The findings of the initial survey, conducted 11/2/20 through 11/5/20, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
CBG: capillary blood glucose or
blood sugar
cc: cubic centimeter
CG: caregiver
cm: centimeter
F: Fahrenheit
HH: Home Health
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MA: Medication Aide
MAR: Medication Administration
Record
MCC Memory Care Community
mg: milligram
ml: milliliter
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PT: Physical Therapist
PRN: as needed
qd: every day or daily
qid: four times a day
RN: Registered Nurse
SP: service plan
TAR: Treatment Administration
Record
tid: three times a day
The findings of the re-visit to the initial survey of 11/5/20, conducted 2/1/21 through 2/3/21, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.
4. Resident 2's record was reviewed during the survey. The record indicated Resident 2 was started on insulin injections (to treat high blood sugar levels) on 8/21/20 to address his/her diagnosed diabetic condition. The physician made a number of changes to the insulin regimen as Resident 2 adjusted to the new medication. The facility failed to respond to these medication changes as follows:
* On 9/24/20, Resident 2's bedtime dosage of Lantis (long-acting insulin) was decreased from 35 units to 26 units. The facility failed to determine and document what actions or interventions were needed for the resident and there was no documented evidence the facility monitored and documented on the resident's response to the medication change.
* On 9/29/20, Resident 2's breakfast, dinner and bedtime insulin dosages were decreased. The facility failed to determine and document what actions or interventions were needed for the resident and there was no documented evidence the facility monitored and documented on the resident's response to the medication changes.
The need to ensure actions were determined and documented and staff were informed of changes of condition and instructed as to how to monitor the resident was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
5. Review of Resident 3's records indicated the resident had eight incidents where the resident fell or was found on the floor between 9/17/20 and 10/31/20. The following deficiencies were identified:
* Following a fall on 9/21/20, the facility RN wrote in her review of the incident staff should do hourly checks of the resident and reassure the resident that s/he was not alone (as the resident was new to the facility). These instructions were not added to the resident's service plan and there was no evidence staff were informed of, or provided, hourly checks.
* Following a fall on 9/30/20, Resident 3's service plan was updated for staff to encourage the resident to spend time in the common areas of the facility around other people to decrease anxiety and where the resident could be better supervised. Following another fall while in his/her apartment on 10/5/20, the facility failed to evaluate whether staff had been encouraging the resident to spend time in the common areas as instructed and whether that was an effective intervention or something new needed to be developed.
* On 10/20/20, the resident returned from an overnight hospital stay with a new prescription to begin Lasix (a diuretic used to treat fluid retention in the body). The facility did not update the resident's service plan and inform the staff to monitor the resident for needing to use the toilet more often (an effect of the diuretic) until 10/23/20. On 10/21/20, the resident was found on the floor after having pulled his/her call light for assistance to the bathroom. In her review of the fall, the facility RN wrote that staff should provide two-hour checks of the resident. However, there was no documented evidence the resident's service plan was updated and staff were instructed to begin two-hour checks.
* Resident 3 experienced a fall while in his/her room on 10/24/20. There was no review as to whether staff had been providing two-hour checks of the resident. The facility RN, in her review of the fall, documented that staff should ensure the call light cord was accessible for the resident. However, there was no documented evidence the directive was added to the resident's service plan and staff were informed of the intervention.
* The facility RN documented on 10/2/20 that Resident 3 developed two open areas on the buttocks and a red, painful area between the buttock cheeks. There was no documented evidence the skin issues were communicated to staff and actions or interventions were developed, documented and implemented to address the wounds.
The need to ensure the facility evaluated whether interventions were being followed and were effective, and that the facility updated Resident 3's service plan and communicated new instructions to staff following changes of condition, was reviewed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure actions and interventions were consistently developed and shared with staff for short term changes, interventions were monitored for effectiveness, and/or failed to consistently monitor changes through to resolution for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) who had changes of condition. Findings include, but are not limited to:
1. Review of Resident 5's record revealed the following:
Resident 5 was identified as a fall risk who had a history of falls. The resident could not express his/her needs and preferences.
Between 8/15/20 and 10/31/20, the resident had seventeen documented falls. Thirteen were non-injury falls. All falls had a corresponding service plan update but there was no documented evidence the facility monitored service-planned interventions for effectiveness.
On 11/4/20 during an interview with Staff 2 (Executive Director), she stated the facility had a new document they were using to evaluate fall interventions for residents. She was unable to provide a review for Resident 5.
The need to ensure interventions developed in response to changes of condition were adequate and monitored for effectiveness was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
2. A review of Resident 1's record revealed the following:
a. Resident 1 experienced 10 falls between 8/11/20 and 10/30/20. There was no documented evidence investigations of these falls included a review of previous interventions for effectiveness and/or new interventions developed after falls were consistently monitored for effectiveness.
b. Resident 1 was identified with a rash on his/her inner thighs on 9/11/20 and a bruise on the back of his/her left hand on 9/13/20. There was no documented evidence the skin issues were monitored at least weekly until they resolved.
The need to include a review of previous interventions for effectiveness and develop new interventions, monitor interventions for effectiveness and to monitor and document on short-term changes of condition at least weekly through resolution was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
3. A review of Resident 4's clinical record revealed several incidents where his/her behavior negatively impacted other residents and/or staff. With the exception of a resident-to-resident altercation on 10/10/20, there was no documented evidence Resident 4's behavior was being monitored or that interventions had been developed and implemented to mitigate the effect of his/her behavior on others.
The need to develop and implement interventions and to monitor their effectiveness was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
1. The Actions to be taken to correct each violation is the RN is to address each area. She will make corrections with RN assessments, Chart notes, and add any care plans that need completed as result. RN will ensure all information is communicated to the team.
2. The System will be corrected so these violations do not happen again by the following:
a. Updated incident reports for reminders to med techs for initial charting for skins, putting residents on alert, and added reminders for MCC and RN for care plan updates, Fall assessments. Also made an Incident report check list for Med techs to ensure they complete everything they need to.
b. Fall Assessment added to initial move in assessment, Quarterly assessment, and as needed.
c. Behavior Monitoring form for staff with RN triggered to review Monthly on specific date for all residents for behaviors noted.
d. All staff to do training on recognizing change of condition and monitoring. Binder created for all staff to access. Staff to document any changes noted in this binder and RN will check and respond.
e. Box for all Care plan updates created. This will be called the RED BOX. It will have all the new updates for the week. This is to be checked by RN weekly to ensure all updates are current and signed and charted on. Med techs to ensure all staff see these at the beginning of their shift and read and sign them prior to going on the floor.
f. Binder created for communication from RN to MCC. RN to document any changes noted and this will be signed off by both RN and MCC that these are completed timely.
3. How often willl we be evaluating these proccedures to ensure we are staying in compliance? Bi weekly meeting with MCC and RN with Executive Director. These items will be checked to ensure completed in a timely matter and all areas are completed.
4. Executive Director will ensure all processes are followed by all parties involved.
2. A progress note by the facility RN dated 10/2/20 indicated Resident 3 had developed "2 open areas, one on each buttock, pink and dry and non painful to touch." The RN documented she applied a barrier cream to the areas.
These open areas constituted pressure ulcers and are considered a significant change of condition for the resident for which an assessment by the facility RN was required.
There was no documented evidence the facility RN conducted an immediate assessment which included documentation of findings, resident status and interventions made as a result of this assessment.
The facility's failure to ensure the RN conducted an assessment of Resident 3's pressure ulcers was reviewed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the lack of an assessment.
Based on interview and record review, it was determined the facility failed to ensure an RN completed a significant change of condition assessment including findings, resident status and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 3) who experienced significant changes of condition. Findings include, but are not limited to:
1. Resident 1 was discharged from the hospital back to the facility on hospice care 10/26/20. The resident's care plan was updated on 10/27/20. In an interview on 11/4/20 Staff 1 (Administrator) stated Staff 2 (Executive Director) and Staff 12 (MCC) updated Resident 1's care plan on 10/27/20, not the RN. There was no documented evidence the RN completed a significant change of condition assessment, to include findings, resident status and interventions.
The need for the RN to complete significant change of condition assessments was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20 at 1:25 pm. They acknowledged the findings.
1. RN made chart note in regards to the change of condition. Anoter change of condition completed as well with all processes followed.
2. The system will be corrected in order to prevent this from happening again by:
a.All staff to do training on recognizing change of condition and monitoring. Binder created for all staff to access. Staff to document any changes noted in this binder and RN will check and respond.
b. Binder created for communication from RN to MCC. RN to document any changes noted and this will be signed off by both RN and MCC that these are completed timely.
3. How often willl we be evaluating these proccedures: Twice a month on regular date MCC and RN and Executive director will meet together to go over each resident and ensure these processes are completed.
4. Executive Director will ensure each bi weekly that these are completed and done in timely matter.
Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed staff. Findings include, but are not limited to:
Delegation records for Resident 2, reviewed on 11/5/20, indicated the facility RN failed to complete the process of delegation and document all required components of delegation in accordance with the OSBN Administrative Rules, including:
* Performing and documenting a nursing assessment of the resident's condition;
* Documentation as to how the RN determined the resident's condition was stable and predictable, given the resident had not received insulin injections in the past;
* Documentation of the rationale for deciding the task could be safely delegated to unlicensed persons;
* Documentation of how frequently the resident should be reassessed by the RN regarding continued delegation, including the rationale for the frequency based on the resident's needs;
* Documentation of the skills, ability and willingness of each individual unlicensed staff; and
* Evaluating whether or not to continue delegation of the task of nursing care based on the RN's assessment of the caregiver and the condition of the resident within at least 60 days from the initial date of delegation.
The requirements for proper delegation were reviewed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
1. RN to review her delgations and ensure all staff are competent and make a note for each staff.
2. The system will be corrected so this violation doesn't happen again by: Checklist created for RN to ensure all processes are followed with each delegation.
3. Checklist to be turned into Executive Director once completed for evaluation.
4. Executive Director will ensure completed.
Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 3 sampled residents (#3) who received home health or hospice services. Findings include, but are not limited to:
Resident 3 was recently admitted to the Memory Care Community with diagnoses including dementia with aggressive behavior, Alzheimer's disease, depression, anxiety and Parkinson's disease. The record indicated Resident 3 received home health mental health, PT and OT services from an outside provider to monitor and help manage the resident's history of aggressive behavior toward others, severe anxiety and repeated falls related to strength and balance.
Review of the "Outside Providers Communication Forms" indicated home health providers left the following instructions for the facility:
* 9/22/20: "Tell [Resident 3] what you are going to do so not to surprise [him/her] and back up if [s/he] tells you to - can be easily irritated - perhaps fearful. Address sleep with MD - please monitor. Monitor UTI symptoms: burning and incontinence."
* 9/30/20: "Please cue [Resident 3] to shift weight to left" in response to PT observations that the resident typically sat leaning to one side.
There was no documented evidence the facility updated the resident's service plan with these instructions or communicated the new instructions to staff.
The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
1. Chart note this was documented and care plan update completed and communicated to staff.
2. The system to correct this violation is as follows:
a. A box designated for outside provider notes to be placed in med room. MCC's will review all outside provider notes and make all necessary care plan updates prior to giving to RN for review. Copy of care plan update will be attached to outside provider note for RN to review. RN will review and sign off on note once ensuring all care plan updates and charting is completed.
3. Executive Director will provide monthly audits of system
4. Executive director will ensure compliance
3. Resident 3's 10/2020 MAR was reviewed for accuracy. The following deficiencies were identified:
* Administration of the resident's routine Sinemet (medication used to treat symptoms of Parkinson's disease) was left blank on 10/15/20 and 10/29/20. There was no documentation as to whether the resident received the medication as prescribed.
* The effectiveness of PRN medications administered was not consistently documented as follows: Tylenol (for pain) on seven occasions, lidocaine gel (for pain) on one occasion and Seroquel (to treat agitation) on six occasions.
* Nystatin powder (an antifungal topical medication) was administered on 10/21/20 without documentation as to why or where it was administered. The instructions for the Nystatin powder on the MAR lacked information as to what condition the medication was to be administered for, stating only "Apply to affected areas as needed."
The need to ensure the MAR was accurate and complete was reviewed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure that MARs/TARs were complete and accurate, reflective of directions to staff, no blanks were left on the MARs/TARs, medication effectiveness was documented and contained resident-specific parameters for PRN medications for 3 of 4 sampled residents (#s 1, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:
1. A review of Resident 5's MAR, effective 10/10/20 through 10/31/20, revealed the following:
* Multiple blanks on the MAR for meal monitoring;
* Not following PRN orders to give acetaminophen prior to morphine; and
* Not consistently documenting effectiveness of PRN medications once given.
The need to ensure MARs/TARs were complete and accurate was discussed on 11/5/20 with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner). The staff acknowledged the findings.
2. A review of Resident 1's 10/2020 MAR revealed the following:
* The effectiveness of several PRN medications was not consistently documented; and
* The resident's use of oxygen was not listed on the MAR.
The need for staff to follow-up on and document the effectiveness of PRN medications administered to residents and to include all treatments on the MAR was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
1. All orders needing correction in MAR was fixed. All med techs were trained on signing out after administration, and how to properly document on effectiveness. These were reviewed and updated accordingly.
2. The system will be corrected for this violation by the following:
a. Med Techs given Training on Documentation of PRN medications, effectiveness, and following MAR orders with signing off they understand the training.
b. Med Techs to check Dashboard at each shift change and sign off there are no missing items and all tasks are completed
3.Med variance report to be pulled and reviewed weekly by MCC.
4. Executive Director will review the completed variance report by MCC BI-weekly
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 for 2 of 2 sampled residents (#s 2 and 3) who were prescribed PRN medications to treat the residents' behaviors. Findings include, but are not limited to:
1. Resident 2 was prescribed PRN lorazepam to treat symptoms of anxiety. The 10/2020 MAR indicated the resident was administered the medication on 16 occasions.
The facility failed to document non-pharmacological interventions were attempted and ineffective prior to administering the psychotropic medication on 9 of the 16 occasions. The facility failed to document the effectiveness of the medication after it was administered on 12 of the 16 occasions.
2. Resident 3 was prescribed PRN Seroquel (an antidepressant) to treat the resident's agitation. The 10/2020 MAR indicated the resident was administered the medication on 12 occasions.
The facility failed to document non-pharmacological interventions were attempted and ineffective prior to administering the psychotropic medication on 4 of the 12 occasions.
The need to ensure staff attempted and documented non-pharmacological interventions were ineffective prior to administering PRN psychotropic medications to treat a resident's behavior was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
1. Staff educated on how to document non pharmacological interventions as well as how to document the effectiveness. They signed off they received this education.
2. The system in place to ensure this vilation is resolved is as follows:
All PRN psychotropics will be evaluated weekly by RN to ensure all interventions are documented and effectivenss is accurately documented as well.
3. To ensure this system is working the Executive Director will review this Bi-weekly.
4. The Executive Director will ensure this system is monitored and completed.
Based on interview and record review, it was determined the facility failed to ensure direct care staff were trained in the use of abdominal thrust and First Aid within 30 days of hire for 1 of 3 sampled direct care staff (#16) whose training records were reviewed. Findings include, but are not limited to:
On 11/5/20 review of staff training records and interview with Staff 1 (Administrator) and Staff 2 (Executive Director) indicated the following deficiencies:
There was no documented evidence that Staff 16 (CG) had completed training on First Aid and abdominal thrust within 30 days of hire.
On 11/5/20 the need to ensure direct care staff had completed all required training within 30 days of hire was discussed with Staff 1 and Staff 2. They both acknowledged the findings.
1.All employees needing this training will receive ASAP.
2. The system in place to ensure this vilation is resolved is as follows:
Administrator will follow checklist for new hire and ensure all areas complete within staff 1st 30 days.
3. This will be evaluated monthly to ensure all items completed.
4. To ensure compliance Executive Director ensure all items completed.
Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:
Fire drill and fire and life safety training records from 5/21/20 to 9/30/20 were reviewed on 11/4/20. The following deficiency was identified: There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.
The requirements regarding fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) and Staff 2 (Executive Director) on 11/4/20 They acknowledged the findings.
1. Schedule developed for trainings for staff on fire and life safety.
2. The system in place to ensure this violation is in compliance is as follows:
Administrator will plan trainings for staff on alternating months for life safety and fire safety instruction.
3. Administrator will submit trainings to Executive Director once completed bi-monthly to ensure compliance.
4. To ensure this stays in compliance Executive director will ensure Adminsitrator stays in compliance.
Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building. Findings include, but are not limited to:
In an interview with Staff 1 (Administrator) and Staff 2 (Executive Director) on 11/4/20 at 10:45 am, Staff 1 was asked to explain the facility's process for reviewing fire and life safety procedures with residents annually. Staff 1 acknowledged the facility hadn't finished developing a plan to review safety procedures with residents annually.
The requirements regarding fire and life safety instruction for residents were reviewed with Staff 1 (Administrator) and Staff 2 (Executive Director) on 11/4/20 They acknowledged the findings.
1. Instruction given to all residents that have been in facility for 1 year and this was documented in chart note.
2. The system in place to ensure this violation will be resolved is to have MCC to review fire safety with each resident/family when doing quartelry reviews. This will be documented in resident chart once completed.
3.To ensure this is completed Executive director will do quartelry audits on residents to ensure compliance.
4. The Executive Director will oversee this.
C 260: 411-054-0036(1-4) Service Plan: General. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include
resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (b) The initial service plan must be reviewed within 30-days of move- in to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
C 303: 411-054-0055 (1)f-h Systems: Treatment Orders. (f) Medication and treatment orders must be carried out as prescribed.
Based on observation, interview and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to:
Refer to C 372, C 420 and C 422.
Refer to C 372, C 420 and C 422.
C372
Based on interview and record review, it was determined the facility failed to ensure staff had completed orientation training prior to beginning job duties, and pre-service training prior to providing care and services independently for 4 of 4 sampled newly hired staff (#s 10, 14, 15 and 16) whose training records were reviewed. Findings include, but are not limited to:
On 11/5/20, review of staff training records and interview with Staff 1 (Administrator) and Staff 2 (Executive Director) indicated the following deficiencies:
a. There was no documented evidence Staff 14 (CG) and Staff 15 (Cook) completed orientation training prior to beginning job duties, and Staff 15 was not provided a written job description.
b. There was no documented evidence Staff 10 (MT) completed pre-service dementia training on the topics:
* Dementia disease process, including progression of the disease, memory loss and psychiatric and behavioral symptoms; and
* Techniques for understanding, communicating and responding to distressful behavioral symptoms.
c. Staff 10, Staff 15 and Staff 16 (CG) did not receive dementia training through an approved curriculum for the topic "Strategies for addressing social needs of persons with dementia and engaging them in meaningful activities."
d. There was no documented evidence Staff 10, 14, 15 and 16 received training on "Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.)"; Staff 14 and Staff 15 did not have documentation of training on "Family support and the role the family may have in the care of the resident"; and Staff 15 did not have documentation of training on "How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment."
e. There was no documented evidence Staff 10, 14 and 16 demonstrated competency on the topic of "Changes associated with normal aging" within 30 days of hire.
f. Staff 14 and 16's caregiver competency checklist form did not indicate a date the staff person was determined to be competent and able to work independently with residents.
On 11/5/20 the need to ensure staff had completed orientation training prior to beginning job duties and pre-service training prior to providing services independently was discussed with Staff 1 and Staff 2. They both acknowledged the findings.
1. Job descriptions updated and given to all staff members and signed. All trainings needed for staff completed including: "Environmental factors that are important to resident's well-being,"Family support and the role the family may have in the care of the resident"; "How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment.", "Changes associated with normal aging"
2. The system in place to prevent rule violation is: Checklist in place for Administrator to follow for all trainings needed prior to being alone on the floor and trainings needed within 1st 30 days. Adminstrator to check off each item as completed and keep in staff file along with all completed training records.
3. To ensure compliance Executive director will do monthly audits on staff files on all new hires to ensure compliance.
4.The Executive Director will ensure Administrator is staying in compliance.
Based on observation, interview and record review, it was determined the facility failed to provide healthcare services in accordance with OARs 411 Division 54 for Assisted Living and Residential Care Facilities. Findings include, but are not limited to:
Refer to C 270, C 280, C 282, C 290, C 310 and C 330.
Refer to Refer to C 270, C 280, C 282, C 290, C 310 and C 330
Based on interview and record review, it was determined the facility failed to ensure a comprehensive activity evaluation and individualized activity plan was completed for 2 of 4 sampled residents (#s 1 and 3) whose activity records were reviewed. Findings include, but are not limited to:
Resident activity evaluations and activity sections of each service plan were reviewed. Resident 1 and 3's evaluations and activity plans were deficient in the following areas:
* The evaluations noted past and current interests, abilities and skills, emotional needs and patterns and physical abilities but did not clearly identify physical limitations, adaptations necessary for the resident to participate and activities that could be used as behavioral interventions.
* The information from the evaluation was not used to develop an individualized activity plan which described what activities would be provided for the resident and instructions for staff as to how to encourage the resident's participation and support and assist him/her in activities.
Resident 1 and 3's activity evaluations and activity plans were reviewed with Staff 1 (Administrator), Staff 2 (Executive Director) Staff 3 (Co-owner) and Staff 4 (Co-owner) on 11/5/20. They acknowledged the findings.
1. All Residents actvity evaluations updated and these to be used to update care plans.
2. The system in place to prevent violation is as follows:
Activity director to update evaluation form to have physical limitations, adaptaions necessary for resident, activites for behavioral interventions included.
MCC to use the evaluation form for reference when builiding personalized care plan.
3. Executive Director will evaluate this for completion on a quartelry basis.
4. The executive Director will ensure compliance.
