The findings of the re-licensure survey conducted 05/02/22 through 05/04/22 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 first  re-visit to the re-licensure survey of 05/04/22, conducted 12/12/22 through 12/14/22, 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

MCCMemory 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

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:

During the relicensure survey, conducted 05/02/22 through 05/04/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

Refer to deficiencies in the report.

C150

OAR 411-054-0025 (1) Facility Administration Operations

Refer to all citations in this report.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. This is a repeat citation. Findings include, but are not limited to:

During the first revisit to the re-licensure, conducted 12/12/22 through 12/14/22 administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

Refer to deficiencies in the report.  

C150

OAR 411-054-0025 (1) Facility Administration Operations

Refer to all citations in this report.

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

The clinical record revealed:

a. Resident 1 experienced unwitnessed falls on 04/05/22 and 04/19/22.

b. Following the fall on 04/05/22, staff observed the resident with "bleeding from forehead and chin" and was sent to the emergency department for evaluation.

c. On 04/19/22, Resident 1 was found on the floor in another resident's room with the other resident present. Staff documented observing "redness on forehead and between eyes" and the resident was sent to the emergency department for evaluation.

On 05/03/22, incident reports were requested for review. During an interview on 05/04/22, Staff 3 (RCC) stated she was unable to locate the incident reports but recalls reporting both incidents to the local SPD office as the falls were unwitnessed and abuse or neglect could not be ruled out.

The need to ensure a timely and thorough investigation of falls and injuries was completed and that those records were maintained was reviewed with Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and falls with injury were promptly and thoroughly investigated to rule out abuse and neglect and reported to the local SPD office as required for 2 of 5 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the MCC in 04/2021 with diagnosis of dementia.

A review of Resident 2's incident reports and chart notes from 02/10/22 through 05/02/22 indicated the following injury of unknown cause:

* 02/20/22 Skin tear to right wrist.

A review of the incident report documented, "Resident has a ST [skin tear] of unknown origin to right wrist, area noticed when giving resident a shower. Zero suspected abuse. Zero neglect."

The date of the investigation was 03/28/22 and there was no follow-up action or administrative review of the investigation.

There was no documented evidence the facility either reported the injury as suspected abuse to the local APD office or conducted an immediate investigation of the injury which reasonably concluded and documented that the injury was not the result of abuse.

The facility's failure to immediately investigate Resident 2's injury and document the investigation to rule out abuse or neglect and report the injury as suspected abuse was reviewed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

The facility was directed to self-report the incident to the local APD office. Staff 2 provided verification that the incident was self reported to local APS office prior to survey exit.

C231

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse

1. Immediate action taken to correct the rule violation include thoroughly investigating and self reporting incident to APS for Resident #2, and completing incident reports for Resident #1. Interventions have also been put in place to reduce risk for these incidents to happen again. Care plan has been updated with the interventions for staff to know how to assist the residents.

Abuse Reporting and Investigation Guide for Providers for Oregon has been reviewed with the department management team, and will be reviewed at next all staff meeting to provide staff training related to reporting requirements at next all staff meeting.

2. The system will be corrected so the violation will not happen again by ensuring all incidents are investigated timely. If abuse and neglect can not be ruled out, or for injuries of unknown cause, community will follow abuse reporting requirements. Incident reports will be reviewed daily at daily stand up meetings. The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan. Community will verify the correct process for self reporting to APS has taken place for all reportable incidents.

3. This area will be reviewed on a daily basis in stand up upon review of communication log, alert charting and quarterly basis.

4. The Administrator or designee will be responsible to see that the corrections are being completed and monitored.  

Based on interview and record review, it was determined the facility failed to report suspected abuse to the local Seniors and People with Disabilities (SPD) office and failed to conduct an investigation of an injury of unknown cause, to rule out possible abuse or report the injury to the local SPD office for 1 of 3 sampled residents (#6) whose record was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease.

Review of Resident 6's clinical records during the survey revealed the following:

a. 10/21/22 - "Resident on alert charting for [left] skin tear above eyebrow."

The investigation of the injury of unknown cause failed to reasonably rule out abuse or neglect as the cause of the injury. The injury was not reported to the local SPD office.

b. 11/22/22 - An outside provider reported witnessing another resident push Resident 6.

There was no documented evidence the facility notified the local SPD office of the suspected abuse, investigated the suspected abuse or implemented measures necessary to protect residents and prevent the reoccurrence of abuse.  

The need to investigate injures of unknown cause to rule out abuse and neglect or report the injury to the local SPD office, report suspected abuse to the local SPD office and implement measures to prevent the reoccurrence of abuse was discussed  with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings. The survey team requested the facility submit the reports. Documentation was provided prior to survey exit.

C231

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse

1. Immediate action taken to correct the rule violation include thoroughly investigating and self-reporting incident to APS for Resident. Interventions have also been put in place to reduce risk for these incidents to happen again. Care plan has been updated with the interventions for staff to know how to assist the residents.

Abuse Reporting and Investigation Guide for Providers for Oregon has been reviewed with the department management team,

On 1/9/2023 at 10:00 am Department heads and Med techs attended a virtual in-service provided by APS on the topic of Abuse and Neglect reporting. Education on Abuse and neglect reporting, will be reviewed at next all staff meeting to provide staff training related to reporting requirements at next all staff meeting.

2.  The system will be corrected so as to reduce the risk of re-occurrence by ensuring all incidents are investigated timely. If abuse and neglect cannot be ruled out, or for injuries of unknown cause, community will follow abuse reporting requirements. Incident reports will be reviewed daily at daily stand up meetings. The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan. Community will verify the correct process for self-reporting to APS has taken place for all reportable incidents.

3. This area will be reviewed on a daily basis in stand up upon review of communication log, alert charting and quarterly basis.

4. The Administrator or designee will be responsible to see that the corrections are being completed and monitored.

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

On 05/02/22 at 11:00 am, the central kitchen and kitchenettes on each floor were toured.

a. The central kitchen on the first floor was observed to need cleaning and repair in the following areas:

* Multiple ceiling tiles had holes that allowed for the potential entrance of insects and rodents into the kitchen;

* Ceiling light fixtures or light bulbs near the entrance of the kitchen, above the steam table, and in the dry storage room were broken;

* Ceiling light fixtures were missing light covers near the ware wash and in the dry storage room; and

* Four ceiling vents were covered in brown or black matter.

b. Kitchenette's on each floor had food spills, splatters, debris, dust and black matter that was observed on or underneath the following:

* Interior of all cupboards and cabinets;

* Exterior cupboards and cabinets were gouged and had a sticky residue buildup;

* Multiple cabinet hardware (knobs and hinges) were loose or missing;

* Interior and exterior surface doors, bottom and sides of refrigerator shelves and freezers;

* Refrigerator handles were loose;

* Baseboards and walls; and

* Interior and exterior surfaces of the microwaves and toaster ovens.

c. The kitchenette on the second floor required the following cleaning and repair:

* Interior of the cabinet wall underneath the sink had black matter buildup;

d. Kitchenette on the fourth floor required the following repairs:

* A broken wall soap dispenser; and

* Wall paint near the baseboard wall heater was peeling off.

The kitchen was toured with Staff 1 (Executive Director) and Staff 5 (Dining Services Director) on 05/03/22 at 9:38 am and the need to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed. They acknowledged the findings.

C240

OAR 411-053-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

1. Actions taken to correct rule violation will include:

a. central kitchen on the first floor ceiling tiles that have holes will be replaced, ceiling light fixtures / light bulbs will be fixed / repaired, ceiling light fixtures will missing covers will be replaced and ceiling vents will be cleaned.

b. kitchenettes on each floor will have food spills, splatters, debris, dust and black matter cleaned, interior of all cupboards and cabinets will be cleaned.

Exterior cupboards and cabinets will be repaired or replaced due to gouges, knobs and hinges will be replaced on cabinets, interior and exterior surfaces bottom and sides of refrigerator shelves and freezers will be cleaned, refrigerator handles will be repaired,baseboards and walls will be cleaned and repaired, interior and exterior surfaces of the microwaves and toasters will be cleaned.

c. kitchenette on first second floor will have interior of the cabinet wall underneath sink cleaned.

d. kitchenette on fourth floor will have the soap dispenser replaced and wall near baseboard heater repaired and repainted.

2. The system will be corrected so this violation will not happen again by creating daily, weekly, monthly and quarterly cleaning schedules for the kitchen and kitchenette.

3. The cleaning schedule will be reviewed daily, weekly and quarterly with environmental audits.

4. The Administrator or designee will be responsible for reviewing / monitoring the weekly cleaning schedule to ensure the corrections remain in compliance.

3. During the survey, facility staff stated the quarterly evaluation and service plan were combined into the same document.

Resident 5's most recent service plan was not dated. When reviewed on 05/03/22, the most recent update was noted as 01/07/22, with no evidence of quarterly evaluation or update in the last 90 days.

The need to ensure timely review and updates to the evaluation was reviewed with Staff 27 (Regional Director of Operations) and Staff 3 on 05/04/22. They acknowledged the findings.

2. During the survey, facility staff stated the quarterly evaluation and service plan were combined into the same document. Resident 1's evaluation/service plan was completed on 08/11/21. The next quarterly evaluation would have been due on 11/11/21. There was no documented evidence of any evaluation completed after 08/11/21.

During an interview on 05/03/22, Staff 3 (RCC) stated the facility was currently working on some updates for the evaluation/service plan for Resident 1, but it had not been completed.

The need to ensure timely review and updates to the evaluation was reviewed with Staff 27 (Regional Director of Operations) and Staff 3 on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements or that a quarterly evaluation was completed timely, for 3 of 5 sampled residents (#s 1, 3 and 5). Findings include, but are not limited to:

1. Resident 3's move-in evaluation lacked information regarding the following required elements:

* The new move-in evaluation was not dated and did not indicate who was involved in the evaluation process.

In an interview with Staff 2 (RN) on 05/02/22 at 2:30 pm, he stated that he did not complete the new move-in evaluation for Resident 3 and the previous facility RN was in charge of the new move-in evaluations.

The move-in evaluation and the need to complete all required components was reviewed with Staff 1 (Executive Director) on 05/03/22. He acknowledged the findings.

C252

OAR 411-054-0034 (1-6) Resident Move-In and Evaluation: Res Evaluation

1.Immediate actions to correct the rule violation include comprehensive review and update to Resident #3 move-in evaluation has been updated to reflect the move-in date and indicate who was involved in the evaluation process.

Resident #1 and #5 evaluation has been updated and reflective of Memory Care specific requirements and current needs and preferences per Oregon Administrative Rules.

2. To ensure the system will be corrected so this violation will not happen again, evaluations including all required factors will be completed per company policy and Oregon State Rule prior to move in, updated within 30 days, quarterly thereafter and with any significant change of condition. The document should be signed to indicate who completed the evaluation.

3. The area will need to be reviewed and audited on a quarterly basis via continuous quality improvement system. Completion and accuracy of Evaluation will be reviewed in daily clinical stand up meeting prior to each new move in to ensure all components are reflective and all areas are complete with appropriate information.

4. The Administer, Licensed Nurse or designee will be responsible to ensure the system has been corrected and the system is monitored.

Based on interview and record review, it was determined the facility failed to ensure evaluations included all required elements, for 2 of 4 sampled residents (#s 6 and 8) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 move into the facility in 11/2022 with diagnoses including dementia.

Resident 8's move in evaluation was not dated and did not indicate who was involved in the evaluation process.

The move-in evaluation and the need to complete all required components was reviewed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease.

The most recent evaluation was dated 10/12/22. The evaluation did not indicate who was involved in the evaluation process.

The need to include information on who was involved in the evaluation process was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

C252

OAR 411-054-0034 (1-6) Resident Move-In and Evaluation: Res Evaluation

1.Immediate actions to correct the rule violation include comprehensive review and update to Resident #3 move-in evaluation has been updated to reflect the move-in date and indicate who was involved in the evaluation process.

Resident #6 and #8 evaluation has been updated and reflective of signature of person and date of doing the assessment. per Oregon Administrative Rules.

2. The system will be corrected so as to reduce the risk of re-occurrence, evaluations including all required factors will be completed per company policy and Oregon State Rule prior to move in, updated within 30 days, quarterly thereafter and with any significant change of condition. The document should be signed to indicate who completed the evaluation.

3. The area will need to be reviewed and audited on a quarterly basis via continuous quality improvement system. Completion and accuracy of Evaluation will be reviewed in daily clinical stand up meeting prior to each new move in to ensure all components are reflective and all areas are complete with appropriate information.

4. The Administer, Licensed Nurse or designee will be responsible to ensure the system has been corrected and the system is monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status and failed to provide clear direction to staff for 3 of 5 sampled residents (#s 1, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan, temporary service plans and progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas:

* Use of a geri-chair;

* Directions for catheter care; and

* Sitting up 90 degrees to eat meals and remaining at 90 degrees for at least 30 minutes after.

The need to ensure resident service plans were reflective and provided clear directions to staff was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. Staff acknowledged the findings.

3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II.

The most recent service plan was reviewed and was not reflective or lacked clear instruction for staff in the following areas:

* No copy of the service plan was available for staff on the 4th floor where Resident 5 lived;

* Not updated after bi-lateral fractures that left Resident 5 non-weight bearing;

* Listed wheelchair and walker for mobility, however, Resident 5 was bed bound; and

* Failed to list hospice home health services.

A service plan update was completed on 3/23/22 instructing staff to place braces on both legs when Resident 5 woke up in the morning, and leave them on until sleep in the evening.  Observations on 05/02/22 showed Resident 5 was not wearing the braces, and Staff 16 (Caregiver) stated he was not aware the braces had been added to the service plan.

The need to ensure resident service plans were reflective, provided clear directions to staff, and were readily available for staff to review was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. Staff acknowledged the findings.

2. Resident 1 moved into the facility in October 2019 with diagnoses including dementia and depression. The most recent service plan, dated 08/11/21 was reviewed and was not reflective or lacked clear instruction for staff in the following areas:

* Walking ability including use of a wheelchair for mobility;

* Current, effective fall interventions;

* Ability to eat independently and level of meal assistance required;

* Interventions to address weight loss;

* Sleep pattern and late night waking hours;

* Behaviors including agitation and current interventions:

* Use of glasses; and

* Emergency evacuation needs.

The need to ensure service plans were reflective of resident needs, accurate and included clear direction to staff was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C260 Service Plan: General

1. Immediate actions taken to correct the rule violation was to update Resident #4, #1, and #5 care plans.

Resident #4 care plan has been updated and is reflective of the evaluation, person centered with individual preferences and care needs. It reflects the use of a geri chair, directions for catheter care, and sitting up 90 degrees to eat meals and remain at 90 degrees for at least 30 minutes after.

Resident #1 care plan has been updated and is reflective of the evaluation, person centered with individual preferences and care needs. It reflects walking ability including use of wheelchair for mobility, current, effective fall interventions, ability to eat independently and level of meal assistance required, interventions to address weight loss, sleep pattern and late night waking hours, behaviors including agitation and current interventions, use of glasses and emergency evacuation needs.

Resident #5 care plan has been updated and is reflective of the evaluation, person centered with individual preferences and care needs. It reflects non-bearing status and bed bound status, and hospice services. Service plan has been placed on floor resident resides.

2. This system will be corrected so this violation does not happen again by ensuring that the care plan is updated with any acute or significant change of condition, as well with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the residents current status per Oregon State Rule.

Clinical services and Administrator participate with this process to ensure accuracy and personalization, as well as the resident and / or their POA / Representative.

3. At time of move in, 30 day review, quarterly and as needed if a change of condition occurs.

4. The administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans included clear direction for staff and were followed for 2 of 4 sampled residents (#s 6 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1.  Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease.

The resident's 10/12/22 service plan was reviewed and revealed the resident was at risk for aspiration and noted the following information:

* "[The resident] needs nectar thick liquids. S/he needs to avoid foods that melt into thin liquids (ice cream and popsicles."); and

* "[The resident] likes all fluids thin. S/he can manage this if you hand him/her a drink while s/he is sitting."

There was no documented evidence Resident 6's service plan provided clear direction to staff related to hydration and liquid consistency.

The need to ensure service plans included clear direction to staff was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

2. Resident 8 moved into the facility on 11/08/22 with diagnoses including dementia.

The service plan dated 11/08/22 noted Resident 8 was scheduled for showers twice a week. The shower schedule available to staff at the time of the survey failed to document Resident 8's shower days.  

During interviews on 12/13/22 and 12/14/22, Staff 28 (Personal Care Assistant), Staff 34 (MT) and Staff 27 (RCC) were unable to verify whether or not Resident 8 was receiving bathing assistance as scheduled in the service plan.

During an interview on 12/13/22 at 10:45 am, Witness 1 (Family member)

stated s/he was not concerned about the cleanliness of Resident 8. Resident 8 was observed throughout the survey and appeared well groomed.  

The need to ensure service plans provided clear direction to staff on the delivery of services was reviewed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 11:50 am. They acknowledged the findings.

C260 Service Plan: General

1. Immediate actions taken to correct the rule violation was to update Resident #6, and #8 care plans.

Resident #6 care plan has been updated and is reflective for their thicken liquids, person centered with individual preferences and care needs. It reflects the use of nectar thick liquids.  Also retraining staff on Where to find Shower logs for all residents on each floor this was for residents #8.  

2. The system will be corrected so as to reduce the risk of re-occurrence by ensuring that the care plan is updated with any acute or significant change of condition, as well with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the resident's current status per Oregon State Rule.

Clinical services and Administrator participate with this process to ensure accuracy and personalization, as well as the resident and / or their POA / Representative.

3. At time of move in, 30-day review, quarterly and as needed if a change of condition occurs.

4. The administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Service plans for Resident's 1, 2, 3, 4 and 5 were reviewed and lacked documented evidence that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Executive Director) and Staff 3 (RCC) 05/03/22. They acknowledged the findings.

C262

OAR 411-054-0036 (5) Service Plan: Service Planning Team

1. Immediate actions taken to correct the rule violation include: Resident #1, #2, #3, #4 and #5 service plan will be updated with evidence that the resident and / or, the resident's legal representative / person of resident's choice, the facility Administrator or designee, and at least one other staff person familiar with their provided services participates.

2. To ensure the system will be corrected so this violation will not happen again; the service plans will be developed by a service planning team.

Monthly service plan review schedule has been set up to ensure timely reviews take place consistently. An invitation will be extended to family / person of resident's choice to attend service plan meeting. All those in attendance will review and sign the service plan. Those not able to attend will be sent a copy of the service plan for review and signature. Signature page will then be attached to service plan.

3. The area will need to be evaluated at resident move in, 30 day review and quarterly update and / or as needed if significant change of condition occurs.

4. The Administered, RCC or designee will be responsible to ensure the corrections are completed and monitored.

2. Resident 4 was admitted to the facility in January of 2022 with a diagnosis of dementia and a Foley catheter.

Resident 4's narrative chart notes dated 02/01/22 through 05/01/22 were reviewed and revealed there was no documented evidence the facility monitored changes, resolved monitored changes, notified the facility RN of changes and/or updated the service plan for the following changes of condition:

a. The following short term changes were not monitored until resolution:  * 01/14/22 New Move-in;

* 02/01/22 Blood at catheter insertion site;

* 02/02/22 Golf ball size lump on upper left thigh;

* 02/03/22 Foot pain; and

* 04/19/22 Missed medications.

b. The resident experienced that following change of condition related to weight loss:

* On 01/14/22 weight upon admission was 194 pounds;

* On 02/2022, Resident 4's weight was 188 pounds (six pound loss from previous month);

* On 02/23/22, an RN assessment identified Resident 4 ate 100% of meals but had weight loss of 4% since admission;

* On 02/24/22, staff documented, "resident has not been eating well in the evenings with an average of 25% of meal intake since RTC [return to community].";

* On 04/01/22, progress notes documented intake of dinner was 45% and on 04/04/22 intake was 10%; and

* On 04/2022, Resident 4's weight was 181 pounds, which resulted in a total weight loss of 6.7% total body weight within three months.

Although the RN identified the change of condition for weight loss in 02/2022, there was no documented evidence weight loss interventions were implemented and the service plan was not updated with direction to caregivers to ensure the resident did not continue to lose weight.

c. The resident experienced the following significant changes of conditions that were not monitored to resolution or referred to the RN:

* 02/19/22, Return from hospital;

* 02/28/22, Pressure ulcers on bilateral heels;

* 03/10/22, Pain from catheter insertion site with mucus draining;

* 03/17/22, "purulent drainage" from genitalia and "pus coming from catheter";

* 03/31/22, Return from hospital for UTI and sepsis;

* 04/03/22, Open wound on buttocks;

* 04/14/22, Return from the hospital; and

* 04/16/22, Starting home health for catheter care, wound care and OT.

* 05/02/22, Progress notes documented, Resident 4 continued to experience pain from genitalia and a decline in health condition.

There was no documented evidence the facility RN was notified of changes of condition when the resident continued to have pain and  decline in health condition and failed to update the service plan following the changes in condition.

The need to ensure the facility documented evidence of interventions, monitored changes, resolved changes, notified the facility RN of changes and/or updated the service plan for changes of condition was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

4. Resident 5 was admitted to the facility in 2020 with a diagnosis of dementia and Diabetes Type II.

Resident 5's narrative chart notes dated 01/01/22 through 05/01/22 were reviewed and revealed:

a.  On 01/05/22 Resident 5 was found on the bathroom floor at 4:30 am after an unwitnessed fall. The fall with possible injury constituted a change of condition that required documented evaluation.

A med tech note dated 01/05/22 at 9:41 pm stated "facility nurse and nurse consultant assessed during day shift and decided did not need to be sent out". The assessment referenced in the med tech note was not located during the survey and no service plan updates, interventions, monitoring, or instructions to staff were documented or included in the resident record.  

A progress note dated 01/06/22 at 9:50 am stated "sent out this morning to hospital and admitted for fractures".   

b.  A progress note dated 11/19/21 documented "will receive scabies treatment as a preventative measure C/O exposure to a resident with active rashes and itching".  

On 12/02/21, 14 days later, a note documented "will notify pharmacy so resident can start his/her medication". There was no documented monitoring or resolution of the scabies, and the service plan was not updated with any instructions for staff.

The need to ensure the facility documented evidence of monitored changes, resolved changes, notified the facility RN of changes and/or updated the service plan for changes of condition was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

3. Resident 1 was admitted to the facility in October 2019 with diagnoses including dementia. A review of the clinical record revealed the following:

a. In early February 2022, the resident was identified as having a swollen left foot with redness. The facility notified the physician and a video medical appointment was held on 02/04/22. Progress notes documented on 02/04/22 stated "NP [nurse practitioner] will order new medication for leg swelling and redness..." Resident 1 was placed on alert charting.

On 02/10/22, Resident 1 went to a scheduled in-person appointment with his/her physician and the provider stated the medication "should have been started". The facility determined the prescription had been sent to another pharmacy.

During an interview on 05/04/22, Staff 3 (RCC) acknowledged the facility did not monitor to follow up on the status of the medication order to treat the cellulitis. The order and medication was received and administered starting on 02/12/22 (eight days after the video appointment). In addition, there was no documentation that the facility nurse had been monitoring the swelling at least weekly through resolution.

b. Resident 1 experienced two falls in April 2022. There was no documented evidence the facility determined what action or interventions were needed nor was the resident monitored through resolution.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution and determining what action or interventions were needed was shared with Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, weekly progress notes until the condition resolved and/or the facility failed to refer significant changes of condition to the facility RN for 4 of 5 sampled residents (#s 1, 2, 4 and 5) who had changes of condition.  Residents 2 and 4 continued to experience an overall health decline and an increase in ADL care needs. Findings include, but are not limited to:

1. Resident 2 was admitted to the memory care facility in 04/2021 with diagnosis of dementia.

Resident 2's clinical records, service plans, and temporary service plans were reviewed during the survey and identified the following changes of condition.

a. On 04/07/22, Staff 26 (Former RN) documented, Resident 2 was sent to the emergency room for stomach pain and vomiting. The resident returned the same day with hospital orders to monitor bowel movements and after two days, if the resident doesn't have a bowel movement staff were to administer Miralax every 6 hours until the resident had a bowel movement. Additionally, Resident 2 had PRN Miralax orders, from 11/12/21, to give up to four times per day.

There was no documented evidence the facility followed the PRN Miralax orders written on 11/12/21 or contacted the health care provider when the resident failed to have a bowel movement prior to being sent to the ER on 04/07/22.

During an interview on 05/04/22, Staff 2 (RN) and Staff 3 (RCC) indicated the facility staff were suppose to monitor and track bowel movements on hand written sheets of paper on each shift and give them to the RCC. Staff 2 and 3 were unable to locate documentation that staff monitored Resident 2's bowel movements or administered the Miralax (intervention) as prescribed.

On 04/08/22, the resident was sent out to the emergency room for a body temperature of 101.3 degrees F.

On 04/11/22, Staff 21 (RCC) documented in chart notes, Resident 2 returned to the facility with a diagnosis of potential UTI, diverticulitis and sepsis. Staff were instructed to administer Cipro (antibiotic) and Culterelle (probiotic) for seven days and hold fortified beverages while on the antibiotic.

A review of the April 2022 MAR pass notes indicated the Culturelle was not received and the resident was not administered Culturelle while taking Cipro and the facility failed to hold daily Med Pass 2.0 (fortified beverage).

There was no documented evidence the facility monitored the Culturelle (probiotic) and Cipro (antibiotic) medication errors, the effectiveness of the antibiotic, the resident's bowel movements to determine if the intervention (PRN Miralax) was needed and effective, failed to ensure the determined actions or interventions were communicated to staff and failed to refer the change in condition related to multiple ER visits and decline in health status to the facility RN.

b. Between 04/12/22 and 04/25/22 multiple facility staff documented the resident continued to decline, won't eat, had nausea, vomiting, stomach pain, won't get up for breakfast, and needed to assist the resident with meals in his/her room.

On 04/18/22, Staff 22 (MT) documented in chart notes, unable to obtain BP due to resident had been septic while in the hospital (seven days ago).

There was no documented evidence the facility staff referred Resident 2's continued decline in health status and increase in ADL care needs to the facility RN until 04/25/22 (two weeks later) at which time Staff 26 (RN) documented "was notified today that [s/he] is not eating and has not had a bowel movement since [his/her] return from the hospital. There are no bowel tones noted in any quadrant, even after palpation." Resident 2 was sent to the emergency room.

c. On 04/26/22, Staff 3 (RCC) documented in chart notes, Resident 2 returned from the emergency room with a diagnosis of dehydration and a referral for hospice services.

On 04/28/22 Staff 22 documented in chart notes, Resident 2 was admitted to hospice services.

There was no documented evidence the facility determined actions or interventions for the resident, communicated the actions or interventions to staff and failed to refer the change in condition related to return from hospital with admission to hospice services to the facility RN.

The need to ensure the facility determined interventions needed for residents with identified changes of condition, monitored the interventions for effectiveness, communicated the interventions and changes to staff and referred changes of condition to the facility RN when appropriate was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C270

OAR 411-054-0040 Change of Condition and Monitoring

1. Immediate actions take to correct the rule violation include the following:

Resident #2 - a comprehensive nursing assessment and appropriate follow up will be completed related to resident multiple ER visits, decline in health status, and admission to hospice services.

Resident #4 - a comprehensive nursing assessment and appropriate follow up will be completed related to weight loss, pain, and decline in health condition.

Resident #1- a comprehensive nursing assessment and appropriate follow up will be completed related to skin issues, falls and fall interventions.

Resident #5 - a comprehensive nursing assessment and appropriate follow up will be completed related to fall, fractures, and skin issues.

2. To ensure the system will be corrected so this violation will not happen again, a 24 hour communication system is in place to include:

a. Shift to Shift Communication Log

b. Alert Charting Log / Audit Log

c. Significant Change of Condition Log

d. Weekly Skin Monitoring Log

Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as UTI, missed medication, return from the hospital, or fall for an example.

When change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician.

The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with the resident change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP.

Staff should monitor resident status until resident condition resolves and they are back to their baseline, 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessed by the RN. For significant change condition such as

3. The area needed correction will be evaluated daily during stand up with 24 hour audit system compliance.

Community will also complete Monthly Continuous Quality Improvement audit to ensure clinical systems follow company policy and Oregon Administrative Rule.

4. The Administrator and Registered Nurse will be responsible to ensure the system has been corrected and is monitored.   

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who had short-term changes of condition was evaluated, resident-specific instructions or interventions were developed, communicated to staff on each shift, reviewed for effectiveness and the condition was monitored to resolution at least weekly for 1 of 4 sampled residents (# 6), who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 2017 with diagnoses including Alzheimer's disease.

Review of the resident's 08/04/22 through 12/12/22 progress notes revealed the resident experienced the following changes of condition:

* 09/02/22 - Medication change, decrease rivastgmine tablet (dementia) to 1.5 mg twice daily;

* 09/19/22 - Admission to hospice, risk for weight loss;

* 09/27/22 - Medication change, levothyroxine (hypothyroidism) discontinued; and

* 10/22/22 - Resident-to-resident physical altercation.

a. The facility failed to show documented evidence interventions were developed and communicated to staff on all shifts for Resident 6's medication changes and the physical altercation. In addition, the resident was not monitored with progress noted at least weekly through resolution regarding the physical altercation.

b. The resident was admitted to hospice on 09/19/22 and was noted to be at risk for weight loss. The resident had a 09/20/22 physician's order for a nutritional supplement, (Two Cal) 90 milliliters three times per day. In an interview on 12/14/22, Staff 34 (MT) confirmed the nutritional supplement had not been administered to the resident between 11/01/22 and 12/13/22.

There was no documented evidence the facility routinely monitored the resident's weight, reviewed the intervention for effectiveness or implemented new interventions when found to be ineffective.

Short-term changes of condition and monitoring was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

C270

OAR 411-054-0040 Change of Condition and Monitoring

1. Immediate actions take to correct the rule violation include the following:

Retrained and corrected all issues with Residents #6.  

2.  The system will be corrected so as to reduce the risk of re-occurrence, a 24-hour communication system is in place to include:

a. Shift to Shift Communication Log

b. Alert Charting Log / Audit Log

c. Significant Change of Condition Log

d. Weekly Skin Monitoring Log

Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as UTI, missed medication, return from the hospital, or fall for an example.

When change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician.

The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with the resident change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP.

Staff should monitor resident status until resident condition resolves and they are back to their baseline, 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessed by the RN. For significant change condition such as

3. The area needed correction will be evaluated daily during stand up with 24-hour audit system compliance.

Community will also complete Monthly Continuous Quality Improvement audit to ensure clinical systems follow company policy and Oregon Administrative Rule.

4. The Administrator and Registered Nurse will be responsible to ensure the system has been corrected and is monitored.

2. Resident 4 was admitted to the facility in 1/2022 with diagnoses including chronic kidney disease and had a catheter.

Resident 4's record was reviewed including progress notes dated 02/01/22 through 05/01/22. The progress notes revealed the following:

* On 02/01/22 care staff reported the resident had blood coming from the catheter insertion site and leaking into his/her brief. S/he was also experiencing pain. The note included the RN was notified, but there was no documented evidence the RN assessed the resident or updated the service plan.

* On 02/02/22 the RN was asked to look at a golf ball sized lump on the Resident's upper left thigh, but there was no documented assessment.

* Progress notes on 02/18/22 identified the resident had "greenish white discharge coming from insertion point" of the catheter that had been "ongoing for about a week." The notes also documented there was a foul smell present, and Resident 4 had a decrease in range of motion in his/her legs "over the past few days." The Resident was unable to bend his/her legs, was complaining of hip pain, moaning in pain and was less responsive than normal. Resident 4 was sent out to the hospital.

* On 02/19/22 the progress notes identified the resident returned to the facility from the hospital and was still having pain. The progress notes included there was blood around the tubing, brief and blankets.

There was no RN assessment of the resident until 02/23/22. The assessment included the resident's pants had pulled on the catheter tubing causing issues and the tubing needed to be secured properly to the resident's leg. There was no documented evidence the RN assessed the drainage or the catheter pain.

On 03/10/22 a progress note revealed the resident had pain associated with his/her catheter tubing with what appeared to be mucus draining from it. A subsequent note on 03/17/22 included there was "purulent drainage."

Resident 4 was sent out to the hospital on 03/27/22 with "stroke like symptoms."  Antibiotics were started at the hospital and the resident returned to the facility on 03/31/22 with a diagnosis of UTI with sepsis. There was no further assessment by the RN or documented evidence the service plan was updated with direction to caregivers on catheter care, properly securing the catheter tubing or interventions to ensure the resident did not continue to experience pain.

In interview on 05/04/22, Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) the need for a timely RN assessment for a significant change of condition and the service plan to be updated by the RN was discussed. They acknowledged the findings. No additional information was provided.

3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II.

Resident 5's clinical record, service plans, and temporary service plans were reviewed during the survey and identified the following:

a. On 02/05/22,Resident 5 returned to the facility from a 30 day hospital stay.

Resident 5 had not been receiving insulin before the hospitalization, but arrived with orders for insulin.  Additionally, Resident 5 had used a walker for mobility before the hospitalization, and then bed bound and non-weight bearing due to fractures of both knees, requiring a Hoyer lift to transfer.

There was no evidence Resident 5's significant changes had been assessed by an RN at return to the facility.

b. A progress noted dated 02/10/22 documented "Resident was admitted to hospice this morning" and noted there would be medication changes, bath schedule changes, and a new bed.  The admission to hospice constituted a significant change of condition.  

There was no evidence the change was reviewed by an RN until 02/16/22 when an RN note incorrectly stated Resident 5 had returned from the hospital on hospice on 02/05/22.  The service plan was not updated to reflect hospice services and no instructions were developed for staff.

The significant changes of condition and the need for an RN assessment that included findings, resident status, and interventions developed as a result of the assessment was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct a significant change of condition assessment including findings, resident status and interventions made as a result of the assessment and update the service plan for 3 of 3 sampled residents (#s 2, 4 and 5) who experienced significant changes of condition related to return from hospital, falls, pain and decline in health status. Residents 2 and 4 continued to experience a decline and increased pain. Findings include, but are not limited to:  

1. Resident 2 was admitted to the memory care facility in 04/2021 with a diagnosis of dementia.

Resident 2's clinical record, service plan, temporary service plans and chart notes reviewed during the survey identified the following:

Between 04/07/22 and 04/28/22 the resident was hospitalized on three occasions, had an increase in his/her ADL care needs related to meal assistance, mobility, an overall decline in his/her health condition and an admission to hospice services. These incidents represented a significant change of condition that required an RN assessment and update to the service plan.

During an interview on 05/03/22, Staff 8 (CG), reported the resident "used to eat really well and would even try to take other resident's food. Now, s/he will barely eat anything and sometimes won't get up for breakfast. S/he started to decline about three weeks ago and is now on hospice."

During an interview on 05/03/22, Staff 2 (RN), reported he was unable to locate an RN assessment for the decline in health status which resulted in multiple ER visits during the month of April 2022 and he was unable to locate an RN assessment for admission to hospice services.

There was no documented evidence the facility RN conducted an assessment which documented findings, resident status, and interventions made as a result of this assessment and updated the service plan to reflect hospice admission, meal assistance and ambulation assistance. The lack of an evaluation and RN assessment resulted in the resident experiencing multiple hospitalizations, continued decline in condition and hospice admission.

The significant changes of condition and the need for an RN assessment was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Refer to C 270, example 1.

C280

OAR 411-054-0045 Resident Health Services

1. Immediate actions taken to correct the rule violation include:

a. Resident #2 will have a comprehensive significant change of condition assessment specific to three hospitalizations, increase in ADL care related to meal assistance, mobility and overall decline in health condition and admission to hospice services. Care plan will be updated to reflect current interventions / needs of the resident.

Resident #4 will have a comprehensive significant change of condition assessment specific to hospitalization, pain, catheter care and overall decline in health condition. Care plan will be updated to reflect current interventions / needs of the resident. Resident #5 will have a comprehensive significant change of condition assessment specific to hospitalization, fractures, and mobility. Care plan will be updated to reflect current interventions / needs of the resident.

2. This system will be corrected so this violation does not happen again by the following measures:

All resident changes are reported and documented via the 24 hour reporting system. The community nurse will assess the resident and condition change in a timely manner to determine any need for further monitoring. A comprehensive assessment should be completed by RN if the change is significant. Comprehensive assessment involves, but is not limited to, the synthesis of the biological, psychological, social, sexual, economic, cultural and spiritual aspects of the resident's condition or needs, within the environment of practice, for the purpose of establishing nursing diagnostic statements, and developing, implementing and evaluating a plan of care.

RN will utilize a significant change of condition log to direct who requires a weekly nursing assessment until the resident is back at their baseline health status, or a new baseline can be established. A significant change of condition includes, but is not limited to return from hospital, falls, pain and decline in health status.

3. The area needing correction will be evaluated on a daily basis. Changes of condition are reviewed through the 24 hour process audit in daily standup meeting to provide oversight and follow up by RN when needed.

4. The Administrator and Registered Nurse will be responsible to ensure the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 1 of 1 sampled resident (# 4) reviewed for the delegation of insulin injections by unlicensed staff.  Findings include, but are not limited to:

Resident 4 was identified as having insulin-dependent diabetes and was administered insulin injections by non-licensed staff.

On 05/02/22, the facility's RN delegation records were requested and revealed the following:

* The previous facility delegating RN left the position on 04/30/22; and

* There was no transfer of delegation documentation completed.

In an interview with Staff 2 (RN), he stated the facility RN was no longer there and he would be filling in until they had one. He said the previous RN had not been in the facility since 04/26/22 even though her last day was to be 04/30/22 and did not do a transfer of delegation. He stated he let staff know he was available for questions or concerns, but had not completed any delegations of his own.  

Due to the facility not having a delegating RN, there were no MT staff with current delegations in place to administer insulin injections in the facility.

Staff 1 (Executive Director) and Staff 2 provided an immediate plan for ensuring delegations were completed. Staff 2 completed delegation for a night shift MT and continued delegating staff the next morning to ensure there was a delegated staff member on each shift until all delegations could be completed.

On 05/04/22, the need to ensure RN delegation was completed and maintained as required by rule was discussed with Staff 2, Staff 3 (RCC) and Staff 27 (Regional Director of Operations). They confirmed the findings.

C282

OAR 411-054-0045 RN Delegation and Teaching

1

2. This system will be corrected so this violation does not happen again by the community RN having documented evidence of completing the RN Delegation in Community Based Care self study course, schedule and complete the exam and print the certificate for CEU to be kept in delegation binder

3. A comprehensive delegation audit will take place, and 100% of residents and delegated staff will be assessed to ensure stability and predictability, as well as delegation log updated and a copy kept in the medication room for all med techs to share accountability with schedule / plan to re-delegate.

4. A comprehensive delegation audit will be completed to ensure delegation and supervision of special tasks of nursing care are being done consistently in accordance with OSBN Administrative Rules.

5. The area needing correction will be evaluated on a monthly basis, utilizing the delegation audit tool and updating delegation log monthly and as needed.

6. Delegating RN is responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers left written information in the facility that addressed the on-site service being provided and any supplemental care needed, for 1 of 3 sampled residents (#4) who received Home Health services. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia and catheter care.

The record indicated Resident 4 received home health services upon admission in 01/2022. Additionally, in 03/2022, weekly home health for wound care was started.

The facility was only able to locate seven home heath provider notes since the resident was admitted in 01/2022.

The need to ensure the facility had a system for coordinating on-site services with outside providers was discussed with Staff 2 (RN ), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C290

OAR 411-054-0045 (2) Res Hlth Srvc: On and Off - Site Health Services

1. Immediate actions taken to correct the violation include requesting documentation for Resident #4 from previous visits with outside provider from 01/2022 - 03/2022 to ensure the chart is reflective.

A full chart review for Resident #4 will be completed to ensure care is coordinated with outside services.

Resident #4 care plan will be reviewed and updated to reflect any reasonable and appropriate recommendations made by outside provider. This will allow staff to be instructed on and follow any recommendations that were previously made if still appropriate.

2. The system will be corrected so the violation will not

happen again by coordinating care with all outside providers per coordination of care policy and procedure that complies with Oregon Administrative Rules.

3. The areas needing correction will need to be evaluated on a daily basis with 24 hour process and order checks, as well as quarterly through the continuous quality improvement system.

4. The community Licensed Nurse or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:

During the re-licensure survey, conducted 05/02/22 through 05/04/22, the survey team identified the following concerns:

* C 282: RN Delegation and Teaching;

* C 303: Medication and Treatment Orders;

* C 310: Medication Administration; and

* C 330: PRN Psychotropic Medications.

During the exit meeting on 05/04/22, Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) were informed the overall medication and treatment administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas.

C300

OAR 411-054-0055 Systems: Medications and Treatments

Please refer to the following deficiencies for POC under C300 to ensure a safe medication system and adequate professional oversight:

*C282: RN Delegation and Teaching

*C303: Medication and Treatment Orders

*C310: Medication Administration; and

*C330: PRN Psychotropic Medications

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. This is a repeat citation. Findings include, but are not limited to:

During the first re-visit to the re-licensure survey, conducted 12/12/22 through 12/14/22, the survey team identified the following concerns:

* C 303: Medication and Treatment Orders; and

* C 310: Medication Administration.

During the exit meeting on 12/14/22, Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) were informed the overall medication and treatment administration system was determined to be inadequate based on the deficiencies related to the above medication areas.

C300

OAR 411-054-0055 Systems: Medications and Treatments

Please refer to the following deficiencies for POC under C300 to ensure a safe medication system and adequate professional oversight:

*C303: Medication and Treatment Orders

*C310: Medication Administration; and

2. Resident 4 was admitted to the facility in 01/2022 with diagnoses including dementia.

Resident 4's most recent signed physician's orders, 04/01/22 through 04/30/22 MAR, and 02/01/22 through 05/01/22 progress notes were reviewed, and the following deficiencies were identified:

* Humulin was documented as not given because it was not available on 04/03/22 and 04/04/22; and

* Humulin lacked documentation if it had been given on 04/16/22 at 8:00 pm, 04/17/22 at 8:00 am, 04/19/22 at 8:00 pm and 04/25/22 at 8:00 pm.

There was no written, signed orders for the following:

* Progress note dated 02/05/22 and 02/06/22 identified staff started a treatment on Resident 4's feet without orders; and

* Progress notes dated 02/19/22 revealed Staff 21 (RCC) directed Staff 9 (MT) to administer PRN Tylenol as a routine medication and Staff 9 followed her direction.

The need to ensure physician's order were followed and signed physician's orders were documented in the resident's facility record for all medication and treatments the facility was responsible to administer was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

3. Resident 5 was admitted to the facility in 2020 with diagnoses including dementia and Diabetes Type II.

Review of Resident 5's hospital discharge orders dated 02/05/22, MARs dated 04/01/22 through 05/01/22, and progress notes dated 01/05/22 through 05/02/22 were reviewed during the survey and the following was identified:

On 02/05/22 Resident 5 returned from a hospital stay with physician's discharge orders.

A Medication Technician note dated 02/05/22 documented "insulin wasn't given tonight... I wasn't able to administer any PRN pain medications as we had to fax over all documents to the pharmacy".

Review of the MAR from 02/05/22 to 02/11/22 documented the following hospital discharge orders were not followed:

* Insulin Aspart 100 u/ml flexpen - 24 missed doses;

* Insulin Glargine 100 u/ml pen - eight missed doses;

* Donepezil 5 mg - four missed doses;

* Metformin 500 mg one missed dose; and

* Mirtazapine 7.5 mg two missed doses.

On 02/11/22 the physician orders were clarified and the insulin was discontinued.

On 05/05/22 the need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed or immediately clarified with the prescriber was discussed with Staff 2 (RN) and Staff 27 (Regional Director of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a legally recognized practitioner were documented in resident records and carried out as prescribed for 3 of 5 sampled residents (#s 2, 4 and 5) whose records were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 2021 with a diagnosis of dementia.

Resident 2's hospital discharge orders dated 04/07/22, physician orders dated 04/09/22 and 04/28/22 and MARs dated 04/01/22 through 05/01/22 were reviewed during the survey and the following was identified:

a. The physician orders dated 04/09/22 were not signed and accessible in the resident's chart;

b. PRN Miralax 17 gm pack originally prescribed on 11/12/21 for no bowel movement in three days and instructed staff to contact the health care provider if the resident did not have a bowel movement after two doses; and

hospital discharge orders dated 04/07/22 prescribed Miralax every six hours if the resident didn't have a bowel movement within two days of returning to the facility.

There was no documented evidence the facility followed the PRN Miralax orders written on 11/12/21 or contacted the health care provider when the resident failed to have a bowel movement prior to being sent to the ER on 04/07/22. Additionally, the facility failed to follow the hospital discharge orders for Miralax every six hours until the resident had a bowel movement.

During an interview on 05/04/22, Staff 2 (RN) and Staff 3 (RCC) indicated the facility staff were suppose to monitor and track bowel movements on hand written sheets of paper on each shift and give them to the RCC. Staff 2 and 3 were unable to locate documentation staff monitored Resident 2's bowel movements to ensure the PRN bowel medications were administered as prescribed.

c. On 04/11/22, Resident 2 returned to the facility with hospital discharge orders that prescribed Culturelle (probiotic) for seven days while on Cipro. Instructions were given to hold fortified beverages while on the antibiotic.

The MAR pass notes indicated the culturelle was not received and the resident was not administered culturelle while taking Cipro and the facility failed to hold daily Med Pass 2.0 (fortified beverage).

d. On 04/28/22, Resident 2 was prescribed Tylenol, TID and Senna 1 tablet, daily. The medications were not transcribed on the MARs and Resident 2 had not been administered the medications.

On 05/05/22 the need to ensure all written, signed orders from a legally recognized practitioner were documented in resident records and carried out as prescribed was discussed with Staff 2, Staff 3 and Staff 27 (Regional Director of Operations). They acknowledged the findings.

C303

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

1. Immediate actions taken to correct the rule violation include full audit of physician orders for Resident #2, #4 and #5 to ensure physician orders are being carried out per MD order and that all medications are available to be given per order.

2. The system will be corrected so this violation will not happen again by all resident medication and treatment orders will be reconciled to ensure medications and treatments re dispensed as ordered.

3. Medication reconciliations will be completed on a quarterly basis. Additionally, all new orders will be reviewed and approved by a minimum of two staff. Further daily audits to review missing medications, omissions and PRN usage will be completed.

4. The Nurse, Administrator or trained designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, for 2 of 4 sampled residents (#s 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 06/2017.

A review of the 11/01/22 through 12/12/22 MARs and current physician's orders revealed the following:

Resident 9 had a physician order for lispro (insulin for diabetes) 10 units to be given before meals.

The MAR indicated on 11/16/22 at 4:30 pm, only 3 units of lispro had been administered instead of 10 units. On 11/17/22 at 7:30 am, there was no documented evidence lispro was administered as ordered.

An Administration History entry of the lispro on 11/16/22 indicated that there were only 3 units of medication left and the ordered dose could not be given at 4:30 pm. A second entry dated 11/17/22 revealed the facility was out of the medication and the 7:30 am dose could not be administered. The physician was notified of both incidents and there was not a documented negative outcome to the resident.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 35 (ED) on 12/14/22. He acknowledged the findings.

2. Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia.

Resident 8's 11/08/22 through 12/12/22 MARs and current physician orders were reviewed.  There was a current order for PRN Carboxymethylcellulose (eye drops) noted on the MAR.

During an interview on 12/13/22 with Staff 34 (MT) s/he verified the order however stated the medication was not available for the resident to use if requested.  

The need to ensure that physician's orders were carried out as prescribed was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings.

C303

OAR 411-054-0055 (1) (f-h) Systems: Treatment Orders

1. Immediate actions taken to correct the rule violation include full audit of physician orders for all residents.  PO were sent out and received to ensure physician orders are being carried out per MD order and that all medications are available to be given per order.

2.   The system will be corrected so as to reduce the risk of re-occurrence by all resident medication and treatment orders will be reconciled to ensure medications and treatments re dispensed as ordered.

3. Medication reconciliations will be completed on a quarterly basis. Additionally, all new orders will be reviewed and approved by a minimum of two staff. Further daily audits to review missing medications, omissions and PRN usage will be completed.

4. The Nurse, Administrator or trained designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure that MARs contained reason for use, resident-specific parameters for PRN medications and clear instruction to staff for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 3's 04/01/22 through 04/30/22 MARs were reviewed.

Resident 3's physician orders and 04/2022 MARs were reviewed and revealed the following:

The following medications did not include a reason for use:

* Aspirin (heart health);

* Donepezil (Alzheimer's disease);

* Lisinopril (hypertension);

* Mirtazaoine (depression);

* Simvastatin (hyperlipidemia); and

* Vitamin B 12 (supplement).

In an interview with Staff 2 (RN) at 2:30 pm on 05/03/22, he acknowledged the lack of reasons for use.

The need to ensure an accurate MAR was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (RCC) and Staff 4 (RCC) on 5/03/22. They acknowledged the MARs were not accurate.

2. Resident 4 was admitted to the facility in 01/2022 with diagnoses including diabetes.

Resident 4's physician orders and 04/2022 MARs were reviewed and revealed the following:

The following medications did not include a reason for use:

* Plavix (blood thinner);

* Vitamin C (supplement);

* Zinc Sulphate (supplement);

* Zinc oxide (sealant);

* Nystatin (antifungal);

* Aspirin; and

* Ciprofloxacin (antibiotic).

The following medication was given by one MT, but documented by another MT:

* Humulin (insulin).

The following medications had blanks on the MAR:

* Ciprofloxacin;

* Humulin;

* Memantine (for dementia);

* Quetiapine (antipsychotic):

* Bedtime snack;

* Foot treatment;

* Nystatin;

* Povidone iodine; and

* Pressure area treatment to heels.

The need to ensure an accurate MARs was reviewed with Staff 2 (RN), Staff 3 (RCC), and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

4. Resident 5's 04/01/22 through 05/02/22 MAR was reviewed during the survey. The following medications lacked a reason for use:

* Calcium carbonate (calcium supplement);

* Glucerna (sugar free nutrition);

* Acetaminophen (analgesic);

* Metformin (oral blood sugar;

* Mirtazapine (antidepressant);

* Polyethylene glycol (laxative);

* Senna (laxative); and

* Sertraline (antidepressant).

The need to ensure MARs were accurate and included reasons for use was discussed with Staff 2 (RN) on 05/04/22. He acknowledged the findings.

3.  Resident 2 was admitted to the MCC in 04/2021 with a diagnosis of dementia.

Resident 2's 04/01/22 through 05/02/22 MARs were reviewed and identified the following:

a. The following PRN medications prescribed to treat the same condition lacked clear instructions for unlicensed staff regarding the sequence of administration (which one to administer first, second, etc.)

* PRN Tylenol 325 mg tablet and PRN Tylenol 625 mg suppository;

* PRN Miralax 17 gm pack, twice daily and PRN phosphate/saline enema once daily both had instructions to administer after three days without a bowel movement; and

* PRN Miralax 17 gm pack twice daily and PRN bisocodyl suppository once daily lacked instructions for which one to use first.

b. The following inaccuracies on the MAR were identified:

* PRN Miralax Powder and PRN Miralax 17 gm pack were discontinued on 04/28/22, however the medications were still transcribed on the May 2022 MAR. Resident 2 had not been administered either of the medications.

The need to ensure MARs were accurate and included parameters for PRN medications was reviewed with Staff 2 (RN), Staff 3 (RCC), and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C310

OAR 411-054-0052 (2) Systems: Medication Administration

1. Immediate actions taken to correct the rule violation included completing a comprehensive review of Resident #3, #4 & #5 MAR and adding specific reason for administering medications / treatments.

Resident #2 included a comprehensive review of MAR and adding clear instructions for the sequence of administration of PRN medication prescribed for the same use.

Review also included ensuring all medications and treatments are being given per MD order.

100% of residents will have med reconciliation

completed to ensure all medications and treatments are accurate to signed physician order, reflect reason for use, appropriate directions / parameters for use and when to notify MD or nursing. Once reconciled, quarterly physician orders will be sent out for 100% of residents for MD review and signature.

2. The system will be corrected so this violation will not happen again by ensuring trained community staff perform a daily MAR audit to ensure no holes / missed medications. All new physician orders go through a triple check system where the order is initially processed by the receiving med tech to ensure no delay of treatment. 2nd check is the next oncoming med tech or RCC to verify orders are accurate, and appropriate directions and parameters for staff to follow are in place. Nursing to be final check to verify all components are in place, and to make updates as indicated.

Trained staff will complete weekly and monthly MAR audits to ensure any concerns with medication discrepancy, omission PRN effectiveness, and parameters are followed up on timely. Residents who require MD notification for daily weights or vitals out of parameters will be added to the acuity report to self audit and ensure MD notifications take place timely and follow up as indicated.

3. The area needing correction will be to be reviewed on a daily, weekly, and monthly basis with triple check, MAR audits and monthly continuous quality improvement program. All orders will be reconciled quarterly prior to physician orders sent for MD review.

4. The Licensed Nurse, RCC or trained designee will be responsible to ensure the corrections are completed and monitored.

2. Resident 9 was admitted to the facility in 06/2017 with diagnoses including diabetes and dementia.

Resident 9's 11/01/22 through 12/12/22 MARs were reviewed and identified the following blanks:

* 11/07/22 - 8:00 pm atorvastatin (for cholesterol);

* 11/07/22 - 8:00 pm Lantus (for diabetes);

* 11/07/22 - 8:00 pm metformin (for diabetes); and

* 11/17/22 - 8:00 pm Lantus.

On 12/14/22, the need to ensure MARs were accurate and included if a medication was administered and by whom was discussed with Staff 35 (ED). He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure accurate MARs were kept for all medications prescribed by a legally recognized practitioner and administered by the facility for 3 of 4 sampled residents (#s 7, 8 and 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the memory care community in 02/2021 with diagnoses including dementia and insomnia.

Review of Resident 7's MAR, dated 11/01/22 through 12/12/22, identified the following:

The MAR contained blanks in dosage administration for the following medications:

* Benztropine (for muscle control/stiffness) - 11/10/22, 11/11/22 and 11/13/22;

* Lorazepam (for anxiety) - 11/11/22; and

* Mirtazapine (for unspecified dementia) - 11/10/22, 11/11/22 and 11/13/22.

On 12/14/22 the need to ensure accurate MARs were kept for all medications prescribed by a legally recognized practitioner and administrated by the facility was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings. No further information was provided.

3. Resident 8 was admitted to the facility in 11/2022 with diagnoses including dementia.

Resident 8's MARs dated 11/08/22 through 12/12/22, current physician's orders and interview and observation with Staff 34 (MT) on 12/13/22 at 12:45 pm of Resident 8's available medications were reviewed and revealed the following discrepancies:

*Duplicate entries of medications were identified on the MAR for apixaban/Eliquis (blood clots), furosemide (edema), nifedepine (blood pressure) and Carboxymethylcellulose sodium 0.5%/Lubricating Plus 0.5% (dry eyes).

*Review of the physician order's for Resident 8 identified the following: nifedepine (for blood pressure) stated one 30 mg tab to be taken by mouth daily and on the MAR it is stated as one 60 mg tab.

*Review of the available medications identified there were two medication bottles available for administration for furosemide (for edema). One of the bottles contained 40 mg tabs and the other bottle contained 20 mg tabs. The physician's order and the MAR stated one 20 mg tab was to be taken by mouth every morning. Medication Pass Notes on the reviewed MARs identified dates when 40 mg tab was cut in half prior to administration, but it was uncertain as to which tab was given each time the medication was administered.   

The need to ensure the accuracy of the MAR was discussed with Staff 35 (ED), Staff 37 (Director of Operations) and Staff 38 (Regional Director of Operations). They acknowledged the findings.

C310

OAR 411-054-0052 (2) Systems: Medication Administration

1. Immediate actions taken to correct the rule violation included completing a comprehensive review of Residents MAR and adding specific reason for administering medications / treatments, included a comprehensive review of MAR and adding clear instructions for the sequence of administration of PRN medication prescribed for the same use.

Review also included ensuring all medications and treatments are being given per MD order.

100% of residents will have med reconciliation completed to ensure all medications and treatments are accurate to signed physician order, reflect reason for use, appropriate directions / parameters for use and when to notify MD or nursing. Once reconciled, quarterly physician orders will be sent out for 100% of residents for MD review and signature.

2.  The system will be corrected so as to reduce the risk of re-occurrence by ensuring trained community staff perform a daily MAR audit to ensure no holes / missed medications. All new physician orders go through a triple check system where the order is initially processed by the receiving med tech to ensure no delay of treatment. 2nd check is the next oncoming med tech or RCC to verify orders are accurate, and appropriate directions and parameters for staff to follow are in place. Nursing to be final check to verify all components are in place, and to make updates as indicated.

Trained staff will complete weekly and monthly MAR audits to ensure any concerns with medication discrepancy, omission PRN effectiveness, and parameters are followed up on timely. Residents who require MD notification for daily weights or vitals out of parameters will be added to the acuity report to self audit and ensure MD notifications take place timely and follow up as indicated.

3. The area needing correction will be to be reviewed on a daily, weekly, and monthly basis with triple check, MAR audits and monthly continuous quality improvement program. All orders will be reconciled quarterly prior to physician orders sent for MD review.

4. The Licensed Nurse, RCC or trained designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had resident-specific parameters, staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering the medications, direct care staff administering the medications had knowledge of common side effects and when to contact a health professional regarding side effects, and all direct care staff had knowledge of non-pharmacological interventions for 2 of 2 sampled residents (#s 1 and 5) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 2020 with diagnosis including dementia and Diabetes Type II.

Review of the resident's service plan, physician orders, and 04/01/22 through 05/02/22 MAR revealed the following:  

Resident 4 was prescribed Lorazepam 0.5 mg (anti-anxiety medication) one tablet every hour PRN for anxiety.

The facility failed to ensure the resident's MAR and clinical record included the following required information:

* Resident-specific parameters regarding how Resident 5 expressed anxiety;

* Common side effects;

* When to contact a health professional regarding side effects; and

* Non-pharmacological interventions to attempt prior to administration of the medication.

The need to ensure the required information for PRN psychotropic medications was documented in the MAR or clinical record was discussed with Staff 2 (RN) on 03/15/22 at 2:30 pm. He acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in October 2022 with diagnoses including dementia and depression.

The resident was prescribed Risperidone PRN for agitation. The clinical record, including the March 1, 2022 through May 3, 2022 MARs, current service plan and temporary service plans failed to include information on resident-specific symptoms of "agitation".

The need to ensure the facility included resident-specific parameters for use of psychotropic medications was discussed with Staff 3 (RCC) on 05/04/22. She acknowledged the findings.

C330

OAR 411-054-0055 (6) Systems: Psychoactive Medications

1. Immediate actions taken to correct the rule violation include completing a comprehensive audit of Resident #5 and Resident #1 MAR and adding resident specific parameters for use of PRN psychoactive medications as well as adding a trigger for staff to document the resident specific non-pharm interventions attempted

2. Any new order for PRN psychoactive medication to treat mood or behavior issues will be reviewed by the Licensed Nurse through the triple check process. The Licensed Nurse will ensure appropriate resident specific indicators for use are in place as well as non-pharm interventions staff should offer prior to using. All active PRN psychoactive medications will be reviewed

prior to quarterly physician orders sent for signature as well as with scheduled PRN medication audits.

3. This area will be evaluated on a quarterly basis prior to sending quarterly physician orders for signature, on a monthly basis with medication administration record audits and daily with triple check review if a new order is received.

4.The Licensed Nurse, RCC or trained designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 8, 11 and 14) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 05/04/22 and identified the following:

Staff 8 (CG) hired 01/05/22, Staff 11 (CG) hired 02/01/22 and Staff 14 (CG) hired 03/08/22 lacked documentation of demonstrated competency in First Aid/abdominal thrust.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

C372

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1. Immediate action taken to correct this rule violation includes ensuring Staff #8, #11 and #14 First Aid / Abdominal Thrust.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings, including First Aid / Abdominal Thrust in compliance with the Oregon Administrative Rules.

3. Staff training records will be to be evaluated upon each staff hire as well as on a monthly basis.

4. Business Office Manager, Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on record review and interview, it was determined the facility failed to ensure 2 of 3 sampled newly hired direct care staff (#s 21, 25) completed First Aid and Abdominal Thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 12/13/22 and 12/14/22. The following deficiencies were identified:

Staff 25 (MT) was hired 11/18/22 and Staff 21 (MT/CG) was hired 10/20/22. There was no documented evidence Staff 25 or Staff 21 completed First Aid and Abdominal Thrust training within 30 days of hire.

The need to ensure staff completed all required training as specified in the OARs was reviewed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 12:20 pm. They acknowledged the findings.

C372

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1. Immediate action taken to correct this rule violation includes ensuring all staff have all training requirements.

2. The system will be corrected so as to reduce the risk of re-occurrence, the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings and these trainings will be monitored by the RCC ongoing.  

3. Staff training records will be to be evaluated upon each staff hire as well as on a monthly basis.

4. Staffing and orientation will be responsible for this moving forward; Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers, and multiple resident that were bed bound or used wheelchairs for mobility.  The MCC housed residents on four floors, with two stairwells and one elevator.

On 05/04/22, the facility's fire and life safety records were requested for review.

There was no documented evidence of the following general fire and life safety requirements:

* Evidence of fire drills completed on alternate months;

* Evidence of life safety instruction other months;

* Evidence alternative exit routes were used during fire drills;

* Residents ability to participate in an evacuation;

* Staff interviewed were not aware of the designated point of safety;

* Evidence staff and residents participated in fire drills and training to assess ongoing evacuation capabilities of both residents and staff; and

* Documentation of interventions and resolution related to resident evacuation concerns identified during fire drills.

The need to ensure all general fire and life safety requirements were implemented and followed was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.

C420

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1. Actions taken to correct the rule violation will include;

a. Facility will conduct unannounced fire drills every other month at different times of the day, evening, and night.

b. Fire and life safety instruction to staff will provided on alternate months.

c. Written fire drill records will be kept that include but not limited to; alternative exit routes used, staff and residents that participated in fire drill and interventions and resolution related to resident evacuation concerns identified during fire drills.

d. Evaluation of each resident will be completed to evaluate their ability and needs to evacuate safely.

2. The system will be corrected so this violation does

not happen again by completing a comprehensive review of current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule and in servicing administration or designee conducting fire and life safety drills and education on process and documentation required.

3. The area needing correction will be evaluated monthly.

4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to provide and document fire and life safety instruction to staff on alternate months, and staff interviewed did not know the designated point of safety. This is a repeat citation. Findings include, but are not limited to:

* Fire and life safety records, reviewed between 07/2022 and 12/2022, revealed fire and life safety instruction was not provided to staff on alternate months; and

* During interviews on 12/13/22, Staff 28 (CG) and Staff 38 (CG) indicated they were unaware of the location of the designated point of safety for evacuating residents.

The need to ensure that staff received fire and life safety instruction on alternate months and that all staff were aware of the designated point of safety was discussed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22 at 12:20 pm. They acknowledged the findings.

C420

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1. Actions taken to correct the rule violation will include;

a. Facility will conduct unannounced fire drills every other month at different times of the day, evening, and night.

b. Fire and life safety instruction to staff will provided on alternate months.

c. Written fire drill records will be kept that include but not limited to; alternative exit routes used, staff and residents that participated in fire drill and interventions and resolution related to resident evacuation concerns identified during fire drills.

d. Evaluation of each resident will be completed to evaluate their ability and needs to evacuate safely.

2. The system will be corrected so as to reduce the risk of re-occurrence by completing a comprehensive review of current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule and in servicing administration or designee conducting fire and life safety drills and education on process and documentation required.

3. The area needing correction will be evaluated monthly.

4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers, and multiple resident that were bed bound or used wheelchairs for mobility.  The MCC housed residents on four floors, with two stairwells and one elevator.

On 05/04/22, the facility's fire and life safety records were requested for review.

There was no documented evidence of the following fire and life safety requirements for residents:

* No evidence that each resident was instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and

* No written record of fire safety training, including content of the training sessions and the residents attending.

There was no documented evidence residents ability to evacuate the building or follow instructions in an emergency had been evaluated or resident training provided and documented.

The need to ensure all resident fire and life safety requirements were implemented and documented was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.

C422

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

1. Immediate action taken to correct this rule violation includes all residents will be instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire safe, and re-instructed annually.

2.The system will be corrected so this violation will not happen again by ensuring new residents will be instructed within 24 hours of move in and re-instructed annually for general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

3. The areas needing correction will be audited daily at stand up meeting and clinical meeting with a new resident move in.

4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

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

Refer to C150, C231, C252, C260, C270, C300, C303, C310, C372, C420, C460, C510, C513, Z155 and Z164.

OAR 411-054-0105 (2-4)

Rule was not meet refer to tags

C150, C231, C252, C260, C270, C300, C303, C310, C372, C420, C460, C510, C513, Z155 and Z 164.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the condition placed on the facility by the Department of Human Services (DHS). Findings include, but are not limited to:

On 07/01/21, the facility was placed under a condition to ensure they had six caregivers and 2 Medication Aides on Day and Evening shifts and four caregivers and 1 Medication Aide on NOC shift.

The facility was an endorsed Memory Care Community home to 52 residents at the time of the relicensure survey. During the acuity interview on 05/02/22 the facility was identified to have residents with high ADL care needs, multiple residents that required two staff for transfers or during care and dementia diagnoses.   

Review of the MCC schedule from 04/1/22 to 05/02/22, observations, and interviews confirmed the facility failed to have six caregivers on the Day or Evening shifts 54 times and failed to have four caregivers on the overnight shift 19 times.

In an interview with Staff 1 (Executive Director), on 05/03/22, he stated they were waiting for additional staffing through a state assistance program. In the interim, current staff were frequently scheduled for double shifts.

The need to ensure sufficient staffing to meet the scheduled and unscheduled resident needs based on the condition that was place on the facility, was discussed with Staff 1 on 05/03/22.  He acknowledged the findings.

C460

OAR 411-054-0110 (1-12) Conditions

1. Immediate action taken to correct this rule violation includes addressing staff ratios that are required to be in place

2.The system will be corrected so this violation will not happen again by ensuring there are six caregivers and two medication aides on day and evening shifts and four caregivers and one medication aide on NOC shift

3. The schedule and any needs will be audited daily at stand up meeting and reviewed prior to weekends with a manager on call in the event of call ins

4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide sufficient numbers of caregiving staff to meet the condition placed on the facility by the Department of Human Services (DHS). This is a repeat citation. Findings include, but are not limited to:

On 07/01/21, the facility was placed under a condition to ensure they had six caregivers and two Medication Aides on Day and Evening shifts and four caregivers and one Medication Aide on NOC shift.

The facility was an endorsed Memory Care Community home to 43 residents at the time of the first re-visit to the relicensure survey. During the acuity interview on 12/12/22 the facility was identified to have residents with high ADL care needs and dementia diagnoses.   

Review of the MCC schedule from 12/1/22 to 12/14/22, observations, and interviews confirmed the facility failed to have six caregivers on the Day or Evening shifts 16 times and failed to have four caregivers on the overnight shift five times.

The need to ensure sufficient staffing to meet the scheduled and unscheduled resident needs based on the condition that was placed on the facility, was discussed with Staff 35, Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations) on 12/14/22. They acknowledged the findings.

C460

OAR 411-054-0110 (1-12) Conditions

1. Immediate action taken to correct this rule violation includes addressing staff ratios that are required to be in place

2. The system will be corrected so as to reduce the risk of re-occurrence by ensuring there are six caregivers and two medication aides on day and evening shifts and four caregivers and one medication aide on NOC shift

3. The schedule and any needs will be audited daily at stand-up meeting and reviewed prior to weekends with a manager on call in the event of call ins

4. The Administrator and / or designee will be responsible to ensure corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit. Findings include, but are not limited to:

The interior and exterior of the building was toured on 05/03/22 and 05/04/22. The following issues were noted:

On 05/03/22, multiple observations were made of bottles with disinfectant cleaner accessible to the residents on the countertops and in unlocked cabinets of the dining room kitchenettes on the first, second and fourth floors of the facility.

The need to ensure all toxic materials were maintained in locked storage to avoid access by residents was discussed with Staff 1 (Executive Director) and Staff 5 (Food Service Director) on 05/03/22 and Staff 6 (Maintenance Director) on 05/04/22. They acknowledged the findings.

C510

OAR 411-054-0200 (3) General Building Exterior

1. Actions taken to correct the rule violation will include; all chemicals and toxic materials will be stored in locked cabinets.

2. The system will be corrected so this violation does not happen again; all staff being inserviced on correct storage and use of all chemicals and toxic materials.

3.The area needed corrections will be monitored daily, weekly and monthly via walk throughs of community by administration, and quality improvement process.

4. The Administrator, Maintenance Director or designee will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit. This is a repeat citation. Findings include, but are not limited to:

During a tour of the facility on 12/12/22 at 1:15 pm the following was identified:

* The door next to Room 102 that opened to a corridor leading to the kitchen on the ground floor was not closed and secured. Cleaning materials were observed to be in the corridor that connected to the kitchen. The kitchen door was also opened allowing residents full access to the kitchen.

A walk through with Staff 35 (Executive Director), Staff 32 (Maintenance Director), and Staff 24 (Maintenance Assistant) was conducted on 12/13/22 at 11:00 am. They acknowledged the findings.

C510

OAR 411-054-0200 (3) General Building Exterior

1. Actions taken to correct the rule violation will include; all chemicals and toxic materials will be stored in locked cabinets, Also Door next to 102 is locked at this time.  

2. The system will be corrected so as to reduce the risk of re-occurrence; all staff being in-service on correct storage and use of all chemicals and toxic materials.

3.The area needed corrections will be monitored daily, weekly and monthly via walk throughs of community by administration, and quality improvement process.

4. The Administrator, Maintenance Director or designee will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:

Observations of the facility on 05/02/22 through 05/04/22 showed the following areas were in need of cleaning and/or repair:

On the first floor:

* A door leading to the back kitchen corridor (near Room 102) could not close completely and latch;

* A section of flooring in the hallway in front of the elevator was lifting and uneven, with areas peeling away;

* Walls, chair rails and door jambs in the dining room were scuffed, gouged and had some areas of chipped paint; and

* Walls on the hallway leading to the medication room had patched but unpainted holes.

On the second floor:

* An area of the wall was damaged leaving exposed drywall next to the "mechanical room"; and

* The trim and door jamb around the elevator was scuffed, gouged and had peeling paint.

On the third floor (no residents currently resided on this floor):

* A section of exposed wiring on the wall next to the medication room; and

* The double doors leading to the balcony area were unsecured, leaving access to a stair way.

On the fourth floor:

* Room 416 door jambs on the bathroom door and apartment door were gouged, scuffed and had missing paint.

The need to ensure the environment was kept clean and in good repair was discussed with Staff 6 (Maintenance Director) on 05/04/22. She acknowledged the findings.

C513

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

1. Actions taken to correct this rule violation include;

a. on the first floor door leading to the back of kitchen corridor will be repaired, flooring in the hallway in front of elevator will be repaired or replaced, walls, chair rails and door jambs will be repaired and repainted, walls on hallway leading to the medication room will be sanded and repainted.

b. on the second floor area of wall with exposed drywall next to mechanical room will be repaired and trim and door jamb around the elevator will be repaired and repainted.

c. on third floor section of exposed wiring on the wall next to the medication room will be repaired and the double doors leading to balcony will be secured.

d. on fourth floor room 416 door jambs on bathroom door and apartment door will be repaired and repainted.

2. The system will be corrected so this violation will not happen again by; staff will be provided with inservicing on reporting damaged, broken facilities or equipment, utilization of maintenance request log as means of communication regarding repair needs that are not urgent, and Maintenance Director will respond to repair needs timely.

3. The area needing corrected will need to be evaluated on a monthly basis as part of the environmental audit.

4. The Administrator, Maintenance Director or designee will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained, clean, and in good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility on 12/12/22 showed the following areas in need of cleaning and/or repair:

a. First floor entrance, hallway, and resident rooms:

* Flooring section in front of elevator was damaged and uneven;

* Ceiling vent in the main entrance was covered with dust;

* The door leading to the back kitchen corridor next to Room 102 was unable to be latched and secured;

* Wall corner next to Room 120 was damaged with chipped paint;

* Room 120 bathroom was missing a toilet paper holder; and

* Room 124 flooring areas in the bathroom and upon entrance had uneven and bulging floor sections.

b. Second floor:

* Water damage stains and peeling paint on the ceiling arch in the dining room entrance next to the "mechanical room"; and

* A section of window was missing and patched with cardboard in the seating area next to Room 219.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 35 (Executive Director), Staff 32 (Maintenance Director), and Staff 24 (Maintenance Assistant) on 12/13/22 at 11:00 am. They acknowledged the findings.

C513

OAR 411-054-0200 (4) (d-i) Doors, Walls, Elevators, Odors

1. Actions taken to correct this rule violation include;

a. on the first-floor in room 120 and room 124, fixing the flooring and painting.   

b. Flooring in front of elevator is being fixed on first floor.  Working on a bid for this project.  

c. Ceiling vent has been cleaned.

d. Back corridor kitchen door is locked at this time.  

2. The system will be corrected so as to reduce the risk of re-occurrence; staff will be provided with in servicing on reporting damaged, broken facilities or equipment, utilization of maintenance request log as means of communication regarding repair needs that are not urgent, and Maintenance Director will respond to repair needs timely.

3. The area needing corrected will need to be evaluated on a monthly basis as part of the environmental audit.

4. The Administrator, Maintenance Director or designee will be responsible to see that the corrections are completed and monitored.

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, C 372, C 420, C 422, C 460, C 510 and C 513.

Z142

OAR 411-057-0140 (2) Administration Compliance

Refer to C150, C231, C240, C372, C420, C422, C460, C510 and C513 per plan of correction

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 C150, C231, C372, C420, C460, C510 and C513.

Z142

OAR 411-057-0140 (2) Administration Compliance

Refer to C150, C231, C240, C372, C420, C460, C510 and C513 per plan of correction

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 6, 8, 11 and 14) completed pre-service orientation topics, 1 of 3 newly-hired direct care staff (#11) failed to complete 6 hours of pre-service dementia care training, 3 of 3 newly hired staff failed to complete all required training and demonstration of competency (#s 8, 11 and 14) and 3 of 3 sampled long term direct care staff (#s 7, 12 and 16) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

Training records were reviewed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. The following were identified:

a. Staff 6 (Maintenance Director), was hired 02/02/22, Staff 8 (CG) hired 01/05/22, Staff 11 (CG) hired 02/01/22 and Staff 14 (CG) hired 03/08/22. There was no documented evidence the following orientation topics were completed:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

b. There was no documented evidence Staff 11 had completed pre-service dementia care training.

c. There was no documented evidence that Staff 8, Staff 11 and Staff 14 completed the required training in:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Changes of condition and changes that require reporting; and

* General food safety, serving and sanitation.

d. Staff 7 (CG) was hired 01/29/2015, Staff 12 (CG) was hired 03/01/14 and Staff 16 was hired 04/20/15. For the annual period of their respected hire dates, there were no documented hours of the required 16 hours of in-service training on topics related to dementia and provision of care.

The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, that newly hired staff demonstrated and documented required 30 day competencies and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 3 and Staff 27 on 05/04/22. They acknowledged the findings.

Z155

OAR 411-057-0155 (1-6) Staff Training Requirements

1. Immediate actions taken to correct the rule violation include;

a. Staff #6, #8, #11, and #14 will receive the required training in resident rights and values of CBC care, abuse reporting requirements, standard precautions for infection control, and fire and life safety and emergency procedures.

b. Staff #11 will receive the required pre-service dementia care training.

c. Staff #8, #11 and #14 will receive the required training; role of service plans in providing individualized care, providing assistance with ADL's, changes associated with normal aging, change of condition and changes that require reporting and general food safety, serving and sanitation.

d. Staff #7, #12, and #16 will receive the required 16 hours of in-service training on topics related to dementia and provision of care.

2. Ongoing, any newly hired staff will receive the required pre-service training prior to beginning their job duties. All new staff will receive Memory Care required training with 30 days of hire, and ongoing inservice training for Memory Care per annual inservice requirements.

3. The areas needing correction will be evaluated prior to any new hire beginning by using new hire checklist as well as with community continuous quality assurance system reviews.

4. The Administrator, Business Office Manager and / or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 25 and 30) completed all required training and demonstrated competency, 3 of 3 sampled long term direct care staff (#s 12, 29 and 31) completed a total of 16 hours of annual in-service training, including six hours of annual dementia care training, and 2 of 3 sampled newly hired direct care staff (#s 25 and 30) completed orientation and pre-service topics. This is a repeat citation.  Findings include, but are not limited to:

Training records were reviewed on 12/13/22 and 12/14/22. The following were identified:

a. Staff 25 (MT) hired 11/18/22 and Staff 30 (MT/CG) was hired on 08/05/22. There was no documented evidence the following orientation topics were completed:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Changes of condition and changes that require reporting; and

* General food safety, serving and sanitation.

b. There was no documented evidence Staff 30 had completed Med Pass training.

c. There was no documented evidence that Staff 25 and Staff 30 completed the required training in:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention; and

* Fire safety and emergency procedures.

The need to ensure newly hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, that newly hired staff demonstrated and documented required 30 day competencies and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 35 (Executive Director), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations)

on 12/14/22 at 12:20 pm. They acknowledged the findings.

Z155

OAR 411-057-0155 (1-6) Staff Training Requirements

1. Immediate actions taken to correct the rule violation include;

a. Staff will receive the required training in resident rights and values of CBC care, abuse reporting requirements, standard precautions for infection control, and fire and life safety and emergency procedures.

b. Staff will receive the required pre-service dementia care training.

c. Staff will receive the required training; role of service plans in providing individualized care, providing assistance with ADL's, changes associated with normal aging, change of condition and changes that require reporting and general food safety, serving and sanitation.

d. Staff will receive the required 16 hours of in-service training on topics related to dementia and provision of care.

2. Ongoing, any newly hired staff will receive the required pre-service training prior to beginning their job duties. All new staff will receive Memory Care required training with 30 days of hire, and ongoing in-service training for Memory Care per annual in-service requirements.

3. The areas needing correction will be evaluated prior to any new hire beginning by using new hire checklist as well as with community continuous quality assurance system reviews.

4. The Administrator, Business Office Manager and / or designee will be responsible to see that the corrections are completed and monitored.

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 252, C 260, C 262, C 270, C 280, C 282, C 290, C 300, C 303, C 310 and C 330.

Z162

OAR 411-057-0160 (2b) Compliance with Rules of Health Care

Refer to C252, C260, C262, C270, C280, C282, C290, C300, C303, C310 and C330 for plan of correction.

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 C252, C260, C270, C300, C303 and C310.

Z162

OAR 411-057-0160 (2b) Compliance with Rules of Health Care

Refer to C252, C260,C270,C300, C303,and 310 for plan of correction.

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 service plans for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3, 4 and 5'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.  

On 05/04/22, the need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 2 (RN), Staff 3 (RCC), Staff 27 (Regional Director of Operations). They acknowledged the findings.

Z163

OAR 411-057-0160 (2)(c )(A)(B) Nutrition and Hydration

1. Immediate actions taken to correct the rule violations include resident #1, #2, #3, #4 and #5 and 100% of other residents will be evaluated and individualized nutrition and hydration plans that include resident preferences will be developed and included on their care plan.

2. The following actions will be implemented to ensure the system is corrected so this violation will not happen again, at the time of move in an individualized nutritional and hydration plan will be developed based on residents evaluated needs and included on the new admission care plan.

3. Each resident's nutritional and hydration plan will be reviewed and updated as needed at their quarterly care plan review or as needed when a significant change of condition occurs.

4. The Administrator, Licensed Nurse or designee will be responsible to see the corrections are completed and monitored.

Based on observation, 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 and failed to consistently provide meaningful activities for all residents that promoted or helped sustain physical and emotional well-being, for 5 of 5 sampled residents (#s 1, 2 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, 4 and 5's service plans offered some information about the residents' interests, however, 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 were no specific activity plans developed from the evaluations that detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

Observations and interviews indicated the residents were dependent on staff to initiate activities and scheduled activities did not happen on each floor of the building.

On 05/04/22 the need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 2 (RN), Staff 3 (RCC) and Staff 27 (Regional Director of Operations), who acknowledged the findings.

Z164

OAR 411-057-0160 (2d) Activities

1. Immediate actions taken to correct the rule violation include the review and development of residents #1, #2, #3, #4 and #5 individualized activity plans based of activity evaluation. The activity plans will address the following: past and current interest, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate; and / or identification of activities for behavioral interventions.

Activity plans will consistently provide meaningful activities for residents #1, #2, #,3, #4 and #5, and will be developed for 100% of residents to promote or help sustain their physical and emotional well-beings. Their personalized activity plan will be included in their care plan for staff reference to engage in meaningful

planned and spontaneous activities with the residents throughout the day.

2. This system will be corrected so this violation will not happen again by ensuring that at the time of move in, an individualized activity plan will be developed and included on the new admission care plan. The activity plans will be person directed and meaningful with focus to promote or help sustain physical and emotional wellbeing for the residents. It will take into consideration past and current interests, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate, and identification of activities for behavioral interventions. The community will provide daily structured and non-structured / spontaneous activities throughout the day. The activities will be selected based on resident preferences and ability to participate.

3. To ensure the activity plan meets the current needs of each resident, it will be reviewed and updated as needed at their quarterly service plan review. In addition, it will be updated as needed when a significant change of condition occurs. Activity Director will review activity options and scheduled appropriate activities on a monthly basis when updating the activity calendar.

4. The Administrator, RCC, Activity Director or designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure individualized activity plans were developed for each resident, based on their activity evaluations, for 1 of  4 sampled memory care residents (#7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the MCC in 02/2021 with diagnoses including dementia and insomnia.

Residents 7's service plan offered some information about the residents' historical and current interests. However, the facility had not fully evaluated the resident in the following areas:

* 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 developed from the evaluation which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

On 12/14/22 the need to ensure the facility developed individualized activity plans for each resident in the MCC was discussed with Staff 35 (ED), Staff 36 (Director of Operations) and Staff 37 (Regional Director of Operations). They acknowledged the findings. No further information was provided.

Z164

OAR 411-057-0160 (2d) Activities

1. Immediate actions taken to correct the rule violation include the review and development of residents individualized activity plans based of activity evaluation. The activity plans will address the following: past and current interest, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate; and / or identification of activities for behavioral interventions.

Activity plans will consistently provide meaningful activities for all residents, and will be developed for 100% of residents to promote or help sustain their physical and emotional well-beings. Their personalized activity plan will be included in their care plan for staff reference to engage in meaningful planned and spontaneous activities with the residents throughout the day.

2.  The system will be corrected so as to reduce the risk of re-occurrence by ensuring that at the time of move in, an individualized activity plan will be developed and included on the new admission care plan. The activity plans will be person directed and meaningful with focus to promote or help sustain physical and emotional wellbeing for the residents. It will take into consideration past and current interests, current abilities and skills, emotional and social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate, and identification of activities for behavioral interventions. The community will provide daily structured and non-structured / spontaneous activities throughout the day. The activities will be selected based on resident preferences and ability to participate.

3. To ensure the activity plan meets the current needs of each resident, it will be reviewed and updated as needed at their quarterly service plan review. In addition, it will be updated as needed when a significant change of condition occurs. Activity Director will review activity options and scheduled appropriate activities on a monthly basis when updating the activity calendar.

4. The Administrator, RCC, Activity Director or designee will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident and others in the community and include information and instructions for staff to follow, for 1 of 1 sampled resident (#1) who exhibited behaviors. Findings include, but are not limited to:

Resident 1 resided on the memory care unit since October 2021 and was diagnosed with Alzheimer's dementia.

Progress notes indicated the resident became agitated and was involved in a physical altercation with another resident on 02/16/22. Other progress notes, reviewed from 02/01/22 through 04/03/22, indicated the resident would occasionally become agitated and difficult to re-direct, wandered through the unit and occasionally went into other resident's rooms. The resident's current service plan, dated 08/11/21, did not provide any information on agitation, behaviors or interventions for staff to provide when behaviors occurred. The resident had a physician's order for staff to administer a psychotropic medication as needed for agitation.

In an interview on 05/02/22, Staff 8 (CG) stated the resident would often require re-direction if s/he got into arguments with other residents or entered other resident's rooms.

The facility failed to evaluate Resident 1's behavior, add information about the behavior to the service plan and develop interventions for staff to attempt when the behaviors occurred.

The need to evaluate Resident 1's behavior and provide an individualized behavior plan was discussed with Staff 3 (RCC) and Staff 27 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

Z165

OAR 411-057-0160 (e ) Behavior

1. Immediate actions taken to correct the rule violations include evaluating resident #1 for behavioral symptoms and ensuring the care is updated to reflect all current and effective interventions identified for staff to utilize to better meet resident needs and minimize behaviors including agitation, resident to resident altercations and wandering.

All current residents will be evaluated for behavioral symptoms, which negatively impact the resident or others. Based off of this evaluation, resident specific interventions to reduce, eliminate or de-escalate any identified behaviors that do negatively impact the resident and others will be identified and added to the care plan.

2. The system will be corrected so this violation will not happen again by ensuring that an evaluation of behavioral symptoms will take place as part of the evaluation process at the time of move in. An individualized behavior support plan will be developed based on residents evaluated needs, and included on the new admission care plan. This area will be re-evaluated within 30 days, and quarterly thereafter to ensure the behavioral plan remains effective to support the residents current needs and preferences.

3. Each resident's behavioral support plan will be reviewed and updated as needed at their next scheduled care plan review (30 day or 90 day) or as needed when a significant change of condition occurs.

4. The Administrator, Licensed Nurse or designee will be responsible to see the corrections are completed and monitored.