Nyssa Gardens Assisted Living Facility

The findings of the kitchen inspection, conducted 03/14/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen survey of 03/14/24, conducted on 06/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:a. Observations of the facility kitchen, food storage areas, food preparation, and food service on 03/14/24 revealed splatters, spills, drips, debris and black matter noted on:* Wall behind sink (adjacent to stove);* Wall and top of cove base in dish machine area;* Pipes and floor drain underneath three-compartment sink; and* Three of four ceiling vents.b. Cove base in the dish machine area was coming apart from the wall. The surveyor and Staff 2 (Dietary Supervisor) toured the kitchen on 03/14/24. The areas in need of cleaning and repair were reviewed. He acknowledged the findings. The need to ensure the kitchen was maintained in accordance with the Food Sanitation Rules was discussed with Staff 1 (Administrator) on 3/14/24 during the exit interview. She acknowledged the findings.

The findings of the re-licensure survey, conducted 05/16/23 through 05/18/23, 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 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 05/18/23, conducted 03/12/24 to 03/14/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 second re-visit to the re-licensure survey of 05/18/23, conducted 06/27/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure resident evaluations contained all required elements and were updated within 30 days of move-in to the facility for 1 of 1 sampled resident (#2) whose new move-in evaluation was reviewed. Findings include, but are not limited to:Resident 2 was admitted in 03/2023.The new move-in evaluation, completed on 03/23/23 and 03/28/23, failed to address the following areas:* Customary routine: bathing;* Interests, hobbies, social, and leisure activities;* Spiritual, cultural preferences and traditions;* Mental Health issues: Presence of depression, thought disorders, behavioral or mood problems, history of treatment, and effective non-drug interventions;* Personality, including how a person copes with change or challenging situations; * Housework and laundry;* Nutrition habits, fluid preferences, and weight if indicated;* List of treatments: type, frequency, and level of assistance needed;* Emergency evacuation ability;* Complex medication regimen;* Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including noise, lighting and room temp.Additionally, the initial evaluation was not updated as needed during the 30 days following the resident's move into the facility.The need to ensure new move-in evaluations contained all required elements and were updated within 30 days following the resident's move into the facility was discussed with Staff 1 (Administrator) on 05/18/23 at 8:50 am. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure initial evaluations contained all required elements for 1 of 1 sampled resident (#4) whose new move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 4 was admitted in 12/2023.The new move-in evaluation, completed on 11/28/23, failed to address the following areas:* Customary routine: eating and bathing;* Eating: dental status and assistive devices;* Housework and laundry;* Pain: how a person expresses pain or discomfort;* Fall risk or history;* History of dehydration or unexplained weight loss or gain; and * Unsuccessful prior placements.The need to ensure new move-in evaluations contained all required elements was discussed with Staff 1 (Administrator) on 03/13/24 at 9:00 am. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, and updated as appropriate within the first 30 days of move-in for 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to:Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services. Interviews with care staff and family, and observations of Resident 2 during the survey revealed s/he was incontinent, dependent on staff for ADL care, did not use a call light to summon assistance, needed meal assistance, used side rails and was bedbound. Resident 2's service plan, dated 03/23/23, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:* Pain;* Use of a hospital bed and side rails;* Falls;* Oral care;* Bowel and bladder management;* Bed bound status;* Floating heels;* Dressing status;* Use of an air mattress; * Decline in cognition; and * Risk for choking.Additionally, the service plan had not been reviewed and updated as appropriate within the first 30 days of move-in.The need to ensure the service plan was reflective of Resident 2's current care needs, provided clear direction to staff, and was reviewed and updated within the first 30-days of move-in was discussed with Staff 1 (Administrator) during an interview on 05/18/23 at 8:50 am. She acknowledged it had not been reviewed within 30 days of move-in and needed to be updated. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition had weekly progress documented until the condition resolved for 2 of 3 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease), depression and esophageal reflux. The resident's 04/10/23 service plan, 02/01/23 through 05/17/23 progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:* Medication changes;* ER visit for difficulty breathing and panic attack; and * Falls.Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's condition until resolution.The need to ensure short-term changes of condition had documented resolution was discussed with Staff 1 (Administrator) on 05/16/23 at 10:20 am. She acknowledged the findings. 2. Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services. Resident 2's clinical record and progress notes, reviewed from 3/27/23 through 5/16/23, revealed the following:* The resident fell on 05/06/23. Review of the record revealed no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved. On 05/08/23 at 9:00 am, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term change in condition had no documented resolution. No further information was provided.
Based on interview and record review, it was determined the facility failed to ensure short term changes of condition were monitored until resolution, interventions were determined, and documented, communicated to staff on each shift, and reviewed for effectiveness for 2 of 2 sampled residents (#s 4 and 5) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 5 was admitted in 07/2022.Resident 5's clinical record and charting notes, reviewed from 12/21/23 through 03/12/24, revealed the following:a. Resident 5 fell or was found on the floor 13 times between 12/21/23 and 03/12/24. The facility failed to investigate the circumstances for several of the falls to determine if service-planned interventions were implemented, were effective or if new interventions were needed, and failed to communicate determined actions/interventions to staff on each shift. Additionally, there was no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved.b. Resident 5 had a medication change on 01/26/24. Although alert monitoring was initiated for the change, there was no documented monitoring of resident's condition until resolution.The need to ensure short term changes of condition were monitored until resolution, interventions were determined, documented, communicated to staff on each shift, and reviewed for effectiveness was shared with Staff 1 (Administrator) and Staff 3 (LPN) on 03/14/24. They acknowledged the findings.2. Resident 4 was admitted to the facility on 12/04/23.The resident's current service plan, 12/04/23 through 03/12/24 progress notes, and physician communications were reviewed. The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:* 12/04/23: New move-in;* 01/05/24: Nasal congestion; and* 02/26/24: Nausea and vomiting.Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's conditions until resolution.Additional information was requested from Staff 1 (Administrator) on 03/14/24 at 9:15 am. On 03/14/24 at 9:15 am, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had no documented resolution.

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 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 2021 with diagnoses which included hypertension.a. The resident had an order for Amlodipine 10 mg one tablet daily for high blood pressure. Staff were to hold the medication if the systolic BP (upper number) was less than 110.Resident 1's MAR, reviewed from 05/01/23 - 05/17/23, revealed the blood pressure was outside the parameters on 05/01/23. Per the physician order, the Amlodipine should have been held, but staff administered it. b. Resident 1 had an order for Losartan Potassium 100 mg one twice a day. Staff were to hold the medication if the BP was less than 100/60 or pulse was under 50. According to the MAR, the BP was outside parameters on one occasion and the medication was still administered. The need to ensure medications were administered as prescribed was reviewed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. She reviewed the MAR and acknowledged the orders were not followed. 2. Resident 3 was admitted in 2016 with diagnoses which included multiple sclerosis.Resident 3 had an order for Breo Ellipta Aerosol inhaler one puff daily. According to the MAR, reviewed from 05/01/23- 05/17/23, s/he did not receive the medication between 05/01/23 and 05/17/23 because it was "unavailable".In an interview with Staff 1 (Administrator) on 05/18/23 at 9:00 am, she verified the medication had not been given as ordered. She said the facility contacted the physician to obtain a re-fill order but had no documentation verifying when the MD had been contacted. The need to ensure medications were available and administered as prescribed was reviewed with Staff 1 (Administrator), Staff 2 (LPN) and Staff 3 (LPN) during the exit conference on 05/18/23. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 2021 with diagnoses which included hypertension.Residents 1's MARs, reviewed from 05/01/23 through 05/17/23 revealed the following:* Lack of resident-specific instructions for multiple PRN anxiety medications, including sequence of administration.The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. No further information was provided.2. Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services. Residents 2's MARs, reviewed from 05/01/23 through 05/17/23 revealed the following:* Lack of resident-specific instructions for multiple PRN medications for pain and anxiety, including sequential order of use. The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) on 05/08/23 at 10:15 am. No further information was provided.
Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident specific parameters and instructions for PRN medications, for 1 of 3 sampled residents (#6) whose MARs included multiple PRN medications used to treat the same condition. This is a repeat citation. Findings include, but are not limited to:Resident 6 was admitted to the facility in 08/2023.Residents 6's MARs were reviewed from 03/01/24 through 03/12/24 and the following was noted:* Lack of resident-specific instructions for multiple PRN pain and anxiety medications, including which one to administer first.In an interview on 03/13/24 at 12:20 pm, Staff 12 (MA) reviewed the resident's MAR. She confirmed the multiple PRN pain and anxiety medications lacked specific instructions for staff including sequence of administration.The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 03/14/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had documentation that non-pharmacological interventions had been tried with ineffective results prior to administering the medications and all direct care staff had knowledge of non-pharmacological interventions for 1 of 2 sampled residents (#1) who received PRN psychotropic medications. Findings include, but are not limited to:Resident 1 moved into the facility in 07/2021 and had diagnoses which included anxiety. Review of the resident's service plan, physician orders, and 05/01/23 - 05/17/23 MAR revealed the following: Resident 1 was prescribed lorazepam 1 mg (anti-anxiety medication) one tablet every eight hours PRN for anxiety. The facility failed to ensure the resident's MAR and clinical record included the following required information:* Documentation that all direct care staff had been informed of non-pharmacological interventions for Resident 1; and * Staff administered the PRN lorazepam on 17 occasions without documentation that non-pharmacological interventions were attempted prior to administration of the medication. During an interview with Staff 10 (MT) on 05/18/23 at 10:10 am, she reviewed the resident's record and confirmed staff had not documented that non-pharmacological interventions had been attempted prior to administering the medication. The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 1 (Administrator) on 05/18/23 at 10:15 am. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's evaluation and service plan for 1 of 1 sampled resident (#2) who had side rails on their bed. Findings include, but are not limited to:Resident 2 was admitted to the facility on 03/27/23 with diagnoses which included dementia and was receiving hospice services.On 05/17/23 at 10:25 am, the resident's bed was observed to have bilateral half-length side rails in the up position. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.The above information was discussed with Staff 1 (Administrator) on 05/18/23 at 9:00 am. She was unaware the resident had side rails on his/her bed. She acknowledged the resident's record lacked an assessment by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation in the evaluation and service plan.

Based on interview and record review, it was determined the facility failed to ensure an Acuity Based Staffing Tool (ABST) was reviewed and amended for each resident at least quarterly. Findings include, but are not limited to: Review of the facility's online ABST information with Staff 2 (LPN) on 05/17/23 at 11:45 am revealed the facility was not reviewing and amending the ABST tool for residents at least quarterly.The need to ensure the facility reviewed the ABST assessments quarterly was discussed during the exit interview with Staff 1 (Administrator) and Staff 2 on 05/18/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 direct care staff (#s 6, 7 and 8) had documented evidence of completion of First Aid certification and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 05/17/23 and revealed Staff 6 (CG) hired 03/01/23, Staff 7 (CG) hired 03/09/23, and Staff 8 (CG) hired 02/01/23, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Administrator) on 05/17/23 at 12:45 pm. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training at least annually. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation of annual fire and life safety training provided to residents.The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Administrator) on 05/08/23 at 10:30 am. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 252, C 270, and C 310.

Based on observation and interview, it was determined the facility failed to ensure pathways were maintained in good repair and did not have potential hazards. Findings include, but are not limited to:Observations of the outer courtyard surfaces and pathways on 05/18/23 showed the following:* Multiple drop-offs of 2-5 inches along several pathway edges.The need to ensure pathways were maintained in good repair and did not have potential hazards was discussed with Staff 1 (Administrator) during a tour of the exterior grounds on 05/18/23 at 11:15 am. The findings were acknowledged.

The findings of the kitchen inspection, conducted 11/01/22, 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 first revisit to the kitchen inspection of 11/01/22, conducted 05/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was clean and good repair, and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facilities kitchen, food storage areas, food preparation, and food service on 11/01/22 revealed:* Splatters, spills, drips, and debris noted on: - Walls behind counters; - Stand mixer and blender; - Behind the ice machine; - The blades and cage of a box fan blowing on the trayline; - Both sides and the interior of the range, grill, and convection oven; and - The shelving posts of the trayline steam table.* The laminate was damaged on the counter adjacent to the refrigerator, creating an un-cleanable surface. * Undated and unlabeled food items were noted in the refrigerator.* No documented evidence the wiping cloth sanitizer bucket was monitored to ensure the bleach sanitizer was at the correct parts per million.* Pasteurized eggs were not available for soft cooked entrees.* There was not a small diameter probe thermometer available to temp thin foods. The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) and Staff 2 (Dietary Manager). They acknowledged the findings.

Based on interview and observations it was confirmed the facility is not exercising reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include:During tour of facility on 05/24/2022 Compliance specialist observed the following:* No screening for COVID was done upon entering facility* staff member observed with mask below the nose and mouth* multiple staff members not wearing masks in the facilityInterview with Staff # 1 on 05/24/2022 who acknowledged the findings

The findings of the re-licensure survey, conducted 8/30/21 through 8/31/21, 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 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 re-visit to the relicensure survey of 08/31/21, conducted 03/30/22 through 03/31/22, 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.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 on 08/31/21, conducted 06/14/22 through 06/15/22, 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.

Based on interview and record review, it was determined the facility failed to ensure the new move in evaluation contained all required elements for 1 of 1 sampled resident (#3) reviewed as a new move in. Findings include, but are not limited to:Review of Resident 3's new move in evaluation, dated 6/23/21, lacked the following elements:* Customary routines: eating and bathing;* Spiritual cultural preferences and traditions;* List of current diagnosis;* List of medications and PRN use;* Visits to health practitioner, ER or hospital stays in the past year;* History of mental health treatment;* Effective non-drug interventions for mental health;* Memory, orientation, confusion and decision making abilities;* Personality and how the person copes with change and challenging situations;* Pharmaceutical interventions for back pain;* Nutrition habits, fluid preferences and weight;* List of treatment types frequency and level of assistance needed;* Environmental factors that impact the resident's behavior including noise, lighting and room temperature.* Fall risk and history; and* History of dehydration and or unexplained weight loss or gain.The need to ensure all required components were included in the new move in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required components for 2 of 3 sampled residents (#s 5 and 6) whose new move-in or quarterly evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 5 was admitted in 02/2022.The new move in evaluation failed to address the following areas:* Customary routine: Eating and bathing;* Mental Health issues: History of treatment;* Personality, including how a person copes with change or challenging situations; * Housework and laundry;* Pain: How a person expresses pain and discomfort;* Nutrition habits, fluid preferences, and weight if indicated;* Complex medication regimen;* Recent losses; and * Environmental factors that impact the resident's behavior including noise, lighting and room temp.The need to ensure move-in evaluations included all required components was discussed with Staff 1 (Administrator) on 03/31/22. She acknowledged the findings. No further information was provided.2. Resident 6 was admitted to the facility in 2019 with diagnoses which included Alzheimer's dementia, anxiety and hypertension. Observations, staff interviews and review of the record during the survey revealed s/he required full assistance with most ADLs and was currently receiving hospice services.The most recent evaluation, dated 02/28/22, was not reflective of the resident's health status, current needs or did not address the required components in the following areas:* Visits to health practitioner(s), ER, hospital or NF in the past year;* Personality: including how the person copes with change or challenging situations;* Ability to use a call system;* Indicators of nursing needs including potential for delegated nursing tasks; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.On 03/31/22, the need to ensure Resident 6's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator). She acknowledged the findings. No other information was shared.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, care needs and provided clear direction to staff for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 8/2018.Staff identified Resident 1 to be dependent for all ADL care and required two staff for transfers. Resident 1 had a wound to the left heel being treated by a Home Health agency. Staff also reported Resident 1 was in a relationship with another resident.Resident 1 was observed to utilize a wheelchair for mobility and had bi-lateral side rails on his/her bed.Resident 1's service plan did not provide clear direction to staff for:* Transfer assistance including the use of a lift;* Side rail use including risks and precautions;* Instructions for wound care during bathing; and* Relationship with another resident.
2. Review of resident 2's most current service plan dated 1/22/21 revealed his/her service plan was not updated at least quarterly.3. Review of Resident 3's initial service plan dated 6/29/21 revealed his/her service plan was not updated within 30 days of move in.The need to ensure service plans were reflective of care needs, provided clear direction to staff, and were updated within 30 days and quarterly was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). 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 regarding the delivery of services for 2 of 3 sampled residents (#s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 5 wad admitted in 03/2022.During the entrance conference acuity interview on 01/03/22, staff indicated Resident 5 needed assistance with ADLs, two staff were often needed for transfers, and was receiving hospice services. Observations, interviews with the resident and staff, and review of the clinical record revealed the service plan was not reflective or failed to provide clear direction to staff in the following areas:* Oxygen use;* Velcro boot on left foot;* Laundry and housekeeping services;* Staff assistance to make bed;* Use of a walker and wheelchair; and * Glasses for visual impairment.The need to ensure the service plan was reflective of Resident 5's current needs and provided clear direction to staff was reviewed with Staff 1 (Administrator) on 03/31/22 at 3:00 pm. She acknowledged the findings.2. Resident 6 was admitted in 2019.Review of the clinical record, interviews with care staff and observations of Resident 6 were made during the survey. His/her service plan, dated 02/28/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:* Hospice services;* Bathing; and * Ability to use a call light. The need to ensure the service plan was reflective of Resident 6's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 03/31/22. She acknowledged the findings. No further information was provided.

Care plans have been updated and reviewed. All care plans have been incorporated with all elements for a person-centered plan, identifying each residents preferences of dignity, privacy, choice, individuality and independence. Temporary service plans are being done on changes that occur and will be monitored until resolved or deemed permanent.A new form was implemented to assist staff in alerting the nurse of changes to each residents preferences to their person-centered care.Care plans will be monitored and reviewed quarterly and PRN by the LPN, Administrator and RN.

3. Resident 1 was admitted to the facility in 8/2018 with diagnoses including insulin dependent diabetes and was identified with behaviors.a. Staff reported Resident 1 would intentionally get on the floor when staff did not respond to the call system fast enough.A Behavior Support Services Behavior Plan providing strategies and interventions for care staff to reduce Resident 1 staging falls was in place. Progress notes indicated Resident 1 was observed to place him/herself, or was found, on the floor 20 times between 5/1/21 and 8/30/21.There was no documented evidence of a thorough evaluation of the incidents to determine if interventions were implemented and/or effective. b. Resident 1 was identified to have skin tears and abrasions on seven occasions following incidents of being found on the floor.There was no documented evidence the injuries were monitored until resolved.c. Resident 1 was sent to the emergency department twice related to low blood sugars and changes in awareness/cognition.There was no documented evidence Resident 1 was monitored following the hospital visits.d. Resident 1 had multiple medication changes, including insulin and psychoactive medications.There was no documented evidence the changes in critical medications were monitored.The need to ensure Residents 1, 2 and 3 were monitored per their evaluated needs and changes in condition were evaluated and monitored until resolved was discussed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored to resolution, and failed to determine and document actions or interventions and communicate those to staff for 3 of 3 sampled residents (#s 1, 2 and 3) who had changes of condition. Findings include, but are not limited to:1. Review of Resident 3's progress notes and nursing notes dated 6/29/21 through 8/30/21 revealed s/he was not monitored after being admitted to the facility in 6/2021. Physician orders dated 8/2/21 indicated Fluticase Proprionate 50mcg was changed to PRN and the resident was prescribed Hydrocortizone-10 to be applied twice daily. There was no indication Resident 3 was monitored after the medication changes.Interview with Staff 2 (LPN) on 8/31/21 confirmed facility staff did not monitor Resident 3 after moving into the facility or when his/her medications were changed.2. Resident 2 was admitted to the facility with diagnoses including agitation.Physician orders dated 8/5/21 directed staff to administer PRN Risperidone 0.5 mg for agitation. During an Interview with Staff 2 on 8/31/21, she stated Resident 2 was verbally aggressive and threatened physical harm towards her including "he was going to kill me." Resident 2 experienced a change of condition related to behaviors and the addition of a PRN behavior medication. There was no documented evidence actions or interventions were developed and communicated to staff and no evidence the resident was monitored through resolution.


Based on interview and record review, it was determined the facility failed to monitor short-term changes consistent with evaluated needs and service plan until resolution for 2 of 3 sampled residents (#s 5 and 6). This is a repeat citation. Findings include, but are not limited to:1. Resident 6 was admitted in 2019 and had diagnoses which included Alzheimer's dementia. Resident 6's clinical record and charting notes, reviewed from 01/01/22 through 03/30/22, revealed the following:* On 01/02/22, the facility initiated short-term monitoring for behaviors. However, no monitoring until resolution was documented for the change in condition.* On 01/10/22, staff documented that the resident had a blood blister on his/her left big toe. No on-going monitoring of the injury was noted in the record. * A chart note, dated 01/13/22, indicated the resident had a wound on his/her right toe. The record revealed no documented monitoring of the resident's wound at least weekly until resolved.* The resident was sent to the ER on 02/14/22 and was admitted for aspiration pneumonia. S/he returned to the facility on 02/22/22. Although the facility initiated short term monitoring, the record revealed no documented monitoring of the resident's condition at least weekly until resolved.* On 03/01/22, the resident was placed on monitoring because s/he was "slumped" at the dining table and had a decreased level of consciousness. Review of the record revealed no documentation on the progress of the resident's condition at least weekly until resolved.* On 03/03/22, staff documented that the resident injured his/her right-hand knuckle related to a fall. There was no documented treatment nor monitoring of the wound until resolved. * On 03/16/22, progress notes indicated the resident had a wound on his/her right hand. Documentation lacked further information about the wound, including treatment and monitoring until resolved. * Between 01/01/22 and 03/30/22, the resident had fallen 15 times. The facility failed to investigate the circumstances for each fall to determine if service-planned interventions were implemented, were effective or if new interventions were needed. Additionally, the facility failed to monitor the resident's status for each fall until resolved.Additional information was requested on 03/31/22 at 11:00 am.On 03/31/22 at 3:00 pm, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved.Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 and Staff 2 (LPN) on 03/31/22. They acknowledged the findings. No further information was provided.2. Resident 5 was admitted in 02/07/22.Resident 5's clinical record and charting notes, reviewed from 02/07/22 through 03/30/22, revealed the following:* Short-term monitoring was initiated when the resident moved into the facility on 02/07/22. However, the facility failed to monitor the resident until resolution. * On 02/25/22, the resident reported vomiting. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the change in condition.* The resident had falls on 02/12/22, 02/26/22 and 03/25/22. The facility failed to investigate the circumstances for each fall to determine if service-planned interventions were implemented, were effective or if new interventions were needed. Additionally, the facility failed to monitor the resident's status for the falls on 02/12/22 and 02/26/22 until resolved.Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/31/22. They acknowledged the findings. No further information was provided.Policies are in place for monitoring residents change of condition. The policy was reviewed and a new form was implemented to assist staff with alerting nursing of changes they are oberserving. Direct care staff continue to receive training during staff orientation on how to idenitfy and report changes of condition. Additional inservices are scheduled for extended trainings on person-centered plans of care. identifying changes, dignity, privacy, choice, individuality, and independence. RN will be responsible for assessing the change of condition and if further action is required. Inservices are scheduled for charting and documentation from beginning to resolved. From short term charting, to change of condition, wound cares, and behaviors. Fall preventions have been updated and a new alarm system was implemented as coordinated with Hospice services. Bed and chair alarms will continue to be used for residents who are at risk for falls. Each fall will be investigated for the circumstances of the fall and it will be determined if service plan interventions need to be inplemented, were they effective or if new interventions are needed. LPN and Administrator are on call 7 days a week 24 hours a day to be contacted of any and all changes.

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 (#4) whose orders were reviewed. Findings include, but are not limited to:Resident 4 moved into the facility in 2019 and had diagnoses which included high blood pressure. Physician orders and MARs, reviewed from 03/01/22 - 03/30/22, revealed the following orders were not followed:* Resident 4 had an order for Amlodopine 10 mg daily for high blood pressure. Staff were to hold the medication if the pulse was less than 50, systolic BP (top number) was less than 100 or diastolic (lower number) was less than 60. Documentation on the MAR revealed 12 occasions when the diastolic was less than 60 and the medication was not held.The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/30/22 at 3:00 pm. They acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in 8/2018 and was identified to have behaviors.Resident 1 had a physician's order for Risperidone 0.25 mg as needed for behaviors. Resident 1's 8/1/21-8/27/21 MARs were reviewed. The facility failed to ensure there were specific parameters for staff describing what behaviors Resident 1 expressed that would require medication. There were no non-pharmaceutical interventions on the MAR for staff to attempt prior to administering the medication.The need to ensure there were resident-specific descriptions of behaviors and non-drug interventions for staff to attempt prior to the administration of psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications and clear direction for the specific reasons for the use of the psychotropic medication for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN medications to treat behaviors. Findings include, but are not limited to:1. Resident 2 had a physician's order for Risperidone 0.5 mg as needed for behaviors. The medication was administered on 8/11/21 and 8/12/21. The facility failed to ensure there were specific parameters for staff describing what behaviors Resident 2 expressed that would require medication. There were no non-pharmaceutical interventions on the MAR for staff to attempt prior to administering the medication. The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.


Based on interview and record review, it was determined the facility failed to follow parameters prior to administering a PRN psychoactive medication for 1 of 2 sampled residents (#5) reviewed for PRN psychoactive use. This is a repeat citation. Findings include, but are not limited to:Resident 5 moved into the facility in 02/2022 and was receiving hospice services as of the re-visit survey.Resident 5 had an order for Lorazepam 0.5 mg ½ tablet every two hours as needed for anxiety. Parameters for administration included notifying hospice prior to giving the medication. Review of the clinical record and MAR, from 03/01/22 through 03/30/22 revealed eight occasions when staff gave the PRN Lorazepam without notifying hospice prior to administration. During an interview with Staff 9 (MT) on 03/30 22 at 3:40 pm, she reviewed the computer MAR and acknowledged staff had not followed parameters and notified hospice prior to administering the medication. The need to ensure parameters were followed for PRN psychoactive medication was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/31/22. They acknowledged the findings. All PRN psychoactive medications have been updated with parameters for use. Hospice was consulted and phyisican and RN reviewed their residents medications and clarified orders for administration. Med-techs will alert hospice on administration of all prn medications if directed by hospice. Med-techs were inserviced and they reviewed parameters and non-pharmaceutical interventions before administering psychoactive medications. All residents in current survey were updated and parameters were reviewed by Hopsice physician. LPN, Hospice team and RN will be responsible for assuring medications are given under the parameters prescribed by physician.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 7, 10 and 11) whose training records were reviewed. Findings include, but are not limited to:Staff training records were reviewed on 8/31/21.Staff 7 (MT), hired 6/2/21, Staff 10 (MT), hired 6/7/21, and Staff 11 (CG), hired 7/22/21, lacked documented evidence of having completed pre-service dementia training prior to beginning job responsibilities.The need for staff to complete all required pre-service dementia training before working with residents was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired caregiving staff (#s 7, 10 and 11) demonstrated satisfactory performance in all job duties, and 2 of 2 (#s 7 and 11) were certified in First Aid and trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 8/31/21.1. There was no documented evidence Staff 7 (MT), hired 6/2/21, Staff 10 (MT), hired 6/7/21, and Staff 11 (CG), hired 7/22/21, had demonstrated competence in providing assistance with ADLs within 30 days of hire.2. There was no documented evidence Staff 7 and Staff 10 had demonstrated competence in medication administration. Staff 2 (LPN) immediately completed and documented medication pass training, including demonstration of competence. 3. There was no documented evidence Staff 7 and Staff 11 had completed First Aid certification and abdominal thrust training within 30 days of hire.The need to ensure staff had documentation of demonstrated competence in all job duties within 30 days and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 2 long-term staff (#s 6 and 9) whose training records were reviewed. Findings include, but are not limited to:The annual in-service training records for the Year 2020 were reviewed on 8/31/21.Staff 6 (MT), hired 4/29/09, and Staff 9 (MT), hired 6/9/03, failed to have documented evidence of completing 12 hours of required in-service training. There need to ensure staff completed 12 hours of on-going training, including 6 hours related to dementia, was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct fire drills and failed to provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to:Review of fire drill records dated 2/24/21 through 8/31/21 revealed no documented evidence fire drills, including all required components, were conducted every other month.Review of safety committee meetings dated 2/1/21 through 7/31/21 determined the facility did not provide fire and life safety training to staff on alternating months.The need to ensure the facility conducted fire drills and provided fire and life safety instruction to staff on alternating months was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure alternate routes during fire drills were used and new residents were being instructed on fire and life safety procedures within 24 hours of admission. Findings include, but are not limited to:1. Review of fire drill records revealed the facility conducted fire drills in the same location on 2/24/21 and 5/6/21 and used the same evacuation route. 2. Interview with Staff 1 (Administrator) on 8/31/21 revealed the facility did not provide fire and life safety procedures to new residents within 24 hours of admission.The need to ensure the use of alternate routes during fire drills and new residents were instructed on fire and life safety procedures within 24 hours of admission was discussed with Staff 1, Staff 2 (LPN) and Staff 3 (Maintenance Director) on 8/31/21. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission. This is a repeat citation. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* There was no documentation of fire and life safety training provided to residents within 24 hours of move-in. The need to ensure residents received fire and life safety training within 24 hours of admission was discussed with Staff 1 (Executive Director) on 03/30/22 at 1:45 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 their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 252, C 260, C 270, C 330 and C 422.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:During an environmental tour on 8/30/21, the surveyor measured water temperatures in three occupied resident units. Water temperatures exceeded 120 degrees Fahrenheit up to 126.8 degrees. The need to ensure hot water temperatures were between 110 and 120 degrees Fahrenheit was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/30/21. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents entered the courtyard. Findings include, but are not limited to:The facility was toured on 8/30/21. Exit doors to the courtyard were observed without an alarm system in place to alert staff of people entering or exiting the courtyard. The need to ensure exit door alarms or other acceptable system was in place to alert staff when residents entered the courtyard was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.