The findings of the change of ownership survey, conducted 06/13/22 through 06/15/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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 first re-visit to the change of ownership survey of 06/15/22,  conducted on 09/29/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen on 06/13/22 revealed:

* Facility was not using pasteurized eggs when making eggs with runny yolks;

* No thermometers in one refrigerator and both freezers; and

* Multiple dented cans.

The dented cans were discarded on 06/13/22. No thermometers were placed in the refrigerator or two freezers before the surveyor exited on 06/15/22.

The need to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Executive Director) and Staff 4 (Executive Chef) on 06/15/22. They acknowledged the findings.

Applegate House of Grants Pass will implement the

following:

C240

1. Eggs will be kept in their original container that

specifies that they are pasteurized. Thermometers

were purchased for the refrigerator and freezers. Cans

with dents were discarded.

2. Only pasteurized eggs will be purchased.

Refrigerator and Freezer temp logs will be maintained.

Dented cans will be discarded.

3. Weekly monitoring will be done.

4. The Assistant ED and/or Executive Director will be

responsible for monitoring.

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:

During the change of ownership survey conducted on 06/13/22 through 06/15/22, there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community.

One activity calendar was provided for the MCC during the survey and included scheduled activities for each day of the week.

Scheduled group activities during the week for the MCC were to take place between 9:00 am and 3:00 pm. Activities listed on the calendar from 06/13/22 through 06/15/22 included bake time, bingo, outside games, and AM exercise.

Multiple observations of the MCC on 06/13/22 through 06/15/22 showed none of the scheduled activities occurred. Residents were seen sitting in the living room listening to the love songs station on the television, in the dining room or were in their rooms.

In an interview on 06/14/22, Staff 1 (Administrator) stated they did their best to perform activities but sometimes it was hard to get the residents to participate. The surveyor asked the facility to provide individual activities plans for the three sampled residents. Staff 1 was unable to provide the individual activity plans.

During the survey, residents were observed sleeping in their rooms, wandering the halls, or sitting in front of the TV in the common living room area of the MCC.

The lack of an activity program was discussed with Staff 1 (Administrator 1) and Staff 2 (VP of Management Services) on 06/15/22.  They acknowledged the findings.

C242

1. Individual Activity Logs have been created and implemented. The logs will specify the staff on duty and

will include the scheduled activities as well as

individualized activities that are specific to the

indiviuals likes, needs, and physical limitations. The

staff will be required to document participation and/or

refusals.

Memory Care Activity boxes are being created to offer

variety for those that refuse the scheduled activities.

All staff are being required to take the "Teepa Snow:

Filling the Day with Meaning" course

2. All new hires will be trained on how to use the

activity logs, what to do in the event that a resident

refuses, and they will be required to take the "Teepa

Snow: Filling the Day with Meaning" course.

3. The logs will be reviewed weekly.

4. The Assistant ED and/or the Executive Director will

monitor the forms weekly.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of resident care needs and provided clear direction to staff for 1 of 3 sampled residents (# 1). Findings include, but are not limited to:

Resident 1's most recent service plan, dated 05/18/22, revealed it was not reflective of the resident's care needs and lacked clear direction to staff in the following areas:

* Behaviors;

* Physical assist while eating;

* One-on-one time to redirect from suicidal ideations; and

* Suicide attempts.

A progress note dated 05/31/22 revealed Resident 1 attempted to commit suicide by wrapping a string from his/her pants around his/her neck and tying it to a hanging basket chain in the courtyard. Resident 1 was leaning forward attempting to let go of his/her walker before staff intervened.

A progress note dated 06/02/22 revealed Resident 1 was found in the courtyard laying face down on top of the wooden fence which appeared to have climbed using a patio chair. Resident 1 stated s/he was trying to climb the fence to get on the roof to jump off and kill him/herself. Resident 1 was placed on alert charting for elopement risk. A temporary service plan was created to monitor Resident 1 for an elopement risk.

Interview with Staff 1 (Administrator) and Staff 2 (VP Management Services) on 06/15/22  revealed the service plan was vague and did not provide clear direction to staff for Resident 1's behaviors.

The need to update the service plan to reflect the current care needs and provide clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (VP of Management Services) on 06/14/22. They acknowledged the findings.

C260

1. Resident was determined to have care needs that

exceded the abilities of the facility to manage. Resident

was transferred to the hospital and then making other

arrangements in agreement with his wife.

Additional training was provided to the Executive

Director to address personalized service plans and

specifically with regards to behavior monitoring,

suicidal ideations/monitoring and elopement

monitoring.

2. All residents assessments/evals and service plans will be entered into our new system, Point Click Care utilizing the new assessment/evaluation form that addresses all necessary requirements of the OAR's.

Behavior monitoring, elopement

monitoring, and suicidal ideation/attempt monitoring will be included for those that require so.

3. Temporary Service Plans will be implemented for

temporary or short term changes, Service plans will be done initially, 30- day, quarterly and then upon change of condition. This will be monitored weekly.

4. The Executive Director and/or RN will review and

monitor to ensure that the Temporary Service Plans

are being implemented appropriately, care plans are

being done timely, reviewed, signed and that the

proper care is being delivered.

Based on interview and record review, it was determined the facility failed to monitor behavioral changes consistent with the evaluated needs and service plan, and  to determine and document what action or intervention was needed for the resident and communicate the determined actions to staff for 1 of 1 sampled resident (# 1) related to suicide attempts and suicidal ideations. Resident 1 experienced repeated suicide attempts and verbal suicidal ideations. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's with behaviors.

Review of Resident 1's most recent service plan, dated 05/18/22, progress notes dated 05/18/22 through 06/13/22, and incident reports dated 05/31/22 and 06/02/22 revealed the following:

* A progress note dated 05/31/22 revealed Resident 1 attempted to commit suicide by wrapping a string from his/her pants around his/her neck and tying it to a hanging basket chain in the courtyard. Resident 1 was leaning forward attempting to let go of his/her walker before staff intervened.

An incident report was completed on 05/31/22 outlining the incident. The resident was sent to the hospital for a psychological evaluation. Upon return, staff monitored Resident 1 for return from hospital. There was no service plan update to staff directing them to observe for suicidal ideations or attempts.

* A progress note dated 06/02/22 revealed Resident 1 was found in the courtyard laying face down on top of the wooden fence which appeared to have climbed using a patio chair. Resident 1 stated s/he was trying to climb the fence to get on the roof to jump off and kill her/himself. Resident 1 was placed on alert charting for elopement risk.

Review of Resident 1's most recent service plan dated 05/18/22 and all temporary service plan updates revealed the service plan was not updated to provide clear direction to staff on his/her significant behavior changes. An interview with Staff 1 (Administrator) on 06/15/22 revealed the service plan was not updated to reflect the recent behavior changes to Resident 1. On 06/15/22, Staff 2 (VP of Management Services) confirmed the service plan was not updated to reflect the current status of Resident 1's behaviors.

A temporary service plan was created on 06/02/22 to monitor Resident 1 for an elopement risk.

An incident report was created for the second suicide attempt on 06/02/22. Resident 1 was sent to the hospital for a psychological evaluation. On 06/02/22, a temporary service plan was created for staff to conduct 30 minute checks on him/her due to being a new elopement risk. There was no update on the service plan for repeated suicide attempts or what signs and symptoms to look for.

The facility documented Resident 1 attempted to commit suicide on 05/31/22 and failed to develop interventions and communicate those interventions to staff to prevent future suicide attempts. On 06/02/22, Resident 1 attempted to commit suicide again. The facility failed to develop interventions and communicate those to staff to prevent future suicide attempts.

The need to ensure the facility monitored behavioral changes consistent with the evaluated needs and service plan, and facility's failure to determine and document what action or intervention was needed for the resident and communicate the determined actions to staff was discussed with Staff 1 (Administrator) and Staff 2 (VP of Management Services) on 06/14/22. They acknowledged the findings.

C270

1. Resident was determined to have care needs that

exceded the abilities of the facility to manage. Resident

was transferred to the hospital and then making other

arrangements in agreement with his wife.

Additional training was provided to the Executive

Director to address personalized service plans and

specifically with regards to behavior monitoring,

suicidal ideations/monitoring and elopement

monitoring.

A Change of Condition Assessment will be done

timely moving forward.

The TSPs, Incident Reports and Progress notes will

be reviewed to determine if a Change of Condition

assessment is needed.

The staff will be trained to contact the manager on call

if there are any changes that require immediate review

of a residents care needs.

Training will be provided to all staff to specify what

situations and or events require notification.

2. All residents assessments/evals and service plans will be entered into our new system, Point Click Care utilizing the new assessment/evaluation form that addresses all necessary requirements of the OAR's.

Behavior monitoring, elopement

monitoring, and suicidal ideation/attempt monitoring will be included for those that require so.

3. Temporary Service Plans will be implemented for

temporary or short term changes, Service plans will be done initially, 30- day, quarterly and then upon change of condition. ED/Assistant ED/Med aides will monitor TSP's daily and report necessary changes to RN.

4. The Executive Director and/or RN will review and

monitor to ensure that the Temporary Service Plans

are being implemented appropriately, care plans are

being done timely, reviewed, signed and that the

proper care is being delivered.

Based on interview and record review, it was determined the facility failed conduct a timely RN assessment and develop interventions as a result of the assessment for 1 of 1 sampled resident (#1) experienced a significant change of condition related to behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022 with a diagnosis including dementia with behaviors.

Review of Resident 1's progress notes dated 05/18/22 through 06/13/22, RN assessment dated 06/13/22 and incident reports dated 05/31/22 and 06/02/22 revealed the following:

Resident 1 attempted to commit suicide twice on 05/31/22 and 06/02/22. Staff 3 (RN) conducted an assessment on Resident 1 on 06/13/22 related to his/her significant change in behaviors. This RN assessment was conducted 14 days after the first suicide attempt and 11 days after the second suicide attempt.

The RN assessment completed on 06/13/22 lacked interventions to prevent further suicide attempts.

The need to ensure an RN assessment was conducted timely and interventions were developed as a result of the assessment after Resident 1 experienced a significant change of condition was discussed with Staff 1 (Administrator) and Staff 2 (VP of Management Services) on 06/15/22. They acknowledged the findings.

C280

1. A Change of Condition Assessment will be done

timely moving forward.

2. The TSPs, Incident Reports and Progress notes will

be reviewed to determine if a Change of Condition

assessment is needed.

The staff will be trained to contact the manager on call

if there are any changes that require immediate review

of a residents care needs.

Training will be provided to all staff to specify what

situations and or events require notification.

3. The documents will be reviewed on a daily basis.

4. The Med Aide will be responsible for contacting the

manager on call and the Assistant ED and/or Executive

Director will be responsible for contacting the RN to

complete a Change of Condition Assessment as

needed.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were complete and accurate, for 2 of 2 sampled residents (#s 1 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted into the facility in 05/2022 with a diagnosis of Alzheimer's disease.

Resident 1's 05/13/22 through 06/12/22 MAR was reviewed and revealed the following:

* Multiple medications lacked reasons for use; and

* Resident 1 had a PRN order for Omeprazole 20 mg for gastroesophageal reflux disease. The facility was administering the medication daily. An interview with Staff 1 (Administrator) on 06/14/22 revealed the order was changed after his/her discharge from the hospital on 06/02/22. She immediately changed the order on the MAR.

2. Resident 3 was admitted to the facility in 08/2021 with a diagnosis of Alzheimer's and diabetes.

Resident 3's 05/13/22 through 06/12/22 MAR was reviewed and revealed the following:

* Multiple medications lacked reasons for use.

The need to ensure resident MARs were complete and accurate was discussed with Staff 1 (Administrator) and Staff 2 (VP of Management Services) on 06/14/22. They acknowledged the findings.

C310

1. All current orders will be reviewed for accuracy and

reason for use will be recorded for each medication.

2. All initial orders and new orders will be reviewed for

accuracy by 3 staff members to include all necessary

parts of the order.

Clarification will be sent to the physician if any

discrepencies are noted.

3. A MAR audit will be conducted each week and upon

initiation of the new monthly MARs.

4. Audits will be reviewed by the Assistant

ED/Executive Director and RN as needed.

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

Refer to C 240.

Z142

1. Individual Activity Logs have been created and implemented. The logs will specify the staff on duty and

will include the scheduled activities as well as

individualized activities that are specific to the

indiviuals likes, needs, and physical limitations. The

staff will be required to document participation and/or

refusals.

Memory Care Activity boxes are being created to offer

variety for those that refuse the scheduled activities.

All staff are being required to take the "Teepa Snow:

Filling the Day with Meaning" course

2. All new hires will be trained on how to use the

activity logs, what to do in the event that a resident

refuses, and they will be required to take the "Teepa

Snow: Filling the Day with Meaning" course.

3. The logs will be reviewed weekly.

4. The Assistant ED and/or the Executive Director will

monitor the forms weekly.

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

Refer to C 260, C 270, C 280, C 303 and C 310.

Z162

1. Resident was determined to have care needs that

exceded the abilities of the facility to manage. Resident

was transferred to the hospital and then making other

arrangements in agreement with his wife.

Additional training was provided to the Executive

Director to address personalized service plans and

specifically with regards to behavior monitoring,

suicidal ideations/monitoring and elopement

monitoring.

2. All residents assessments/evals and service plans will be entered into our new system, Point Click Care utilizing the new assessment/evaluation form that addresses all necessary requirements of the OAR's.

Behavior monitoring, elopement

monitoring, and suicidal ideation/attempt monitoring will be included for those that require so.

3. Temporary Service Plans will be implemented for

temporary or short term changes, Service plans will be done initially, 30- day, quarterly and then upon change of condition. This will be monitored weekly.

4. The Executive Director and/or RN will review and

monitor to ensure that the Temporary Service Plans

are being implemented appropriately, care plans are

being done timely, reviewed, signed and that the

proper care is being delivered.

1. Resident was determined to have care needs that

exceded the abilities of the facility to manage. Resident

was transferred to the hospital and then making other

arrangements in agreement with his wife.

Additional training was provided to the Executive

Director to address personalized service plans and

specifically with regards to behavior monitoring,

suicidal ideations/monitoring and elopement

monitoring.

A Change of Condition Assessment will be done

timely moving forward.

The TSPs, Incident Reports and Progress notes will

be reviewed to determine if a Change of Condition

assessment is needed.

The staff will be trained to contact the manager on call

if there are any changes that require immediate review

of a residents care needs.

Training will be provided to all staff to specify what

situations and or events require notification.

2. All residents assessments/evals and service plans will be entered into our new system, Point Click Care utilizing the new assessment/evaluation form that addresses all necessary requirements of the OAR's.

Behavior monitoring, elopement

monitoring, and suicidal ideation/attempt monitoring will be included for those that require so.

3. Temporary Service Plans will be implemented for

temporary or short term changes, Service plans will be done initially, 30- day, quarterly and then upon change of condition. ED/Assistant ED/Med aides will monitor TSP's daily and report necessary changes to RN.

4. The Executive Director and/or RN will review and

monitor to ensure that the Temporary Service Plans

are being implemented appropriately, care plans are

being done timely, reviewed, signed and that the

proper care is being delivered.

1. A Change of Condition Assessment will be done

timely moving forward.

2. The TSPs, Incident Reports and Progress notes will

be reviewed to determine if a Change of Condition

assessment is needed.

The staff will be trained to contact the manager on call

if there are any changes that require immediate review

of a residents care needs.

Training will be provided to all staff to specify what

situations and or events require notification.

3. The documents will be reviewed on a daily basis.

4. The Med Aide will be responsible for contacting the

manager on call and the Assistant ED and/or Executive

Director will be responsible for contacting the RN to

complete a Change of Condition Assessment as

needed.

1. All current orders will be reviewed for accuracy and

reason for use will be recorded for each medication.

2. All initial orders and new orders will be reviewed for

accuracy by 3 staff members to include all necessary

parts of the order.

Clarification will be sent to the physician if any

discrepencies are noted.

3. A MAR audit will be conducted each week and upon

initiation of the new monthly MARs.

4. Audits will be reviewed by the Assistant

ED/Executive Director and RN as needed.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 3's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (VP of Management Services) on 06/14/22. They acknowledged the findings.

Z163

1. Each residents Assessments/Service Plans will be

reviewed and a more detailed and individualized

nutrition and hydration plan will be added for each

resident.

2. All future Initial assessments/evaluations/service plans will have a personalized hydration and nutrition section completed.

3. The nutrition and hydration section will be reviewed initially, within 30 days, quarterly and as needed for a change of condition.

4. The Assistant ED and/or Executive Director will be

responsible for monitoring

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Though Resident 1 and 3's service plans offered some information about the resident's interests, the facility had not fully evaluated the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

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 an individualized activity plan was developed for each resident based on their activity evaluation was discussed with Staff 1 (Administrator) and Staff 2 (VP of Management Services) on 06/14/22. They acknowledged the findings.

Z164

1. Each residents evaluation will be reviewed and

include:

(i) Past and current interests;

(ii) Current abilities and skills;

(iii) Emotional and social needs and patterns;(iv) Physical abilities and limitations;

(v) Adaptations necessary for the resident to

participate; and

(vi) Identification of activities for behavioral

interventions

2. Activity calendar will specify the time of day that the

primary activities will take place. Additional activities, to

be done as time allows, and will be listed as well.

An individual activity plan will be included in the

evaluation.

The Universal Caregivers will be responsible for

ensuring that the activities are done.

The Universal Caregivers will be responsible for

completing the activity log and specifying who

participated and who refused participation.

If the none of the Universal Caregivers are able to lead

the activity due to emergency, resident care, etc. they

will notify the Executive Director and/or designated

supervisor so that they can arrange for coverage

and/or perform the activity.

All staff will be trained at the next in-service on the new

procedures for implementing and tracking activities.

Each staff member will take the Teepa Snow- class

"Filling the Day with Meaning".

3. The activity logs will be reviewed weekly.

4. The Assistant ED and/or the Executive Director will

be responsible for reviewing the logs.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 1 of 1 sampled resident (# 1). Resident 1 experienced repeated suicide attempts and verbal suicidal ideations. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/22 with diagnoses of Alzheimer's with behaviors.

Review of Resident 1's progress notes dated 05/18/22 through 06/13/22, most recent service plan dated 05/18/22, interview with staff, and incident reports dated 05/31/22 and 06/02/22 revealed the following:

On 05/31/22, Resident 1 attempted to hang himself/herself with string from his/her pants on a chain for a hanging basket in the courtyard. Staff intervened and sent him/her to the hospital for a psych evaluation.

On 06/02/22, Resident 1 climbed the courtyard fence to get on the roof to jump off and commit suicide. A temporary service plan was created for staff to monitor Resident 1 for an elopement risk.

Interview with Staff 4 (MT) on 06/14/22 revealed Resident 1 had repeat suicidal ideations daily. Staff redirect him/her with conversation, music or sports. Redirection of Resident 1 was not reflected on his/her current service plan.

The need to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted the resident as a result of unaddressed behaviors was discussed with Staff 1 (Administrator) and Staff 2 (VP of Management Services) on 06/14/22. They acknowledged the findings.

Z 165

1. Resident was determined to have care needs that

exceded the abilities of the facility to manage. Resident

was transferred to the hospital and then making other

arrangements in agreement with his wife.

Additional training was provided to the Executive

Director to address personalized service plans and

specifically with regards to behavior monitoring,

suicidal ideations/monitoring and elopement

monitoring.

2. All residents assessments/evals and service plans will be entered into our new system, Point Click Care utilizing the new assessment/evaluation form that addresses all necessary requirements of the OAR's.

Behavior monitoring, elopement

monitoring, and suicidal ideation/attempt monitoring will be included for those that require so.

3. Temporary Service Plans will be implemented for

temporary or short term changes, Service plans will be done initially, 30- day, quarterly and then upon change of condition. This will be monitored weekly.

4. The Executive Director and/or RN will review and

monitor to ensure that the Temporary Service Plans

are being implemented appropriately, care plans are

being done timely, reviewed, signed and that the

proper care is being delivered

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

On 06/13/22 a tour of the facility courtyard showed the following:

There were two patio chairs which were easily moveable and not of sufficient weight or design to prevent potential elopement.

The need to ensure the furniture in the outdoor recreation areas was sufficient in weight and design to not aid in elopement was discussed with Staff 1 (Administrator) and Staff 2 (VP of Management Services) on 06/13/22. They acknowledged the findings

Z 173

1. The unweighted furniture was removed immediately.

All outdoor funiture was evaluated for safety and

proper weight.

2. Any furniture that is placed in the courtyard will be

reviewed for safety.

3. Courtyard will be walked through at a minimum of

every other day to ensure no new furniture has been

placed.

4. The Med Aide, Assistant ED, and/or the Executive

Director will monitor.