Dumpster area had debris on ground and dumpster lids were left open;* Shed near dumpster had various medical and lawn equipment piled around shed; and* Ants were found in the first floor trash closet located near the mailboxes.The building's exterior was toured on 05/11/2023 at 10:25 am with Staff 1 (ED) and Staff 7 (Maintenance Director) and they acknowledged the findings for smooth surfaces to prevent tripping hazards and to ensure the grounds were orderly and free of litter and refuse.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The facility was toured on 05/08/2023 - 05/10/2023. The following was observed: Interior:* Carpet stains in common areas by the mailboxes, by rooms 120, 201, 215, 217 and 234 and the pathway into the apartment and in front of the recliner in room 211;* Debris and brown stains found in multiple cabinets, drawers and sink of the buffet;* Trash cans in closets on first and second floors had no lids with foul odors present;* Trash closet by mailbox had scrapes on the wall, and scuffs/stains on linoleum;* Trash closet inside door was dirty; * Debris in the PTAC unit by rooms 121 and 122;* Worn countertop and broken cabinet door in first floor laundry room;* Scuffs/gouges on doors to rooms 111, 113, 114, 122, and the kitchen entrance; * Handrail by dining room missing end piece exposing sharp edges;* Brown stain on handrail by room 121;* Gouges on wall by room 122;* Window screens dirty by rooms 212, 225, 227 and 230;* Room 207 was missing a window screen;* Bather room had a broken cabinet door;* Hopper in 2nd floor laundry room was not working;* Peeling paint on the wall by rooms 121 and 210;* Room 223 had foul odor in the fridge with no identifiable source, bathroom countertop was broken/chipped, door had gouges and scrapes on it's edge, loose doorknob and brown stains in toilet;* Room 234 had gouges on the door and kitchen cabinet;* Room 114 had a smoke detector unclipped from base, stains around vent above toilet and chipped paint on wall next to toilet;* Second floor laundry had brown stains on floor by entrance, white stains by washing machine, and laminate missing on edge of cabinet by washer exposing sharp edge; * Activity area sink had stains and debris;* Burned out light bulbs outside Rooms 118, 202, 206, 207, 209 218, 220, and 234; and* Broken outlet cover by sitting area on 2nd floor.Exterior Grounds:* Four pillars to the facility entrance breezeway had broken siding at the bottom with exposed sharp edges; * Multiple areas of baseboard trim around the facility had rust colored stains;* Litter on ground in smoking area;* Cobwebs, dirt and debris on ground, siding and light fixtures by exit door by side gate;* Multiple outside vents were dirty and had rust colored stains;* Right exterior door to patio had rust marks; * Curb near dumpster had large pieces of broken cement; and* Lower trim on left side of patio doors had peeling paint.The environment was toured on 05/11/2023 at 10:25 am with Staff 1 (ED) and Staff 7 (Maintenance Director). They acknowledged the above areas needed to be cleaned and repaired.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:Observations of the facility between 05/08/23 and 05/10/23 showed exit doors did not have a consistently, operational system for security or to alert staff when residents left the facility. On 5/11/2023, the need to ensure exit doors were equipped with an alarming device to alert staff when residents exited the building was discussed with Staff 1 (ED) and Staff 7 (Maintenance Director). They acknowledged the findings.