The findings of the re-licensure survey conducted 01/11/22 through 01/14/22 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-licensure survey of 01/14/22,  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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 01/14/22, conducted on 10/12/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.

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 01/11/22 through 01/14/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

1. Terminated administrator on 1/17/22.

2. Temporary Administrator, Michele Peterson and RN/LN to implement all policies and procedures aligned with OAR.

3. Progress will be monitored by chart audits every 2 weeks, by administrator, RN and LN.

Based on interview and record review, it was determined the facility failed to thoroughly investigate resident incidents and injuries of unknown cause to rule out abuse and report to the local SPD office if abuse and/or neglect could not reasonably be ruled out for 3 of 4 sampled residents (#s 1, 2 and 4) who experienced incidents and injuries of unknown cause. Findings include, but are not limited to:  

1. Resident 1 was admitted to the facility in 11/2018 with a diagnosis of Parkinson's disease.

Review of Resident 1's 10/16/21 through 01/10/22 progress notes, incident reports and investigations and his/her 11/13/21 service plan revealed the following :

Resident 1's 11/13/21 service plan identified the resident as impulsive and a high fall risk and instructed staff to provide one-person assist with toileting.

* An incident report dated 11/27/21 indicated Resident 1 was being assisted back to bed when s/he leaned back, fell and sustained an abrasion to his/her right elbow.

There was no documented evidence the facility investigated the fall with injury to rule out abuse/neglect, including follow-up action and measures to prevent reoccurrence and failed to report the incident to the local SPD office.

* An incident report dated 12/16/21 indicated the resident was left unsupervised in the bathroom and experienced a fall from which s/he sustained bruising. Review of the facility documentation revealed the facility failed to thoroughly investigate the incident to rule out abuse and neglect and failed to report the incident to the local SPD office.

*A progress note dated 12/27/21 indicated the resident fell "hit head, no pain, no bruising, decreased range of motion, no headache, no blurry vision." There was no documented evidence the facility investigated the fall to rule out abuse and/or neglect and did not report the incident to the local SPD office.

The need to ensure all incidents and injuries were thoroughly investigated to rule out abuse and/or neglect and report to the local SPD if abuse and/or neglect could not reasonably be ruled out was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/13/22. They acknowledged the findings.

The above incidents were self-reported by the facility per the survey team's request. Confirmation of the report was provided prior to survey exit.

2.  Resident 2 was admitted to the facility in 3/2019 with a diagnosis of dementia.

Review of Resident 2's 10/14/21 through 01/10/22 progress notes and incident reports and investigations revealed the following:

An incident report dated 12/11/21 revealed staff observed blisters on the top and side of the resident's right foot and indicated they were injuries of unknown cause. The facility failed to thoroughly investigate the blisters to rule out abuse and/or neglect, failed to ensure the investigation was reviewed by the administrator and failed to report the injury of unknown cause to the local SPD office when abuse and/or neglect was not reasonably ruled out.

The need to ensure injuries of unknown cause were thoroughly investigated to rule out abuse and/or neglect and reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/14/22. They acknowledged the findings.

The injury of unknown cause was self-reported by the facility per the survey team's request. Confirmation of the report was provided prior to survey exit.

3. Resident 4 was admitted to the facility in 08/2021 with a diagnosis of dementia.

A progress note dated 12/28/21, stated staff discovered a skin tear on the resident's right elbow. There was no documented evidence the facility investigated the cause of the skin tear and there was no documented evidence the facility reported the incident to the local SPD office.

The need to ensure injuries of unknown cause were thoroughly investigated and reported to the local SPD office was discussed with Staff 1 (Owner), Staff 2 (LPN) and Staff 14 (RCF Administrator) on 01/13/22. They acknowledged the findings and reported the incident to the local SPD office, per the survey team's request. Confirmation of the report was provided on 01/13/22.

1. All staff training to policy and OAR requirement with signature of acknowledgement by staff.  This instruction will be done on Oregon Care Partners or LN by 02/28/22.

2. Proper incident report training during all staff meeting by Admin/LN 03/15/22.

3. Each IR will be audited for compliance to poilcy and OAR weekly x 30 days, then quarterly thereafter by LN.

4. PT #1-11/27/2021, 12/6/2021 and 12/27/21 investigation reported to APS. Pt #2 12/11/21 and 12/28/21 investigated and reported to APS.

Based on observation and interview, it was determined the facility failed to prepare and serve food in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to:

A tour of the kitchenette on 01/11/22 at 11:50 am showed the following areas in need of cleaning or repair:

A. Food preparation area

* Worn varnish on multiple cabinet surfaces, exposed bare wood creating an uncleanable surface;

* Grimy gray buildup on cabinetry;

* Sticky floor surface throughout;

* Gap in linoleum flooring 1" wide, with dark debris accumulated in gap;

* Warped particle board shelving with jagged edges in cupboard to right of ovens;

* Loose food debris in drawers;

* Spills and smudges inside microwave;

* Broken faceplate on oven;

* Buildup of dust and gray matter, including strands hanging down, on exhaust vent in ceiling above dishwashing area;

* Caulking missing behind sink;

* Gouges and small chunks of wall missing behind sink;

* Dried dark brown food spill, 4"x 7", on lowest shelf of refrigerator between two freezers (Refrigerator 1);

* Non-resident lunches and drinks were stored in Refrigerator 1;

* Refrigerator 2, near the sink, contained multiple containers of yogurt, 4 cartons of thickened lemon water, and a bottle of ketchup that were past expiration dates; and

* Bottled condiments requiring refrigeration were improperly stored in cupboard.

The expired items and non-refrigerated condiments were shown to Staff 1 (Owner) on 01/11/22. She immediately disposed of them.

B. Dry food storage pantry

* Shelves constructed of unfinished particle board, which created an absorbent, uncleanable surface;

* Gray matter on one side of box fan, stored adjacent to open food storage bin;

* Food splatters, drips and smudges on shelves, storage containers, light switches and box fan;

* Loose food debris on shelves;

* Eye protection/face shield, labeled with caregiver initials, sitting on top of packaged plastic cutlery in bin; and

* Missing caulk and accumulation of black matter in seam in of linoleum flooring between pantry and janitor closet.

C. Janitor closet off pantry

* Hole in wall by base of mop sink, approximately 2" in diameter, with exposed drywall;

* Splatters on wall behind mop sink and garbage can; and

* Buildup of black matter around mop sink.  

The surveyor walked through the kitchenette with Staff 1 on 01/14/22 at 11:00 am. She acknowledged the areas requiring cleaning or repair.

1. All expired items disposed of.

2. Kitchen deep cleaned by outside professional.

3. All refridgerators emptied.

4. Complete kitchen and pantry remodel scheduled and delayed due to COVID. See attached bid.

5. Kitchen maintenance binder to be kept in the kichen. Monthly report submitted to Admin/Maintenance to repair.

Based on observation and interview, it was determined the facility failed to prepare and serve food in accordance with the Food Sanitation Rules OAR 333-150-00. This is a repeat citation. Findings include, but are not limited to:

A tour of the kitchenette on 03/30/22 at 10:50 am showed the following areas in need of cleaning or repair:

A. Food preparation area

* Worn varnish on multiple cabinet surfaces, exposed bare wood creating an uncleanable surface;

* Gap in linoleum flooring 1" wide, with dark debris accumulated in gap;

* Broken faceplate on oven;

* Caulking missing behind sink; and

* Gouges and small chunks of wall missing behind sink.

B. Dry food storage pantry

* Missing caulk and accumulation of black matter in seam in of linoleum flooring between pantry and janitor closet.

C. Janitor closet off pantry

* Hole in wall by base of mop sink, approximately 2" in diameter, with exposed drywall;

* Faucet over mop sink leaking and spraying onto surrounding walls and floor;

* Splatters on wall behind mop sink and garbage can; and

* Buildup of black matter around mop sink.  

The surveyor walked through the kitchenette with Staff 15 (Administrator) and Staff 3 (Maintenance) at 11:00 am. They acknowledged the areas requiring cleaning or repair.

Facility is undergoing a complete kitchen remodel.  This remodel will be needed to be in compliance with the POC. Facility will be asking for and extension for date of compliance.  Please see attached information for completion of kitchen and pantry and janitors closet mentioned in the POC.  All cooking is done in the larger facility next door and the kitchenette is only used to serve and wash dishes. Facility will continue this plan until the kitchen remodel is complete.

3. Resident 1 was admitted to the facility in 11/2018 with diagnoses including Parkinson's disease.

Review of Resident 1's 12/09/21 service plan, 10/16/21 through 01/10/22 progress notes and incident investigations, and 8/23/21 home health PT note revealed the service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Safety related to the use of a lap belt as a device with restraining qualities; and

* Resident 1's tendency to lean back when sitting and standing unsupported.

The need to ensure service plans were reflective of the resident's current status and provided clear direction to staff was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/13/22. They acknowledged the findings.

4. Resident 2 was admitted to the facility in 03/2019 with diagnoses including dementia.

Review of Resident 2's 12/10/21 service plan, interviews with staff and observations of the resident revealed the resident's service plan was not reflective of the resident's current status and care needs and did not provide clear direction to staff in the following areas:

* Positioning for eating;

* Wounds on right ankle/foot; and

* Resident 2's communication ability.

The need to ensure service plans were reflective of the resident's current status and care needs and provided clear direction to staff was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/13/22. 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' current care needs and provided clear direction to staff for 4 of 5 residents (#s 1, 2, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 08/2021 with a diagnosis of dementia.

On 01/12/22, Resident 4 was observed sleeping through the lunch meal. Staff 6 (MT) stated Resident 4 had a poor appetite and frequently slept through meals.

Review of Resident 4's service plan dated 12/10/21, indicated the service plan was not reflective and/or did not provide clear direction to staff in the following care areas:

* Home health services; and

* The resident's tendency to sleep through or refuse meals.

The need to ensure service plans were reflective of residents' current care needs and provided clear direction to staff was discussed with Staff  1 (Owner), Staff 2 (LPN) and Staff 14 (RCF Administrator) on 01/13/22.

2. Resident 5 was admitted to the facility in 01/2021 with a diagnosis of dementia.

Review of Resident 5's service plan dated 11/21/21, indicated the service plan was not reflective and/or did not provide clear direction to staff related to use of a wrap around Posey seatbelt on the resident's wheelchair and recliner. Refer to C 340,  example 1.

The need to ensure service plans were reflective of residents' current care needs and provided clear direction to staff was discussed with Staff  1 (Owner), Staff 2 (LPN) and Staff 14 (RCF Administrator) on 01/13/22.

1. Temporary service plans will be incorporated into the service plan creation and renewals at 30 days, 90 days and change of condition.

2. All direct care staff are to sign new service plans at the start of every shift.  SP binder is kept in the employee resource room to include SP and TSP for each resident. Administrator/LN will monitor all TSP weekly to ensure all care personnel have read, understood and signed the TSP.  All TSP's will remain with the SP until quarterly evals are completed and changes identified and the TSP's are incorporated into the SP.

3. Weekly for TSP and with each SP renewal, by Administrator and LN.

4. See POC for C150

5. Residents 1 and 5 had immediate TSP's put into place regarding Posey belts and teaching to staff done immediately by RN/OWNER. Physical therapy ordered to assess both of these residents as well regarding the posey belts.  

Residents 2 and 4 had careplans rewritten and updated and doctors orders obtained for changes in careplan. Staff read and signed careplan updates.

Resident 4 also had a COC and RN assessment for sleeping through meals as well as MD order for ST eval for diet recommendations.

#2 wound was assessed by nurse IR made and followed through until resolution of wound.

Based on interview and record review, it was determined the facility failed to ensure actions and interventions were determined, documented, and communicated to staff on all shifts, evaluated for effectiveness and conditions monitored at least weekly through resolution for 3 of 3 sampled residents (#s 1, 2  and 4) who experienced short-term changes of condition. Resident 1 experienced repeated falls with injuries. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2018 with diagnoses including Parkinson's disease.

Review of Resident 1's 12/09/21 service plan, 10/16/21 through 01/10/22 progress notes and incident investigations revealed the following:

Resident 1's 12/11/21 service plan identified the resident as impulsive and a high fall risk. There were multiple fall preventions interventions listed on the service plan to minimize falls.

a. Resident 1 experienced four falls between 10/16/21 and 01/10/22:

*10/23/21: Witnessed fall with bruising on left hand;

*11/27/21: Witnessed fall with abrasion to right elbow;

*12/16/21: Unwitnessed fall with bruising on right hip, upper back and left thigh; and

* 12/27/21: A progress note indicated the Resident 1 fell and hit his/her head. There was no documentation whether the the fall was witnessed.

There was no documented evidence the facility evaluated the efficacy of existing fall prevention interventions following each fall, determined and documented what actions and interventions were needed for the resident and communicated them with staff on all shifts related to fall prevention. The resident continued to fall and sustained multiple injuries, causing a serious risk to the health, safety, and welfare of the resident.

b. An incident report dated 11/27/21 indicated Resident 1 had sustained an abrasion to his/her right elbow during a fall. There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident related to the abrasion and no evidence the abrasion was monitored at least weekly through resolution.

c. The following skin issues were not monitored at least weekly through resolution:

* Bruise on Resident 1's left hand sustained during a fall on 10/23/21; and

* A bruise on his/her left knee identified in progress notes on 10/24/21.

The failure of the facility to determine and document what actions and interventions were needed for the resident when s/he experienced short-term changes of condition, communicate them to staff on all shifts, evaluate the interventions for effectiveness and monitor the conditions at least weekly was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/13/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 03/2018 with diagnoses including dementia.

Review of 10/14/21 through 01/10/22 progress notes and incident investigations revealed the following:

An incident report dated 12/11/21 indicated the resident had a "blister on [his/her] right top foot and another on the outside of [his/her] foot."

Review of progress notes revealed the resident was put on alert charting for the blisters on 12/14/21, three days after they were observed. Documentation related to monitoring of the progress of the wounds reviewed from 12/14/21 through 01/10/21 revealed the facility failed to consistently identify the location, size and status of the blisters.

The need to promptly identify what actions and interventions were needed for residents when they experienced short-term changes of condition, communicate them to staff on all shifts, update the service plan and monitor each resident based on their evaluated needs and condition was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/13/22. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 08/2021 with diagnoses including dementia and weakness.

A progress note dated 11/24/21, stated Resident 4 returned from the hospital with a stage I wound on his/her coccyx. There was no documented evidence the facility determined interventions or monitored the wound through resolution.

During an interview on 01/13/22 Staff 6 (MT) and Staff 9 (CG) stated when the resident returned from the hospital there was a slight pink area on the residents coccyx but no actual wound. They stated the caregivers check each residents' skin during bathing and the resident did not have any current skin issues.

The need to ensure, when residents experienced changes in condition, the facility determined interventions and monitored conditions through resolution was discussed with Staff 1 (Owner), Staff 2 (LPN) and Staff 14 (RCF Administrator) on 01/13/22. They acknowledged the findings.

1. Change of condition log given to RN to track all change of conditions. RN to review weekly with administrator and LN.

2. Daily clinical meeting binder to go over documentation and to assure progress notes, timely treatment and follow up until resolved/DC'd. To be done by Administrator,RN,LN.

3. Evaluate at quarterly team meetings, at time of service plan, to review and audit that changes are effective, to be done by Administrator,RN, LN.

4. See also POC for C260.

5.Resident 1-related to falls, IR and investigation performed on falls, changes made to careplan and teaching to staff.  PT assessment, all bruises followed through resolution by LN, self report to APS.

Res #2 blister was put on IR and in wound tab and followed by LN to resolution.  MD order obtained to DC TED hose which was believed to be causing the blister.

Res #4 Stage 1 wound from hospital, assessment done by LN no skin issues at this time.  

2. Resident 1 was admitted to the facility in 11/2018 with diagnoses including Parkinson's disease.

Review of Resident 1's 11/03/21 quarterly evaluation for the use of a lap belt as a supportive device with restraining qualities used to prevent falls revealed it lacked documented evidence the facility had instructed caregivers on the correct use and precautions related to use of the device.

The need to ensure quarterly evaluations of supported devices with restraining qualities included documented evidence the facility had instructed caregivers on the correct use and precautions related to use of the device was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/12/22. They acknowledged the findings.

During an interview with Staff 1 on 01/13/22, she reported she verbally instructed caregivers related to the safe use of Resident 1's seatbelt and provided a copy of a temporary service plan which accompanied the instruction.  

Based on observation, interview and record review, it was determined the facility failed to ensure devices with restraining quality were thoroughly assessed by an RN, PT or OT prior to use and quarterly and the assessment included documented evidence the facility had instructed caregivers on the correct use and precautions related to use of the device for 2 of 2 sampled residents (#s 1 and 5) who had wheelchair seatbelts. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 01/2021 with a diagnosis of dementia.

During the acuity interview on 01/11/22, the facility reported Resident 5 had a seatbelt on his/her wheelchair.

During the survey, Resident 5 was observed in his/her wheelchair with a seatbelt device in place.

A quarterly "Supportive Devices with Restraining Qualities Evaluation" completed by the facility RN dated 11/20/21, did not include documented evidence the facility had instructed caregivers on the correct use and precautions related to use of the device.

During an interview on 01/12/22, Staff 9 (CG), reported the facility used the seatbelt as a fall prevention because Resident 5 had multiple falls in the past, some with serious injury. Staff 9 stated they were not aware of any precautions regarding the potential safety risks of the device.

During an interview on 01/12/22, Staff 6 (MT) stated Resident 5 only required the seatbelt when in the wheelchair and staff completed safety checks every two hours.

Resident 5's current service plan dated 11/21/21, did not provide adequate instruction to staff related to how staff should use the device, such as how staff should apply and fasten the device. Additionally, the service plan and did not provide information related to precautions or possible risks of using the device.

The need to ensure devices with restraining quality were thoroughly assessed by an RN, PT or OT prior to use and quarterly and the assessment included documented evidence the facility had instructed caregivers on the correct use and precautions related to use of the device was discussed with Staff 1 (Owner), Staff 2 (LPN) and Staff 14 (RCF Administrator) on 01/13/22. They acknowledged the findings and provided documentation of staff training and updated Resident 5's service plan.

1. All care staff to take training on devices with restraining qualities by 3/15/22. This training will be provided by LN/RN.

2. LN/RN to do staff training on devices with restraining qualities safety upon hire and annually.

3. To be monitored quarterly by administrator.

4. As stated on page 31 of SOD,Res #5 Had immediate TSP made regarding teaching of Lap belt, all staff physically shown by LN as well to ensure safety, Physical Therapy eval since to address need of lap belt and safe use.  Res #1 As stated on page 32 of SOD, on 1/13/22 LN immediately provided physical instruction as well as a TSP for staff to sign. Since that time we have also aquired a PT evaluation for saftey and teaching regarding the seatbelt.  

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

Refer to C240.  

Based on observation and interview, it was determined the facility failed to ensure exterior pathways were made of smooth material and maintained in good repair, and chemicals were inside locked storage. Findings include, but are not limited to:

The exterior of the facility was toured on 01/11/22 at 1:30 pm. The following was identified:

*Two areas of concrete were deteriorated on entrance pathway, approximately 12" x 12" and 4" x 2" up to 1" deep, creating a tripping hazard; and

*Two bottles of spray disinfectant were noted to be in an unlocked portable canopy shelter in resident outdoor recreation area.

The exterior areas were reviewed with Staff 1 (Owner) on 01/12/22 at 11:00 am. She acknowledged the findings, and had the disinfectant removed immediately.

1. Concrete to be fixed by Star Builders. See attached bid.

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

Refer to C 150, C 231, C 240 and C 510.

See POC for tags C260,C270 and C340.

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

Refer to  C240.  

Please see POC for tag 240.

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

Refer to C 260, C 270,  and C 340

See plan of correction for tags C260.C270.C340.

2.  Resident 2 was admitted to the facility in 03/2019 with diagnoses including dementia.

Review of the resident's 12/11/21 service plan revealed the individualized nutrition and hydration plan lacked information related to the resident's food and fluid preferences.

The need to ensure the resident's individualized nutrition and hydration plan included information related to the resident's preferences was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/13/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an individualized hydration and nutrition plan was developed based upon the residents' preferences and needs and was documented in the residents' service plan for 2 of 2 sampled residents (#s 2 and 4) whose nutrition service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 08/21 with a diagnosis of dementia.

Resident 4's nutrition service plan lacked individualized food preferences and did not address the resident's tendency to sleep through and refuse meals.

The need to ensure an individualized  hydration and nutrition plan was developed based upon the residents' preferences and needs and was documented in the residents' service plan was discussed with Staff 1 (Owner), Staff 2 (LPN) Staff 14 (RCF Administrator) on 01/13/22. They acknowledged the findings.

See plan of correction for tag C260

Facility put together a diet book for each resident specific to each indivduals wants and needs. Diet book is in the kitchen. Will be started at admit and evaluated quarterly and Change of condition.

Res 4 had a diet page put in the kitchen regarding indivdual needs, TSP in place about residents tendency to sleep through meals and refuse meals.

Res #2 had diet order entered into the kitchen, TSP and nursing order to update appropriate thickness for fluids.  .

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed and included in the resident's service plan for each resident based on their activity evaluation for 2 of 2 sampled residents (#s 2 and 4 ) whose service plans were reviewed. Findings include, but are not limited to:

1.  Resident 2 was admitted to the facility in 03/2019 with diagnoses including dementia.

Review of Resident  2's 12/11/21 service plan revealed it offered some information about the resident's interests and listed activities that could be used as behavioral interventions, but the facility failed to document an evaluation of the following required elements:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations; and

* Adaptations necessary for the resident to participate;

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

The need to ensure all residents had an individualized activity evaluation based on their evaluation and included in the service plan was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/13/22. They acknowledged the findings.

2.  Resident 4 was admitted to the facility in 08/2021 with diagnoses including dementia and weakness.

Review of  Resident 4's records indicated the information from the "Activity Interest Survey" and the "Personality and Experience Profile" evaluations was not included in the resident's activity service plan and the evaluations did not include required information related to the resident's physical abilities and limitations.

The need to ensure the activity evaluation included all required information and the  information was included on the resident's activity service plan was discussed with Staff 1 (Owner) and Staff 2 (LPN) on 01/13/22. They acknowledged the findings.

1.Activity and social history form created and will be added to admissions paper work by Administrator.

2. Activity director will be responisble for following up with families to assure these are turned in as well as interviewing new residents to deveolp activity plan.

3. Activity director will turn in plan to administrator at time of service plan creation and renewals at 30 days,90 days and change of condition.

4. Activity plan will be a part of the service plan.  

5. Activity director will maintain activity service plan book and add changes as needed in between service plan review dates.

6. Any changes will be added to service plan upon service plan review by administrator.

7. Admissions paperwork audit form completed by administrator and maintained in the resident chart.  

8. Quarterly QA meetings to ensure changes made are effective and being followed.

9. Appropriate Activity staff to complete training through OCP by 2/25/22

Res #2 has the above listed forms filled out and CP updated with abilities and limitation and adaptations necessary for participation

Res #4 has service plan updated to reflect the findings of the activity interest survey as well as the personality and experience profile. Will continue to work on the above forms to meet compliance by 3/15/22.

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The facility's outdoor area was toured on 01/11/22 at 1:45 pm. The following was identified:

* A rattan couch, a rattan loveseat, and a metal chair were not of sufficient weight and could be easily moved, which created a potential safety and/or elopement risk.

These findings were discussed with Staff 1 (Owner) during a walkthrough of the outdoor recreation area on 01/12/22 at 11:00 am. She acknowledged the findings and reported maintenance was in the process of securing the furniture.

Maintenance will lock down furniture with metal teather.

Maintenance will perform monthly walk through enviroment tour and repair as needed.