The findings of the re-licensure survey, conducted 08/07/23 through 08/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home & Community-Based Services 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

A situation was identified where there was a failure of the facility to comply with the Department's rules which was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first revisit to the change of management survey of 08/11/23 conducted 12/05/23 through 12/07/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:         Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:      Resident Care Coordinator

RN:    Registered Nurse

TAR:Treatment Administration

Record

tid:        three times a day

The findings of the second revisit to the change of management survey of 08/11/23 conducted 04/30/24 through 05/02/24, 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.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

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

Situations were identified where there was a failure of the facility to comply with the Departments rules that caused or were likely to cause an immediate threat to residents' health and safety. An immediate plan of correction was requested in the following area:

OAR 411-054-0040 (1-2) (C0270) - Change of Condition and Monitoring.

The facility put an immediate plan of correction in place during the survey and the situations were abated.

The findings of the third re-visit to the re-licensure survey of 08/11/23, conducted 08/12/24 through 08/13/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors, and available for inspection. Findings include, but are not limited to:

A tour of the facility conducted on 12/05/23 and 12/07/23 identified the facility lacked the following required postings:

* Facility license;

* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator was out of the facility;

* The current facility staffing plan; and

* A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

"C 152:  OAR 411-054-0025 (5) Facility Administration: Required Postings

1.The community will display required postings in conspicuous location for public view.  Postings included but not limited to Facility license, Administrator, current staffing plan, manager on duty, contact information, copies of most recent licensure visits.

2.Community leadership will be trained on required postings to display.  Executive Director or designee will routinely review and update postings to ensure most current forms are displayed or accessible.

3.This process will be monitored on a monthly basis by community leadership and daily by manager on duty.

4.The Executive Director or designee will ensure this process is completed/monitored.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

During the survey, multiple witnesses including family members and outside providers expressed their concerns with the following:

* Lack of staff;

* Residents left unsupervised in dining room during a meal; and

* Residents care plans not being adjusted with changes such as falls and new behaviors.

On 12/07/23, Witness 2 (Family Member) stated concerns related to lack of staff, residents appearing to be sitting in soiled garments and lack of activities for residents. Witness 2 described difficulty communicating with staff about his/her concerns, and sent an email to Staff 1 (ED) approximately two weeks prior and had not received a response.  

On 12/07/23 Staff 27 (MCC Director) was interviewed about the facility's grievance and resolution policy. She stated the facility didn't have a grievance resolution policy and a system was not implemented in the MCC. She acknowledged the need to ensure the facility had a system for responding to and resolving resident complaints.  

"C 156:  OAR 411-054-0025 (7) Facility Administration: Policy and Procedure

1.Facility staff will be trained on written services, health, and safety policies and procedures per the MBK Senior Living Health Services-Memory Care Policy & Progedure Manual; Oregon; ver. 12/2023, the Residential Care Facility Residence and Services Agreement (OR), and Resident Handbook (OR). Including grievance resolution policy. Staff will be trained on where to locate policies & procedures ongoing- in print and online.

2.The grievance system process is published in residency agreement and resident handbook materials.  The process along with Administrator and management contact information will be posted in a public place for residents, family, POAs to access. A grievance form and box will be included to provide for written communication which will be monitored weekdays. When a grievance or complaint is made, the Administrator or designee will respond to the individual within 72 hours, investigate, and support the resolution process and associated actions including relevant parties as needed.

3.Daily, weekly, monthly, and as needed.

4.ED, AED, DHS, CFLD, CFLC or designee.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:

During the first revisit to the change of management survey of 08/11/23 conducted 12/05/23 through 12/07/23; quality improvement and oversight to ensure adequate resident care, services and satisfaction was found to be ineffective based on the number of repeat citations and the number of new citations during the revisit survey.

During an interview on 12/07/23 with Staff 1 (ED) at 3:20 pm, it was reported the facility had a quality assurance program to evaluate services, resident outcomes and satisfaction. The team met at various intervals from weekly for clinical areas to monthly for other areas, such as kitchens. Staff 1 reported the last clinical meeting was conducted on 10/20/23.

The need to ensure the facility conducted an ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction was discussed with Staff 1 on 12/07/23. She acknowledged the findings.

"C 156:  OAR 411-054-0025 (7) Facility Administration: Quality and Improvement

1.Facility ED, AED, CFLD, ALD, DHS or designee will conduct weekly Interdisciplinary Quality Assurance meetings focused on evaluating resident health status, care needs, services, improvements, outcomes, and satisfaction; incident reports and investigations; staff performance training gaps.

2.Facility ED, AED, CFLD, ALD, DHS will ensure meeting is scheduled, recurring, and held weekly on an ongoing basis. Meeting will be documented with minutes and action items will be produced for weekly follow-up and tracking.

3.Weekly

4.ED, AED, DHS, CFLD, CFLC or designee

Based on observation, interview, and record review, it was determined the facility failed to have a quality assurance program that evaluated services, staff performance, resident outcomes and resident satisfaction. This is a repeat citation. Findings include, but are not limited to:

During the second revisit to the change of management survey of 08/11/23, conducted 04/30/24 through 05/02/24, quality improvement and oversight to ensure adequate resident care, services and satisfaction was found to be ineffective based on the number of repeat citations during the second revisit survey.

The need to ensure the facility conducted an effective ongoing quality improvement program that evaluated services, resident outcomes, and resident satisfaction was discussed with Staff 1 (ED) on 05/02/24. She acknowledged the findings.

1.What actions will be taken to correct the rule violation?

a.Facility management team conducts weekly Quality Assurance (QA) meetings focused on evaluating, services, outcomes, and satisfaction. Garden House residents will be reviewed weekly, will be documented, and follow-up including interventions and training for staff where indicated.

2.How will the system be corrected so this violation will not happen again?

a.Facility management team will ensure QA meeting attendance, regular data collection, analysis, and tracking of progress and intervention outcomes. .

3.How often will the area needing correction be evaluated?

a.Weekly and reviewed at QA for sustained substantial compliance.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation and report to the local SPD office, if abuse or neglect could not be ruled out, for 2 of 2 sampled residents (#s 2 and 3) with incidents or injuries of unknown cause. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia with behavioral disturbance.

Observations of the resident, interviews with staff, and review of the resident's 06/29/23 service plan, 05/07/23 through 08/07/23 temporary service plans and progress notes, physician communications, and incident investigations were reviewed, and the following was identified:

* 05/14/23 unobserved fall with injury to right eye;

* 05/19/23 resident to resident altercation resulting in injury to Resident 3;

* 06/01/23 unobserved fall with injury including bruise to right forearm; and

* 08/05/23 injury of unknown cause, large bruise on right hip.

There was no documented evidence the occurrences had been investigated at the time of occurrence and the investigations included all required components, or the occurrences reported to the local APS office, if abuse and/or neglect could not be ruled out.

At the request of the survey team, all incidents above were reported to APS before the survey team exited the facility on 08/11/23.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out and if not, the injuries were reported to the local APS office was discussed with Staff 2 (Associate ED), Staff 3 and Staff 5 on 08/11/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 07/2021 with diagnoses including dementia.

The resident's progress notes, dated 05/11/23 through 08/07/23 were reviewed and the following was identified:   

* On 07/21/23 staff documented, "[Resident's] left hand was bleeding today this writer cleaned it and put on antibiotics."

There was no documented evidence the occurrence had been investigated or reported to the local SPD or AAA office, if abuse and/or neglect could not be ruled out. At the request of the survey team, the incident above was reported to APS before the survey team exited the facility on 08/11/23.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out and if not, the injuries were reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings.

1. Immediate review of policies and procedures to ensure they meet regulatory compliance for investigating and reporting injuries of unknown cause. Director of Health Services conducted retrainings for staff to reorient to policies and procedures for writing and submitting incident reports, investigation procedures, and what to do when abuse cannot be ruled out.

2. When a resident is reported to be injured, staff complete an Incident Report Form and file through electronic system (AL Advantage), notifying care team Memory Care Director (MCD) & Administrator. Director of Health Services (DHS), Associate Executive Director (AED) and/or or Executive Director (ED) investigate injury and determine cause/rule out abuse/neglect. In the event an injury is investigated and abuse/neglect is unable to be ruled out, DHS, AED, ED report to authorities (APD/SPD/law enforcement).

3. Weekly at Quality Assurance meetings

4. DHS, AED, ED

2. Resident 5 was admitted to the facility in 05/2023 with diagnoses including dementia.

The resident's physician orders and 10/10/23 through 12/04/23 MAR, physician communications, and occurrence reports were reviewed and showed the following:

The resident had a signed physician order for olanzapine to be taken "by mouth every evening after dinner for dementia". The medication was on the MAR, but had not been administered.

During an interview on 12/07/23, Staff 5 (LPN) stated that it appeared the pharmacy had put the medication in as a PRN medication instead of a scheduled medication when it was inputted in June 2023, and the error had not been found or corrected. She acknowledged the resident had not been receiving the medication.

At the request of the survey team, the medication error was reported to the local SPD office. Verification was received on 12/11/23.

The need to ensure incidents were immediately investigated, and reported to the local office if suspected abuse could not be ruled out was discussed with Staff 1 (ED), Staff 5 and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to immediately investigate incidents to rule-out abuse, or report to the local Seniors People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 2 of 2 sampled resident's (#s 5 and 6) with medication errors. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 moved into the facility in 03/2023 with diagnoses including dementia with behavioral disturbance.

Interviews with staff, and review of the resident's 10/2023 MAR, physician communications, and occurrence reports were reviewed during the survey. The following was identified:

On 10/16/23 a medication error occurred in which the following 8:00 pm medications were not administered:

* Melatonin (for sleep);

* Memantine (for depression);

* Metoprolol Tartrate (for Hypertension);

* Quetiapine (for behaviors);

* Resperidone (for behaviors); and

* Sodium fluoride cream (for mouth care).

An occurrence report was completed on 10/30/23 and noted, "Med tech stated she wasn't aware of [his/her] 8 pm medication and failed to look in the MAR for any 8 pm medications that were due."

There was no documented evidence the medication error had been investigated at the time of the occurrence and the investigations included all required components, or the occurrences reported to the local SPD office, if abuse could not be ruled out.

At the request of the survey team, the medication error was reported to the local office and verification was received on 12/06/23.

The need to ensure incidents were immediately investigated, and reported to the local SPD office if suspected abuse could not be ruled out was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

1.C 231:  OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

2.Abuse and Incident training to be provided to all direct care staff by 1/21/2024.

a.Resident 6: Incident report investigated and reported accordingly to APS office. Closed.

b.Resident 5: Incident report investigated and reported accordingly to APS office. Closed.

3.In addition to training for direct care staff, all incident reports and med error reports will be reviewed daily and investigations completed within 24 hours.  Incidents of abuse and suspected abuse will be reported to APS.

4.Daily and as needed.

5.ED, AED, DHS, CFLD, CFLC or designee

Based on observation, interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office if abuse or neglect could not be ruled out, for 2 of 3 sampled residents (#s 8 and 10) with unwitnessed falls resulting in serious injury and injuries of unknown cause. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 10/2023 with diagnoses including dementia and anxiety. During the survey the resident required two person transfer assistance and was dependent on staff for wheelchair use.

Observations of the resident, interviews with staff, and review of the resident's 04/19/24 service plan, 02/07/24 through 04/30/24 temporary service plans and progress notes, physician communications, and incident investigations were reviewed, and the following was identified:

* 02/08/24 - Unobserved fall in another resident's room resulting in an emergency room visit;

* 02/24/24 - Bruise on left forehead forming; and

* 02/26/24 - Dark purple bruise on left forehead resulting in an emergency room visit.  

There was no documented evidence the fall and physical injuries of unknown cause were reported to the local SPD office, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the fall and physical injuries of unknown cause were not the result of abuse.

At the request of the survey team, all incidents above were reported to SPD before the survey team exited the facility on 05/02/24.

The need to ensure unobserved falls and physical injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could reasonably be ruled out and if not, the injuries were reported to the local SPD office was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/02/24. They acknowledged the findings.

2. Resident 10 moved into the MCC facility in 05/2023 with diagnoses including dementia. The resident was observed wearing a hard cast walking boot during the survey.

The resident's clinical record including the current service plan, narrative charting notes 02/22/24 through 04/25/24 and occurrence reports were reviewed. The following was identified:

Resident 10 had an unwitnessed fall which resulted in a closed left ankle fracture on 02/22/24.

An occurrence report was initiated on 02/22/24. However, the investigation did not reasonably conclude the fall with serious injury was not the result of abuse.

The facility was requested to report the incident to local SPD office as suspected abuse. The facility provided verification of reporting on 05/02/24.

The need to ensure the facility immediately reported to the local SPD office any incident of abuse or suspected abuse unless an immediate facility investigation reasonably concluded and documented that the fall with physical injury was not the result of abuse was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/02/24. They acknowledged the findings.

1.What actions will be taken to correct the rule violation?

a.Facility director will audit and review current incident reports and discuss for further investigation and reporting to SPD office if determined or concluded a need to do so.

b.Abuse and Incident training to be provided to all direct care staff and managers by compliance date by June 1, 2024.

i.Resident 8: Incident report investigated and reported accordingly to APD office.

ii.Resident 10: Incident report investigated and reported accordingly to APD office.

2.How will the system be corrected so this violation will not happen again?

a.In addition to training for direct care staff, incident reports will be reviewed, and investigations into abuse and neglect will be completed within 24 hours including weekends and holidays.  Incidents of abuse or neglect and suspected abuse or neglect and injuries of unknown cause will be reported to APD.

3.How often will the area needing correction be evaluated?

a.Facility manager will review incident reports during weekday managers meetings, weekly QA meetings, and independently on weekends and holidays.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on observation, interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements for 1 of 1 sampled resident (# 1) whose initial evaluation was reviewed, and the facility failed to ensure quarterly evaluations were reflective of residents' current status for 2 of 2 sampled residents (#s 2 and 3) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2023 with diagnoses including dementia. The move-in evaluation failed to address the following elements:

* Spiritual, cultural preferences and traditions;

* Decision-making abilities;

* Personality, including how the person copes with change or challenging situations;

* Assistive devices;

* Pain; and

* Fall Risk or history.

The need to ensure new move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/11/23. They acknowledged the findings.

2. Resident 3 moved into the facility in 08/2021 with diagnoses including vascular dementia with behavioral disturbance and chronic pain.

Observations, interviews with staff, and review of the record during the survey revealed the most recent quarterly evaluation, dated 06/29/23, was not reflective of the resident's health status, current needs, or preferences in the following areas:

* Interests, hobbies, social and leisure activities;

* Spiritual, cultural preferences and traditions;

* Personality: including how the person copes with change or challenging situations;

* Ability to understand and be understood;

* Pain: including how the resident expresses discomfort and non pharmaceutical interventions;

* Nutrition habits and fluid preferences;

* Fall risk or history; and

* Emergency evacuation ability.

The need to ensure the quarterly evaluation was reflective of Resident 3's health status, current needs or preferences with sufficient information to develop a quarterly service plan was reviewed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 07/2021 with diagnoses including dementia.

Observations, interviews with staff, and review of the record during the survey revealed the most recent quarterly evaluation, dated 07/11/23, was not reflective of the resident's health status, current needs, or preferences in the following areas:

* Speech and communication;

* Ability to understand and be understood;

* Pain, including how the person expresses discomfort;

* Emergency evacuation ability;

* Fall risk and history; and

* Level of assistance for transfers.

The need to ensure the quarterly evaluation was reflective of the resident's health status, current needs, or preferences with sufficient information to develop a quarterly service plan was reviewed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings.

1. Immediate review of policies and procedures to ensure compliance. Pre-admission assessment will be conducted and documented in electronic system (AL Advantage) prior to admission.

2. Facility care team will ensure resident information includes required elements and is complete prior to admission. Facility will ensure schedule of 30-day and/or quarterly updates are prescheduled in electonic system and monitored daily for completion/compliance.

3. Each resident admission will be reviewed for required elements prior to admission.

4. Memory Care Director, Director of Health Services, Health Services Assistant, Wellness Nurse, AED, and/or ED     

3. Resident 1 was admitted to the facility in 06/2023 with diagnoses including diabetes.

The resident's current service plan dated 06/01/23 was reviewed, observations were made, and interviews with staff were conducted between 08/07/23 and 08/10/23. Resident 1's service plan was not readily available to staff, reflective and did not provide clear direction to staff in the following areas:

* Diabetic needs including diet;

* Activities and assistance with participation; and

* Behavioral interventions for agitation/aggressiveness.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/11/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia with behavioral disturbance and chronic pain.

The resident's current service plan dated 06/29/23 was reviewed, observations were made, and interviews with the resident's caregivers were conducted between 08/07/23 and 08/10/23. Resident 3's service plan was not reflective and did not provide clear direction to staff in the following areas:

* Dietary needs including level of assistance required when eating, need for clothing protector, nutrition/fluid preferences;

* Falls including history, interventions and use of fall mat;

* Cognition and communication including ability to make decisions or ask for help;

* Pain including how the resident expressed pain and non-pharmacological interventions;

* Incontinence care including where it is provided, how frequently it is provided during the day and night, and products used;

* Adaptive equipment including wheelchair cushion;

* Level of assist required for dressing, transfers and grooming; and

* Behaviors including shouting, yelling, removing clothing and putting feet up on the dining room table.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, readily available to staff, provided clear direction regarding the delivery of services and were implemented for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 07/2021 with diagnoses including dementia.

The resident's current service plan dated 07/11/23 was reviewed, observations were made, and interviews with the resident's family and caregivers were conducted between 08/07/23 and 08/09/23. Resident 2's service plan was not reflective and did not provide clear direction to staff in the following areas:

* Transfer status;

* Speech/communication status;

* Preferred liquids;

* Activities and assistance with participation;

* Behaviors including oral fixation and resistance to personal care;

* Pain, including how the resident expressed pain and non-pharmacological interventions; and

* Use of fall mat.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings.

1. Review existing resident service plans for content and revise for compliance to include specific instruction for care as evidenced in resident assessment. Ensure pre-admission service plans are thorough and compliant before resident is admitted.

2. Facility will ensure service plan aligns with assessment in electonic system (AL Advantage).

3. For pre-admission, prior to resident moving in and again at the required 30 days. At time of any change of condition/reassessment/any other change as required per resident care team/family/POA/etc.

4. Memory Care Director, Director of Health Services, Health Services Assistant, Wellness Nurse, AED, ED.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, readily available to staff and provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 5, 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 11/2023 with diagnoses including dementia.

The resident's current service plan dated 12/05/23 was reviewed, observations were made, and interviews with caregivers were conducted between 12/06/23 and 12/07/23.

Resident 7's service plan was not reflective and did not provide clear direction to staff in the following areas:

* Use of a grab bar while in bed;

* Use of chest brace for pain; and

* Pain status.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. The findings were acknowledged.

3. Resident 5 was admitted to the facility in 05/2023 with diagnoses including dementia.

The resident's current service plan with most recent updates made 10/12/23 was reviewed, observations were made, and interviews with caregivers were conducted between 12/05/23 and 12/07/23. The following was identified:

* Resident 5's service plan was not readily available to staff.

* The service plan did not reflect the resident's needs, did not include a written description of who shall provide the services and what, when, how and how often the services shall be provided and/or lacked clear direction to staff in the following areas:

* Toileting and level of incontinence;

* Level of assistance required for ambulation, transfers, grooming, positioning;

* Behaviors including refusal of care;

* Fall risk;

* Feeding assistance required;

* Description of dressing routine to decrease confusion; and

* History of pain including use of scheduled pain medication.

The need to ensure service plans were readily available to staff, reflected the resident's needs and included a written description of who shall provide the services was discussed with Staff 1 (ED), Staff 5 (LPN) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

2. Resident 6 moved into the facility in 03/2023 with diagnoses including dementia with behavioral disturbance.

The resident's current service plan with most recent updates made in 09/2023 was reviewed, observations were made, and interviews with caregivers were conducted between 12/05/23 and 12/07/23. The following was identified:

* Resident 6's service plan was not readily available to staff.

* The service plan did not reflect the resident's needs as identified in the evaluation, did not include a written description of who shall provide the services and what, when, how, and how often the services shall be provided and lacked clear direction to staff in the following areas:

* Mental health status and level of care needed;

* Behaviors and interventions;

* Description of exit seeking interventions;

* Agitation with change and doesn't cope well with change in routine;

* Environmental factors including loud noises that cause irritability;

* Cognition including orientation, confusion and decision making;

* Description of dressing routine to decrease confusion;

* Sleep routine preferences;

* Use of a four wheeled walker;

* Vision to include use of glasses;

* Transfer status and level of care needed; and

* Transportation and level of care needed.

The need to ensure service plans were readily available to staff, reflected the resident's needs as identified in the evaluation and included a written description of who shall provide the services was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

"C 260:  OAR 411-054-0036 (1-4) Service Plan: General

1.DHS, CFLD, CFLC, RN will complete all service plans to reflect any changes through TSPs, orders, diagnosis, and incident reports.  All service plans will be printed, signed and placed within access to all care staff.

a.Resident 7: Service plan updated and readily available for staff.

b.Resident 6: Service plan updated and readily available to staff.

c.Resident 5: Service plan updated and readily available to staff.

2.MBK to provide additional training to DHS, CFLD, CFLC, RN in person centered care planning and chart reviews. Training will include how to utilize service plan due alert in EHR platform to ensure ongoing compliance.

3.Pre-admission, 30-days, quarterly and as significant changes occur.

4.ED, AED, DHS, CFLD, CFLC and designee

2. Resident 9 was admitted to the facility in 07/2021 with diagnoses including frontotemporal dementia and dysphasia (difficulty or discomfort when swallowing).

The resident's current service plan dated 04/19/24 was reviewed, observations were made, and interviews with caregivers were conducted between 04/30/24 and 05/02/24.

a. Resident 9's service plan was not reflective, and did not provide clear direction to staff including how often services shall be provided in the following areas:

* Assistance needed for grooming;

* Incontinence care status including how often the service shall be provided;

* Activity status including how often the service shall be provided; and

* Pain status and how the resident expressed pain.

b. Resident 9's service plan was not implemented in the following areas:

* Nutritional status and providing a nutritional supplement three times per day.

The need to ensure service plans were reflective of the identified needs of the resident, provided clear direction to staff including how often services shall be provided, and was implemented was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/02/24. The findings were acknowledged.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided and was implemented for 2 of 3 sampled residents (#s 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 moved into the MCC facility in 05/2023 with diagnoses including dementia.

The resident's current service plan updated 04/23/24 was reviewed, observations were made, and interviews with caregivers were conducted between 04/30/24 through 05/02/24.

Resident 10's service plan was not reflective and did not provide clear direction to staff in the following areas:

* Dressing;

* Toileting;

* Pain and ability to verbally communicate pain;

* Communication including speech; and

* Weight loss and interventions.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/01/24. The findings were acknowledged.

1.What actions will be taken to correct the rule violation?

a.Memory Care Director and RN will audit and review all resident service plans to ensure they are reflective of individualized resident care needs and provide clear direction to staff. RN will correct where necessary. All interim and long-term service plans will be printed and placed within the care staff service plan binder for reference.

i.Resident 9: Servcie plan updated to provide clear direction to staff in the areas a. of grooming; incontinence care including how often; activity status including how often; pain status and how expressed. b. nutritional status and providing a nutritional supplement 3 times per day. Service plan readily available to staff.

ii.      Resident 10: Service plan updated to provide clear direction to staff in the areas of dressing; toileting; pain and abililty to verbally commincate pain; commincation including speech; weight loss and interventions. Service plan is readily available for staff.

2.How will the system be corrected so this violation will not happen again?

a.MBK to provide additional training to RN and Memory Care Director in person centered care planning and staff direction. Will audit monthly for first quarter and review at QA for a sustained substantial compliance.

3.How often will the area needing correction be evaluated?

a.Pre-admission, 30-days, quarterly and as significant changes occur.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, and progress was documented weekly until resolution for 2 of 2 sampled memory care residents (#s 2 and 3). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia with behavioral disturbance.

Observations of the resident, interviews with staff, and review of the resident's 06/29/23 service plan, 05/07/23 through 08/07/23 temporary service plans and progress notes, physician communications, and incident investigations were completed.

The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution:

* 05/14/23: unwitnessed fall with injury to right eye;

* 05/19/23: resident to resident altercation resulting in injury to Resident 3's face;

* 05/21/23: Covid-19 diagnosis;

* 06/01/23: unwitnessed fall with bruise to right forearm; and

* 06/16/23: unwitnessed fall.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 07/2021 with diagnoses including vascular dementia.

Progress notes dated 02/18/23 through 08/07/23 were reviewed and revealed the following:

On 07/21/23 staff documented, "[Resident's] left hand was bleeding today this [sic] writer cleaned it and put on antibiotics." There was no documented evidence the facility determined and documented actions or interventions and communicated them to staff on each shift. There was no documented evidence the facility noted weekly progress until resolution.

The need to ensure the facility determined and documented actions or interventions, communicated them to staff, and noted progress weekly until resolution for all short term changes of condition was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings.

1. Alert charting funtion in electronic system (AL Advantage) feature utilized to alert staff on each shift to monitor change of condition timeframe as determined by Director of Health Services (DHS) and/or Wellness Nurse (WN). Med techs were provided in-service training on identifying short-term change of condition. DHS/LPN on call 24/7 for any notification of short term change of condition and will eveluate if the condition requires further action.

2. Med Techs were retrained on initiating alert charting for short term change of condition. Med Techs to complete an incident report for all new skin issues which will then be reviewed by DHS or Wellness Nurse who will monitor until resolved. Med TEchs were retrained on how to create and interim service plan for specific change of condition in order to communicate specific instructions on what to monitor and who to notify for changes. All significant change of conditions will be reported to facility RN for a significant change of condition assessment and weekly progress notes will be completed by DHS/Wellness Nurse. Each alert charting period set to maximum hours and may be closed/discontinued only by DHS or WN.

3. Determined by status of change of condition monitoring. Once resolved, alert charting ends.

4. DHS, WN

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated to staff on each shift, referred to the facility RN and monitored with weekly progress until resolution for 3 of 3 sampled memory care residents (#s 5, 6 and 7). This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 11/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 12/05/23 service plan, 11/21/23 through 12/05/23 narrative charting notes, interim service plan and occurrence report [incident report] were completed.

The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts.

* 12/02/23: Emergency department visit due to "intense back pain"; and

* 12/04/23: A fall with complaint of pain.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. The findings were acknowledged.

2. Resident 5 was admitted to the facility in 05/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan, 10/10/23 through 12/04/23 interim service plans and narrative charting notes, physician communications and occurrence reports were completed.

The following changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and progress noted at least weekly through resolution and/or were not referred to the RN for assessment:

* Difficulty with swallowing;

* Increased assistance required with ADL care;

* Unwitnessed fall;

* Multiple medication changes including new, missed and discontinued medications;

* New behaviors including refusal of care; and

* New admit to hospice.

The need to ensure actions or interventions for changes of condition were documented, communicated to staff on each shift, monitored through resolution and were referred to the RN for assessment was discussed with Staff 1 (ED), Staff 5 (LPN) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

3. Resident 6 moved into the facility in 03/2023 with diagnoses including dementia with behavioral disturbance.

Observations of the resident, interviews with staff, review of the resident's updated service plan, 10/10/23 through 11/29/23 narrative charting notes, interim service plans and occurrence reports were completed during the survey.  

The following short-term changes of condition lacked an evaluation of the condition, documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts and monitoring at least weekly through resolution:

* 10/09/23: Resident to resident altercation;

* 10/13/23: Verbally threatening physical harm (staff intervened);

* 10/13/23: Unwitnessed found on floor [fall];

* 10/16/23: Missed quetiapine, risperidone, sodium fluoride, melatonin, memantine and metoprolol tartrate medications;

* 10/22/23: Aggressive towards staff and residents all shift;

* 10/22/23: Missed quetiapine and risperidone (psychotropic medications for behaviors);

* 11/01/23 and 11/02/23: Missed atorvastatin and losartan (for high cholesterol and hypertension);

* 11/07/23 through 11/11/23: Missed six doses of quetiapine (for behaviors); and

* 11/09/23: Resident to resident altercation.

The need to ensure changes of condition were evaluated, determined actions or interventions were documented and communicated to staff on each shift and conditions were monitored with weekly progress noted until the condition resolved was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

"C 270:  OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1.The facility will maintain a monitoring and reporting system to be utilized 24 hrs a day.  This 24 hr book will ensure that changes of condition are identified, evaluated, interventions are developed and documented, and conditions monitored through resolution (at least weekly).

a.Resident 7: Condition assessed and plan updated per RN review and direction; monitoring in place as directed.

b.Resident 5: Condition assessed and plan updated per RN review and direction; monitoring in place as directed.

c.Resident 6: Condition assessed and plan updated per RN review and direction; monitoring in place as directed.

2.Staff will receive training on incidents and change in condition reporting by compliance date.  Staff will have received training on the use of the 24-hour book by the compliance date.  The staff will be trained on the use of TSPs and interventions for change in condition by the compliance date.  Staff will receive training on alert charting by the compliance date.

3.This process will be monitored daily through IR and TSP actions and weekly at QA meeting to include ED, DHS, CFLD, CFLC and designee.

4.The ED and AED will ensure that this process is completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, document the change, update the service plan as needed and monitor service plan interventions for effectiveness for 2 of 2 sampled residents (#s 9 and 10) who experienced significant weight loss. Resident 9 continued to have weight loss. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 moved into the memory care facility in 07/2021 with diagnoses including frontotemporal dementia, dysphasia and degenerative brain disease.

During the acuity interview on 04/30/24, the resident was identified to have weight loss.

Resident 9's 04/19/24 service plan, 04/18/24 Interim Service Plan (ISP), 02/01/24 through 04/29/24 progress notes, and 01/2024 through 04/2024 weight records were reviewed and showed the following:

Facility weight records noted the following:

* 01/08/24 - 134.4 pounds;

* 02/08/24 - 128.8 pounds;

* 03/08/24 - 134.6 pounds; and

* 04/10/24 - 126.4 pounds.

Resident 9 lost 5.6 pounds, or 4.16 % of his/her body weight, in one month (01/08/24 through 02/08/24), showing a change of condition in weight. There was no documented evidence the facility evaluated and documented what action or interventions were needed for the resident.

On 03/20/24, a registered nurse assessed the resident's condition and documented interventions that included "finger foods" and "offering foods wherever [the resident] wanted to be." There was no documented evidence the facility communicated the interventions to staff on all shifts.

Between 03/08/24 and 04/10/24, the resident had another weight loss of 8.2 pounds or 6.09 % of his/her total body weight within one month.

A 04/18/24 ISP instructed staff to provide "boost [nutritional supplement] 3x/day [three times daily] with every meal. Encourage the resident to drink the entire shake."

During the survey on 04/30/24 between 11:50 am and 1:35 pm, the following was observed:

* From 11:50 am to 12:05 pm, facility staff escorted the resident to the dining room and served a side dish of salad and a cup of pea soup to the resident;

* The resident was observed to pick up and put down a fork a few times, standing at the table, not sitting on a chair during lunch;

* The resident did not eat the salad and a main entree was not served to the resident;

* Approximately 12:05 pm, staff served a piece of pie to the resident who picked up the piece of pie with their fingers and ate it all;

* Approximately 12:08 pm, the resident left the dining room;

* Approximately 12:12 pm, Staff 9 (MA/CG) gave a carton of boost (nutritional supplement) to the resident and the resident carried it around the facility. In a couple of minutes, the resident put it down on an end table in the TV area;

* Between 12:12 pm and 1:30 pm, the resident did not drink the boost; and

* Approximately 1:35 pm, the boost was discarded.

During the survey on 05/01/24 between 8:10 am and 9:30 am, the following was observed:

* From 8:10 am to 8:28 am, the resident had breakfast and ate approximately 75 % of the meal;

* At 8:28 am, the resident walked away from the dining room; and

* During the observation, staff failed to provide the boost to the resident as planned.

During the survey on 05/01/24 between 11:50 am to 12:25 pm and 12:30 pm to 1:00 pm, the following was observed:

* At 11:50 am, the resident was in the dining room, sitting in a chair for lunch. Staff served a cup of water, a cup of juice and a cup of soup;

* A couple of minutes later, staff served a piece of cake for dessert. The resident used a fork for the dessert then used fingers to finish eating the dessert;

* At 12:10 pm, the resident walked away from the dining area and a main entree was not served to the resident;

* At 12:23 pm, staff offered a boost to the resident;

* Between 12:30 pm and 1:00 pm, the resident was walking around the facility, carrying the boost. The resident was observed to take one sip of the boost. During the observation there was no staff encouragement to drink the entire boost as planned.

During the survey on 05/02/24, the resident's weight was measured and the weight was 122.2 pounds which indicated the resident had lost another 4.2 pounds since 04/10/24.

There was no documented evidence the facility monitored the existing weight loss interventions for implementation and effectiveness. The facility failed to determine and document what new interventions were needed for the resident to prevent further weight loss and the resident continued to lose weight.

This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 05/02/24 at 1:45 pm, a plan to address Resident 9's weight loss was submitted and included the following:

* Offer alternatives;

* Encourage to eat;

* Document missed meals;

* Offer snacks between meals;

* Offer boost in a cup and supervise until the resident finished the boost;

* If the resident refused food, reapproach; and

* Document weekly weights.

The survey team accepted the immediate plan of correction and the situation was abated.

On 05/01/24 and 05/02/24, the above findings were shared with Staff 1 (ED), Staff 4 (RN) and Staff 21 (Interim Designated Administrator). They acknowledged the facility failed to have a monitoring system in place to review the resident's weights and monitor the interventions for effectiveness.

2. Resident 10 moved into the memory care facility in 05/2023 with diagnoses including dementia.

a. During the acuity interview on 04/30/24, the resident was identified with weight loss.

Resident 10's 04/23/24 service plan, Interim Service Plans (ISPs), 02/22/24 through 04/25/24 narrative charting notes, and 01/08/24 through 04/22/24 weight records were reviewed and showed the following:

Facility weight records noted the following:

* 01/08/24 - 138 pounds;

* 02/08/24 - 138.4 pounds;

* 03/08/24 - 138.0 pounds;

* 04/08/24 - 125.8 pounds; and

* 04/22/24 - 125.0 pounds.

Between 01/08/24 and 04/08/24 the resident lost 12.2 pounds or 8.84% of his/her total body weight within three months.

There was no documented evidence the facility evaluated and documented what action or interventions were needed for the resident and monitored the residents change of condition.

On 04/23/24, an RN completed an assessment and put the following intervention in place:

"If [resident name] refuses to eat in the dining room or wants to leave after only eating a small amount, staff to offer/provide a meal tray in [his/her] apartment."

During the lunch meal observation on 04/30/24 the resident was observed to eat approximately 10% of salad and 25% of juice, one bite of cake and one sip of water. The resident was escorted in his/her wheelchair to the common space living room. There were no interventions observed.

During an interview on 04/30/24 with Staff 4 (RN), the surveyor requested information regarding what interventions staff were to use if the resident did not eat and did not retire to his/her apartment. Staff 4 acknowledged the need for clearer service planned interventions for weight loss and provided the surveyor with a revised ISP with additional weight loss interventions that included the following:

* "If [s/he] comes to the dining room and wants to leave after only eating a small amount, take [his/her] food where [s/he] wants to go.";

* "If [s/he] says it's too much or seems overwhelmed, offer smaller portions or only one food at a time.";

* "If [s/he] leaves before the meal is finished pay attention to the environment. Is it too noisy?"; and

* "Monitor and document how much [s/he] eats and where [s/he] eats. If [s/he] refuses, document what [s/he] says and does."

During a lunch meal observation on 05/01/24, the resident was heard saying, "oh, I think it's too much..." S/he ate two bites of a noodle based entree and left the dining room to retire in his/her room at 12:08 pm. There were no observed interventions attempted by staff.

During an interview with Staff 21 (Interim Designated Administrator) on 05/01/24 at 2:00 pm concerns regarding the lack of implementing Resident 10's weight loss interventions and a lack of assistance during meal times was discussed. Staff 21 intervened and went to assist the resident.

There was no documented evidence the facility was monitoring the weight loss interventions for effectiveness and to ensure the interventions were being implemented.

This represented a situation that placed the resident at risk for further weight loss. On 05/01/24 at 4:30 pm, an immediate plan of correction to address the resident's weight loss was requested. The facility submitted an immediate plan of correction on 05/02/24 at 8:30 am.

During an interview on 05/02/24 at 8:15 am, Staff 33 (CG) reported the resident had already left the dining room and went back to his/her room. The caregiver reported s/he ate about half of the scrambled eggs, the meat, a full glass of water and a half glass of juice. The caregiver reported a meal was not brought to his/her room as service planned in the immediate plan of correction.

During the lunch meal observation on 05/02/24 at 12:15 pm, the resident took two bites of fried rice and then scooted his/her chair away from the table, saying" I can't eat this". Staff 33 attempted to redirect him/her back to the table by showing him/her some chocolate cake. The resident seemed interested however, the cake was cold and hard and s/he was unable to cut it with a fork. The resident stated "it's too hard, I can't eat it." The caregiver took the fork and began chopping it into pieces. The resident said "no, no no I can't do it, it's too hard for me" and left the dining room to retire to his/her room. At 12:28 pm, Staff 33 went to the resident's apartment without bringing any food or fluids. No further interventions were observed.

During an interview with Staff 1 (ED), Staff 4 (RN) and Staff 21 (Interim Designated Administrator) on 05/02/24 at 1:30 pm concerns regarding the lack of implementing Resident 10's weight loss interventions and a lack of assistance during meal times was discussed again. Staff 21 intervened and went to assist the resident. Staff 21 confirmed at 1:45 pm that the resident was now eating in the dining room and the following further interventions were put in place and communicated to staff:

* Offer snacks between meals;

* Offer alternatives; and

* Weekly weights.

The survey team accepted the immediate plan of correction on 05/02/24 at 1:45 pm and the situation was abated.

The need to ensure the facility had a system in place to monitor the resident's weight loss and weight loss interventions for effectiveness was discussed with Staff 1 (ED) and Staff 4 (RN) and Staff 21 (Interim Designated Administrator) on 05/02/24. They acknowledged the findings.

b. The following changes of condition were not evaluated to determine and document what action or interventions were needed for the resident, the action or interventions communicated to staff on each shift and/or the residents change of condition monitored weekly with progress noted in the residents record:

* On 02/22/24 - A fall with fracture of the left ankle. There was an RN assessment however, the service plan was not updated and there was no documented ISP in the resident's record to communicate the change of condition and increased ADL care needs to staff on each shift.

* Swollen left eye and redness around the left eye. There was an ISP written however, the facility failed to monitor the condition at least weekly until resolved.

* Discontinued scheduled pain medication Tylenol and Ibuprofen from 03/25/24 through 04/28/24.

The need to ensure changes of condition were evaluated to determine and document what action or interventions were needed for the resident, the action or interventions communicated to staff on each shift and/or the resident's change of condition monitored weekly with progress noted in the residents record was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/01/24. They acknowledged the findings.

1    What actions will be taken to correct the rule violation for providing adequate meals to resident and monitoring weight loss with effective interventions;

Facility will correct rule violations through the following actions:

Provide in-service training to be completed on May 2, 2024 to staff on dietary policies and procedures to ensure resident dietary needs are documented and met, weights are tracked; meal interventions are in place; actions and outcomes are documented utilizing the following policies and supportive associated resources (attached):

a.OR Policy CP12 Special Diets

b.PC Resident Dining

c.PC03 Resident Snacks

i.Dietary Communication Notification Form

d.CP13 Meal Attendance Tracking Policy

i.Meal Attendance Tracking Form

e.CP06 Weights Policy

i.Weight Record Form

2.The following will be implemented for Residents 9 and 10 on May 2, 2024:

a.Service plan dietary information will be reviewed and updated

b.Dietary Communication Notification Form will be implemented

c.Meal Attendance Tracking Form will be implemented

d.Weight Record form will be initiated and tracked

e.Alert Charting and ISP for the above will be put in place; tracked; documented

i.Resident 9 specific interventions in updated ISP

ii.Resident 10 specific interventions in updated ISP

1.Prescriber faxed on May 2, 2024 for updated Physician order for weight monitoring frequency.

3.Addendum to CP13 Meal Attendance Policy:

a.Under Procedure 2: If a resident is not in the dining room during a mealtime, a staff member will locate the resident and begin intervention techniques as outlined in policy, service plan, and/or ISP. If resident choses to eat outside the dining room, they will be supported to do so by staff utilizing interventions and tools outlines in policy, service plan, and ISP.

i.If interventions are not successful, staff will report to Memory Care Director/Memory Care Coordinator and occurrence will be documented on Meal Tracking Form.

2. How will the system be corrected so this violation will not happen again;

Facility will implement the following for all Garden House residents regardless of the presence of weight loss/change:

oDietary Communication Notification Form

oMeal Attendance Tracking Form

oWeight Record Form

oAll residents will be weighed monthly by Caregivers and Medication Technicians as assigned by Memory Care Director /Memory Care Coordinator. Weights will be documented on Weight Tracking form and in EHR system.

oCaregiver and/or Medication Technician will report to Memory Care Director/Memory Care Coordinator, and/or RN all residents who are identified with weight loss/gain.

oCaregivers and Medication Technicians will utilize interventions per policy, service plan, and/or ISP for all residents identified with weight loss/gain.

oResident weight loss or gain of 1 pound or more from the previous weight and/or a resident declining 2 or more meals in one week will be used an indicator for Caregivers and Medication Technicians to notify Memory Care Director/Memory Care Coordinator, and RN of weight change concern. RN will evaluate interventions and update Service Plan to reflect new interventions to prevent Sig Change.

oWhen significant weight loss/gain occurs, RN will complete and document Significant Change of Condition assessment.

oWeekly review of resident weights report will be conducted by Memory Care Director/Memory Care Coordinator, RN, at Garden House Clinical Meeting.

oRN will conduct weekly interviews with staff regarding residents on alert for weight loss and will document sig changes; RN will report weekly resident weight status update to the Administrator and Executive Director

oMonthly: Administrator will audit RN report against Resident Weight Report from AL Advantage

oWeekly review of resident weights report will be conducted by Memory Care Director/Memory Care Coordinator, RN, at Garden House Clinical Meeting.

oMonthly review of resident weights report will be conducted by Executive Director, Associate Executive Director, Director of Health Services, Memory Care Director, Memory Care Coordinator, Assisted Living Director, Health Services Assistant at Interdisciplinary Quality Assurance meeting.

3. How often will the area needing correction be evaluated; and

Facility administrator will review the area needing corrected on a weekly basis. Administrator will report results to Executive Director.

4. Who will be responsible to see that the corrections are completed?

Facility Administrator, RN, Executive Director, or designee will ensure that the corrections are completed and sustained.

C270 Plan of Correction was submitted and accepted on May 2, 2022

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN and the service plan was updated by the RN for 1 of 1 sampled resident (#2) reviewed for significant changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 07/2021 with diagnoses including dementia and hypertension.

a. Progress notes dated 02/18/23 through 08/07/23, an incident report dated 02/18/23, the service plan dated 05/05/23 and 07/11/23 and interviews with staff were reviewed and revealed the following:

* A 02/07/23 progress note indicated the resident was showing signs of pain with walking. Interviews with staff and Witness 1 confirm the resident was able to walk independently at the time.

* A 02/28/23 progress note indicated the resident was sent to the hospital for a fractured hip. Interviews with staff and Witness 1 confirmed the resident was not able to walk upon return from the hospital. Observations made during the survey revealed the resident used a wheelchair for ambulation and was fully dependent on staff.

The change in ambulation status constituted a significant change of condition and required an RN assessment and a service plan update. An RN assessment and service plan update were requested on 08/08/23 at 2:50 pm. No documentation was provided.

There was no documented evidence the facility RN completed an assessment of Resident 1's significant change of condition and that the service plan was reviewed and/or updated by the RN.

The need to ensure all significant changes of condition were assessed by an RN and the licensed nurse participated on the service planning team or reviewed the service plan with date and signature within 48 hours was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings.

1. During survey, RN was unavailable for interview. Facility immediately contracted with RN to provide RN assessment and monitoring resident condition as required by OAR 411-054-0045 (1)(a-f)(A)(C-F).

2. Facility is recruiting staff RN to fill vacant Wellness Nurse position.

3. Once or as indicated by position turnover.

4. DHS, AED, ED  

2. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease and Type II diabetes.

Resident 1 was not observed due to being out of the community at the time of survey.

Review of the resident's weights from 11/01/23 through 12/05/23, revealed the following:

* 10/26/23: 224.2 pounds;

* 11/09/23: 218.2 pounds; and

* 11/16/23: 206.6 pounds.

From 10/26/23 to 11/16/23, the resident lost 17.6 pounds or 7.85 % of his/her body weight in a month. This represented a significant change of condition. The facility notified the physician of the weight loss on 11/16/23.

On 12/06/23, Staff 27 (MCC director) stated the resident had inconsistent appetite.

On 12/06/23 at 9:40 am, Staff 28 (Contract Nurse Consultant) stated the resident was "not eating well" and "they [staff] should call me" when there was a change of condition including changes in residents eating status.  

The weight records were reviewed with Staff 1 (ED) and requested an RN assessment for the significant weight change on 12/07/23 at 12:25 pm.

On 12/07/23 at 3:00 pm, Staff 1 and Staff 27 (MCC Director) confirmed there was no RN assessment for the resident's significant weight loss.

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN and the service plan was updated by the RN for 2 of 2 sampled residents (#s 1 and 5) reviewed for significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 05/2023 with diagnoses including dementia.

The resident's clinical record including the current service plan and narrative charting notes 10/10/23 through 12/07/23 was reviewed, the resident was observed and staff were interviewed. The following was identified:

Narrative charting notes and occurrence reports reviewed from 10/10/23 through 11/08/23 indicate the resident was having difficulty swallowing medications, had a fall, had decreased food intake and refused care multiple times.

The resident was admitted to hospice on 11/24/23.

During the survey, the resident was observed at times requiring two-person assist for transfers, inability to ambulate and requiring a wheelchair for mobility and full meal assistance.

Based on the resident's 10/12/23 service plan and interviews with staff, prior to the dates listed above the resident did not have difficulty with swallowing, did not have behaviors including refusing cares, did not require physical assist with transfers or ambulating and did not require anything more than occasional verbal reminders for meals.

The changes above constituted a significant change of condition and required an RN assessment.

During the survey no nurse was available to answer questions.

During an interview on 12/07/23, Staff 1 (ED) and Staff 27 (MCC Director) confirmed that no RN assessment had been completed.

The need to ensure an RN assessed all significant changes of condition including findings, resident status, and interventions made as a result of the assessment within 48 hours was discussed with Staff 1, Staff 5 (LPN) and Staff 27 on 12/07/23. They acknowledged the findings, and no additional documentation was provided.

1.C 280:  OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

2.Facility will ensure a thorough and accurate RN assessment is completed when resident's experience a significant change in condition.

a.Resident 5: Condition assessed and plan updated per RN review and direction; monitoring in place as directed.

b.Resident 1: Condition assessed and plan updated per RN review and direction; monitoring in place as directed.

3.Clinical staff will receive training on the criteria for significant change in condition and policy regarding the role of the RN an any significant change in condition.  

4.This process will be monitored daily through IR and TSP actions and weekly at QA meeting to include ED, DHS, CFLD, CFLC and designee.

5.The RN/ED/AED will ensure that this process is completed/monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed timely by an RN for 1 of 2 sampled residents (#10) reviewed for significant weight loss. This is a repeat citation. Findings include, but are not limited to:

Resident 10 moved into the MCC facility in 05/2023 with diagnoses including dementia.

The resident was observed during the survey requiring staff cueing, redirection and supervision to eat meals and drink liquids.

Resident 10's 04/23/24 service plan, 02/22/24 through 04/25/24 progress notes, and 01/2024 through 04/2024 weight records were reviewed and showed the following:

Facility weight records noted the following:

* 01/08/24 - 138.0 pounds;

* 02/08/24 - 138.4 pounds;

* 03/08/24 - 138.0 pounds;

* 04/08/24 - 125.8 pounds; and

* 04/22/24 - 125.0 pounds.

On 04/23/24, 14 days later, an RN assessed the resident's condition and documented a service planned intervention that included: "offer to serve [the resident] a tray in [his/her] room for any meals that [s/he] refuses to come out for and for the remainder of any meals that [s/he] leaves early due to frustration."

There was no documented evidence an RN completed a timely assessment which documented resident condition, status, findings and interventions made as a result of the assessment.

The need to ensure an RN completed a timely assessment was discussed with Staff 1 (ED), Staff 4 (RN) and Staff 21 (Interim Designated Administrator) on 04/30/24 and 05/01/24. They acknowledged the findings.

1.What actions will be taken to correct the rule violation?

a.Memory Care Director and RN will audit and review all current residents for a possible significant change in condition. Updates will be addressed and reported and documented. Staff will be directed to the changes.

b.Facility will ensure a thorough and accurate RN assessment is completed when resident's experience a significant change in condition.

i.Resident 10: Condition assessed, and plan updated per RN review and direction; monitoring in place as directed.

2.How will the system be corrected so this violation will not happen again?

a.Clinical staff will receive training on the criteria for significant change in condition and policy regarding the role of the RN and any significant change in condition by June 1, 2024.

b.RN responsibilities and competencies regarding change of condition will be evaluated to ensure compliance with OARs.

c.Weights are being monitored monthly and referred to RN for significant changes.

3.How often will the area needing correction be evaluated?

a.Daily at clinical meeting to include Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designees.

b.Follow up and updates will be reviewed weekly at QA meetings and results reviewed at weekly QA ongoing to sustain substantial compliance.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 1) who received insulin injections by unlicensed facility staff. Resident 1 was at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, unlicensed staff training and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2023 with diagnoses including diabetes and Alzheimer's disease.  

Review of the 07/01/23 through 07/31/23 MAR noted the resident received routine insulin multiple times every day. The MAR noted Staff 8 (MT), Staff 10 (MT) and Staff 12 (MT) administered insulin to the resident during the month of July.

During an interview with Staff 1 (ED), Staff 2 (Associate ED) and Staff 5 (LPN) on 08/10/23 at 12:48 pm, they stated the memory care community had one resident that received insulin and the facility RN had recently completed delegation.

Staff 9, the facility RN, was not present and available during the survey.

Review of the delegation binder for Resident 1 revealed no documented evidence the resident's condition had been assessed by the RN to determine if s/he was stable and predictable or determine the frequency the resident should be reassessed, including rationale. The records also revealed there was no documented evidence Staff 12 had been delegated by an RN including:

* Rationale why the task could be safely delegated;

* Skills, abilities and willingness of non-licensed staff to complete the task;

* Task was taught to the non-licensed staff and they were competent to safely perform task;

* Written instructions available including risks, side effects, response, and risk factors;

* Non-licensed staff were taught the task was client specific and not transferable;

* Determination of frequency the non-licensed staff should be supervised and reevaluated, including rationale; and

* RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance.

On 08/10/23, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1, 2 and 5. They acknowledged the above findings. The surveyor requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.

On 08/10/12 at 5:00 pm, a plan to address the delegation issue which included licensed staff administering insulin until delegation was completed was accepted and the situation was abated.

1. During survey, RN was unavailable for interview. Facility immediately contracted with RN to provide RN assessment and monitoring resident condition as required by OAR 411-054-0045 (1)(a-f)(A)(C-F).

2. Facility is recruiting staff RN to fill vacant Wellness Nurse position.

3. Once or as indicated by position turnover.

4. DHS, AED, ED  

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols. Findings include, but are not limited to:

Observations made during the survey on 08/07/23 and 08/08/23 determined the facility failed to adhere to universal precautions for infection control in the following areas:

1. Resident 2 was admitted to the facility in 07/2021 with diagnoses including dementia. Observations and interviews with staff during the survey identified s/he relied on staff for incontinent care needs.

On 08/08/23 at 10:25 am, Staff 9 (CG) provided ADL incontinent care for Resident 2. Staff 9 donned gloves without first performing hand hygiene. Staff 9 removed the soiled brief and threw it into the trash. Staff 9 then used a wipe and performed pericare without first doffing soiled gloves, performing hand hygiene, and donning clean gloves.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings.

4. Observations were made during the survey to determine adherence to universal precautions for infection control.

On 08/8/23, at approximately 1:15 pm, the surveyor observed Staff 13 (CG) coming out of the shower room with a resident. Staff 13 was carrying multiple wet towels to the laundry room that had been used during the resident's shower. The staff member had the dirty towels against his/her clothing without a barrier or gloves. Staff 13 dropped some of the towels on the floor multiple times and picked the towels up bare handed.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) and Staff 2 (Associate ED). They acknowledged the findings.

2. Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia with behavioral disturbance. Observations and interviews with staff during the survey identified s/he relied on staff for incontinent care needs.

a. On 08/07/23 at 1:20 pm, Staff 9 (CG) and Staff 10 (MT) provided ADL incontinent care for Resident 3. Staff 9 and 10 donned gloves without first performing hand hygiene. Staff 9 assisted the resident by removing soiled clothing and brief, and placing the soiled brief in a plastic bag. Staff 10 then used a foam cleanser and toilet paper to perform pericare. Staff 9 and 10 did not doff soiled gloves, perform hand hygiene, or don clean gloves before assisting resident into a clean brief. The soiled bed pad was not removed after transferring the resident to the wheelchair. Staff 9 and 10 began to adjust the resident's headwear, at which time this surveyor stopped the process and asked them to doff their soiled gloves and perform hand hygiene.

b. On 08/08/23 at 1:20 pm, Staff 9 and Staff 13 (CG) provided ADL incontinence care for Resident 3. Staff 9 and 13 donned gloves without first performing hand hygiene. Staff 9 and 13 removed soiled clothing and soiled brief, performed pericare, and then assisted resident into clean clothing and to sitting in his/her wheelchair without doffing soiled gloves, performing hand hygiene, and donning cleaned gloves. The soiled bed pad was not changed after the resident was transferred to the wheelchair.

Throughout the survey, 08/07/23 through 08/11/23, the resident was observed to be seated in his/her wheelchair on a vinyl cushion with center pommel. The center pommel was ripped approximately six inches from left to right, exposing foam which rendered the surface uncleanable.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

3. During lunch service on 08/07/23 and 08/08/23, all universal workers were observed without aprons while serving food to residents.

The need to establish and maintain effective infection prevention and control protocols was discussed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

1. Facility desginated new Director of Health Services, LPN as Incention Control Specialist when the previous ICS terminated employment on 8/10/2023. DHS/ICS to conduct infection control inservices on universal precautions and infection control protocols and direct staff to remedy practices that do not meet the requirement.  

2. DHS/ICS providing training, documentation, and audit to infection control practices to meet the requirements on an ongoing basis.

3. At weekly QA meetings

4. Memory Care Director, Director of Health Services, Wellness Nurse.

2. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease and Type II diabetes.

During the acuity interview on 12/05/23, the resident was noted to received insulin administration by staff.

The resident was in the hospital at the time of survey.

The resident's physician orders and 11/01/23 through 11/27/23 MAR was reviewed and revealed the following:

a. The MAR had multiple blanks on it regarding insulin administration.

b. On multiple occasions the insulin orders were not carried out as prescribed.

Refer to C303 example 3a and 3b.

c. The MAR instructed staff to hold insulin administration when the resident's CBG [blood sugar level] was 70 or less and there were 20 occasions staff did not measure the CBG result to determine the amount of insulin to administer or hold.

d. Review of the 10/10/23 to 11/27/23 insulin administration records and delegation records showed the following:

* Staff 30 (MT) documented on the MAR she administered Resident 1's insulin injection on 10/28/23. There was no evaluation by the facility RN for Staff 30's skills and ability. Staff 30 was no longer working in the facility.

* Staff 31 (RCC Supervisor) documented on the MAR she administered Resident 1's insulin injection on multiple occasions. There was no current evaluation by the facility RN for Staff 31's skills and ability. The last evaluation for Staff 31's skills and ability was completed on 08/17/23 and scheduled for re-evaluation "approx. [approximately] on 10/16/23."

The need to ensure a safe medication system and to ensure adequate professional oversight including injectable delegated tasks was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. The findings were acknowledged.

3. Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:

* C303 Systems: Treatment Orders;

* C305 Systems: Resident Right to Refuse;

* C310 Systems: Medication Administration; and

* C330 Systems: Psychotropic Medication.

The requirement to ensure adequate professional oversight of the medication and treatment administration system was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

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

1. Resident 5 was admitted to the facility in 05/2023 with diagnoses including dementia and hypertension.

The resident's physician orders and 10/10/23 through 12/04/23 MAR were reviewed and showed the following:

a. The resident had a physician order for olanzapine 2.5 mg which stated "1 tablet by mouth every evening after dinner for dementia". Review of the MAR showed that the medication had not been administered to the resident at all during the dates reviewed.

During an interview with Staff 5 (LPN) and Staff 27 (MCC Director), they stated it appeared the pharmacy had put in the medication incorrectly as a PRN instead of a scheduled medication when it was prescribed in June 2023. They acknowledged the facility's current system for reviewing MARs did not find the discrepancy, and the resident had not been receiving the medication.

b. Resident 5 had a physician's order dated 11/24/23 stating "may crush pills for difficulty swallowing". Multiple facility MTs stated they had been trained that that meant to crush all medications, including opening capsules which had bottles stating "do not crush".

On 12/07/23, Staff 1 (ED) provided a copy of the facility's "Med 15- Crushing/Breaking Medications" policy dated 12/14/20 which noted "capsule may not be opened unless designed and ordered as a "sprinkle" medication." During an interview on 12/07/23, Staff 1, Staff 5, and Staff 27 acknowledged they were unaware of the MT's current practice as described above.

c. Multiple medications had been initialed as provided by "A1" which correlated with "agency staff". Surveyors were provided with conflicting information as to who administered the medications.

The need to ensure a safe medication system and adequate professional oversight was discussed with Staff 1 (ED) and Staff 5 and Staff 27 on 12/07/23. They acknowledged the findings.

1.C 300:  OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

2.Community will implement Oversight of EMAR system to include reviewing new/change of orders for accuracy.  Med staff will be trained in crushing medications policy medication documentation.

a.Resident 5: Resident MAR reviewed for accuracy. Facility staff provided with updated training.

b.Resident 1: Resident MAR reviewed for accuracy. Facility staff provided with updated training.

3.Med staff will be trained in crushing medications policy medication documentation and EMAR system reviewing of orders process.

4.This process will be monitored daily and as needed.

5.ED, DHS, CFLD, CFLC and designee.

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

Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

C 305: Systems: Resident Right to Refuse;

C 310: Systems: Medication Administration; and

C 330: Systems: Psychotropic Medication.

The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/02/24. They acknowledged the findings.

1.What actions will be taken to correct the rule violation?

a.Community has consulted with Pharmacy provider and EMAR system has been evaluated and audit was completed on May 10, 2024. MCD, RN and/or designee will review and implement corrections stated in audit.

2.How will the system be corrected so this violation will not happen again?

a.Memory Care Director, RN and/or designee will review and audit daily for compliance and review outcomes weekly with QA team until a sustained substantial compliance.

3.How often will the area needing correction be evaluated?

a.This process will be monitored weekly and as needed.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (# 3) whose orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia with behavioral disturbance.

Resident 3's MAR, dated 07/01/23 through 08/06/23, corresponding progress notes, and prescriber orders were reviewed and revealed the following:

Resident 3 was prescribed scheduled and PRN olanzapine on 06/20/23. Physician orders stated "Take one tab daily at bedtime. May take additional ½ tab (1.25 mg) once daily for severe agitation only. Must be 4 hours between doses."

a. On the following dates, PRN olanzapine was administered more than once daily as prescribed:

* 07/08/23 1:19 pm; and

* 07/08/23 5:38 pm.

b. The MAR indicated staff administered scheduled olanzapine at 8:00 pm. On the following dates, PRN olanzapine was administered within four hours of the scheduled dose:

* 07/03/23 9:32 pm;

* 07/06/23 7:58 pm;

* 07/08/23 5:38 pm;

* 07/19/23 8:41 pm; and

* 07/23/23 7:43 pm.

c. On the following dates, staff documented administering olanzapine for anxiety, and not as prescribed for severe agitation:

* 07/08/23 5:38 pm; and

* 07/23/23 7:43 pm.

During an interview on 08/07/23, Staff 3 (Connections for Living Director) did not provide additional information and agreed to update the MAR so that the PRN olanzapine was administered as prescribed.

The need to ensure physician's orders were carried out as prescribed was discussed Staff 2 (Associate ED), Staff 3 and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

1.Med tech retraining provided on 1st , 2nd and 3rd check system for all medication orders which will ensure that all medications are checked 3 times for accuracy by Med techs and DHS/wellness nurse. Staff training and education provided for entering treatment orders such as checking CBG, manually to QuickMAR system.

2.All prescription medications are entered to QuickMAR by pharmacy. Med techs retrained on checking for accuracy in verbiage, time, dose, and frequency. Med techs were also trained on checking for duplicate orders when confirming medication orders on QuickMAR. Lead Med Tech will audit for accuracy and documentation.

3. DAily review. Weekly audit.

4. Lead Med Tech, Health Services Assistant, Memory Care Director, Wellness Nurse, DHS.

3. Resident 1 moved into the facility in 01/2021 with diagnoses including Alzheimer's disease and Type II diabetes.

Resident 1's MARs dated 11/01/23 through 11/27/23 and current physician orders were reviewed and identified the following:

a. Resident 1 had a physician's order, dated 11/07/23, to administer "NovoLog 15 units at 8:00 am "with food" and at noon, and 10 units at 6:00 pm."

Resident 1's 11/01/23 through 11/27/23 MAR instructed to hold insulin "if resident is not eating. Do not hold long acting [insulin]."

* On 11/07/23 at 8:00 am, 12:00 pm and 6:00 pm the insulin was not administered.

* On 11/08/23 at 8:00 am, the insulin was not administered as prescribed, and staff documented "invalid med (dc'd or no RX)."    

* On 11/10/23 at 12:00 pm the insulin was not administered as ordered and staff documented "withheld per Dr/RN orders." There was no documented evidence the resident did not eat his/her meal.

* On 11/15/23 at 12:00 pm, the insulin was not administered as prescribed, and staff documented "withheld per Dr/RN orders" and "need clarification instruction for when [s/he] doesn't [does not] want to eat."  

* On 11/20/23 at 6:00 pm, the insulin was not administered, and staff documented "missed insulin no one delegated to give."

b. Resident 1 had a physician's order, dated 11/07/23, to administer insulin NPH [long acting insulin] 45 units at 11:00 am and 24 units before dinner.

Resident 1's 11/01/23 through 11/27/23 MAR showed the dinner time scheduled at 4:00 pm and instructed to hold and notify for further insulin prior to administration of insulin if CBG 70 or less. Additional instruction showed "do not hold long acting [insulin]."

* On 11/06/23 at 11:00 am and at 4:00 pm, the insulin was not administered as prescribed, and staff documented "invalid med (dc'd or no RX)" and "needed clarification."

* On 11/10/23 at 11:00 am, the insulin was not administered, and staff documented "withheld per Dr/RN orders" and CBG of 79.

* On 11/15/23 at 11:00 am, the long acting insulin was not administered, and staff documented "withheld per Dr/RN orders" and "need clarification instruction for when [s/he] doesn't [does not] want to eat." However, the MAR indicated "do not hold long acting [insulin]."

* On 11/20/23 at 4:00 pm, the insulin was not administered, and staff documented "missed insulin no one delegated to do it."

The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. The findings were acknowledged.

2. Resident 5 was admitted to the facility in 05/2023 with diagnoses including dementia and hypertension.

The resident's physician orders and 10/10/23 through 12/04/23 MAR were reviewed and showed the following:

a. A physician order on 11/27/23 stating "Track bowel movements". The resident had multiple PRN medications for bowel care.

Staff 9 (MT) stated staff created a bowel monitoring sheet for the resident but it had not been filled out consistently.

During an interview with Staff 5 (LPN) and Staff 27 (MCC Director) on 12/07/23, they stated no residents in the facility currently had physician orders for bowel monitoring, and no bowel monitoring was currently being provided.

b. On 10/16/23, three medications were not given as prescribed, with the MAR noting "invalid med (dc'd or no RX)":

* Donepezil 10 mg (for dementia);

* Gabapentin 300 mg (for chronic low back/nerve pain); and

* Pravastatin sodium 40 mg (for cholesterol).

The need to ensure the facility administered all medications and treatments as prescribed was discussed with Staff 1 (ED), Staff 5 and Staff 27 on 12/07/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure signed physician orders were documented in the resident's facility record for all medications the facility was responsible to administer and to ensure medications and treatments were carried out as prescribed  for 3 of 3 sampled residents (#s 1, 5 and 6) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 moved into the facility in 03/2023 with diagnoses including dementia with behavioral disturbance.

Resident 6's MARs dated 10/10/23 through 12/05/23 and current physician orders were reviewed and identified the following:

a. There were no signed physician orders in Resident 6's chart for the following medications:

* Discontinue orders for quetiapine, PRN (for behaviors);

* Risperidone, daily at night time (for behaviors);

* Risperidone, PRN; and

* Titration orders for quetiapine 100 mg per night to 50 mg per night.

b. The following medications were not administered as prescribed:

* 10/16/23: Quetiapine, risperidone, sodium fluoride (for oral care), melatonin (for sleep), memantine (for dementia) and metoprolol tartrate (for hypertension) medications;

* 10/22/23: Missed quetiapine and risperidone;

* 11/01/23 and 11/02/23: Atorvastatin and losartan (for high cholesterol and hypertension); and

* 11/07/23 through 11/11/23: Six doses of quetiapine.

Review of the MARs noted "invalid med (dc'd or no RX)".

During interviews on 12/06/23, Staff 9 (MT) and Staff 10 (MT) were unable to confirm if the medications were given for the above dates and times.

The need to ensure signed physician orders were documented in the resident's record for all medications and treatments administered by the facility and ensure medications were administered as prescribed was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

1.C 303:  OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

2.Community will obtain signed current orders for every resident and update orders as needed in EMAR system.

a.Resident 6: Resident MAR orders reviewed for accuracy. Facility staff provided with updated training.

b.Resident 5: Resident MAR reviewed for accuracy. Facility staff provided with updated training on MAR, Physician's Orders, monitoring sheet usage.

c.Resident 1: Resident MAR reviewed for accuracy. Facility staff provided with updated training to ensure medication administration is performed with accuracy.

3.A quarterly physician order review calendar to be created for ongoing reviews.  Staff will receive training medication documentation.

4.Quarterly and as changes occur.

5.ED, AED, DHS, CFLD, CFLC or designee

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 1 of 1 sampled resident (# 1), who had documented medication and treatment refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2023 with diagnoses including diabetes.

The resident's MAR, dated 07/01/23 through 07/31/23, was reviewed and revealed facility staff documented Resident 1 refused the following orders:

* Novolin N (for diabetes) on three occasion;

* Novolog (for diabetes) on two occasions;

* Weekly BP on one occasion; and

* Weekly weight on three occasions;

On 08/11/23, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (ED) and Staff 2 (Associate ED).  They acknowledged the findings, and no additional documentation was provided.

1. Retraining of facility care staff to comply with OAR 411 -054-0055 (1)(j-k) Systems Resident Right to Refuse.

2. Ensure facility care staff have unincumbered access to refusal documentation, physician notification information, and directive for notification.

3. Weekly audit.

4. Lead Med Tech, Health Services Assistant, QA Team

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 2 of 3 sampled residents (#s 1 and 5), who had documented medication and treatment refusals. This is a repeat citation. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease and Type II diabetes.

The resident's MAR, dated 11/01/23 through 11/27/23, was reviewed and revealed facility staff documented Resident 1 refused the following orders:

* Novolin N (for diabetes) on one occasion;

* Novolog (for diabetes) on two occasions;

* Aspirin (for pain and heart) on one occasion;

* Duloxetine DR (for depression) one occasion;

* Furosemide (for edema) one occasion;

* Gabapentine (for restless leg syndrome) one occasion;

* Levothyroxine (for hypothyroidism) one occasion;

* Lisinopril (for hypertension) one occasion;

* Metformin (for diabetes) one occasion;

* Metoprolol (for hypertension) one occasion; and

* Senna/docusate (for bowel movement/stool softener) one occasion.

On 12/07/23, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (ED) and Staff 27 (MCC Director). The findings were acknowledged, and no additional documentation was provided.

2. Resident 5 was admitted to the facility in 05/2023 with diagnoses including dementia and anxiety.  

The resident's MAR, dated 10/10/23 through 12/04/23, was reviewed and revealed facility staff documented Resident 5 refused donepezil 10 mg (for dementia) on 10/14/23. There was no documentation that the physician was notified.  

The need to notify the physician or other practitioner when a resident refuses to consent to orders was discussed with Staff 1 (ED), Staff 5 (LPN) and Staff 27 (MCC Director) on 12/07/23. The findings were acknowledged, and no additional documentation was provided.

1.C 305:  OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

a.Resident 1: Refusal notification parameters reviewed for accuracy. Facility staff provided with updated training.

b.Resident 5: Refusal notification parameters reviewed for accuracy. Facility staff provided with updated training.

2.DHS, CFLD, CFLC or designee will review EMAR daily for medication exceptions.

3.Daily and as needed.

4.DHS, ED, CFLD, CFLC, or designee

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 1 of 1 sampled resident (# 9), who had documented medication refusals. This is a repeat citation. Findings include, but are not limited to:

Resident 9 moved into the facility in 07/2021 with diagnoses including frontotemporal dementia.

The resident's MAR, dated 04/01/24 through 04/30/24, was reviewed and revealed facility staff documented Resident 9 refused the following medications on multiple occasions:

* Galantamine ER 24 mg daily for frontal temporal dementia, nine occasions;

* Quetiapine 100 mg every morning for frontal temporal dementia, nine occasions; and

* Trazodone 100 mg every evening for mood disorder, one occasion.

There was no documentation that the physician or other practitioner was notified of the refusals.  

On 05/01/24, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator). The findings were acknowledged, and no additional documentation was provided.

1.What actions will be taken to correct the rule violation?

a.Memory Care Director and/or RN to audit and review the current residents for potential med refusals and verify that the practitioner is notified.

b.Resident right to refuse and physician notification policy will be reviewed with staff.

i.Resident 9: Physician notified of refusals.

2.How will the system be corrected so this violation will not happen again?

a.Staff will be retrained on Resident Right to Refuse policy and notification process will be followed.

3.How often will the area needing correction be evaluated?

a.Daily and as needed.

b.Audits will be conducted by Memory Care Director, RN or designee weekly and results reviewed at weekly QA ongoing to sustain substantial compliance.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

3. Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease and type II diabetes.

Resident 1's 11/01/23 through 11/27/23 MARs were reviewed during the survey and lacked resident specific parameters and instructions for PRN medications  in the following area:

* No indication of how often or wear to apply Eucerine as needed cream; and

* Multiple blanks on the MAR.

On 12/07/23, the need for resident specific parameters and lacked clear instruction for unlicensed staff was discussed with Staff 1(ED) and Staff 27 (MCC Director). The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 3 of 3 sampled residents (#s 1, 5 and 6) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 05/2023 with diagnoses including dementia and anxiety.

Resident 5's 11/01/23 through 12/04/23 MAR was reviewed and the following PRN medications lacked clear parameters for administration:

* Lorazepam PRN 0.5 mg (for anxiety/shortness of breath);

* Haloperidol PRN 0.5 mg (for hallucinations/agitation);

* Acetaminophen PRN 500 mg (for pain or fever); and

* Oxycodone PRN 5 mg (for pain/shortness of breath).

The need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED), Staff 5 (LPN) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

2. Resident 6 moved into the facility in 03/2023 with diagnoses including dementia with behavioral disturbance.

Resident 6's 10/10/23 through 12/05/23 MARs were reviewed and the following PRN medication lacked resident specific parameters and instructions for Risperidone, PRN (for behaviors).

The need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

1.C 310:  OAR 411-054-0055 (2) Systems: Medication Administration

2.All MARs will be reviewed for resident specific parameters.  The community will obtain signed order clarifications for every resident.

a.Resident 5: MAR reviewed for accuracy to ensure administration parameters are in place. Facility staff provided with updated training.

b.Resident 6: MAR reviewed for accuracy to ensure administration parameters are in place. Facility staff provided with updated training.

c.Resident 1: MAR reviewed for accuracy to ensure administration parameters are in place. Facility staff provided with updated training.

3.Med staff will receive training in required MD order components and policy on requesting order clarifications.

4.Daily and as needed.

5.DHS, ED, CFLD, CFLC, or designee

3. Resident 9 moved into the memory care facility in 07/2021 with diagnoses including frontotemporal dementia.

Resident 9's 03/01/24 through 04/30/24 MAR was reviewed and the following PRN medications lacked clear parameters for administration:

* Milk of Magnesia PRN 30 ml, on second day of no bowel movement;

* Bisacodyl PRN 10 mg, for "no bowel movement in 3 days";

* Acetaminophen 650 mg every four hours as needed for "pain or fever greater than 100"; and

* Ibuprofen 400 mg every eight hours for hip pain.

During an interview with Staff 9 (MT/CG) on 04/30/24 at 1:15 pm, it was reported the facility was not tracking the resident's bowel movements status.

On 05/01/24 at 11:16 am, Staff 32 (MT) reported the resident was not able to report if s/he had pain or location of the pain. Staff 32 reported they observed the resident's facial expression or "body language" for pain status.

The need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/01/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident-specific parameters for PRN medications, and included initials of the person administering the medication for 3 of 3 sampled residents (#s 8, 9 and 10) whose MAR's were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 10/2023 with diagnoses including dementia and anxiety.

Resident 8's 03/01/24 through 04/30/24 MAR was reviewed and the following PRN medications lacked clear parameters for administration:

* Milk of Magnesia PRN 30 ml (for constipation); and

* Senna PRN 8.6 mg (for constipation).

The need to ensure MARs included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/02/24. They acknowledged the findings.

2. Resident 10 moved into the facility in 05/2023 with diagnoses including dementia.

During an interview on 04/30/24 with Staff 9 (MT/CG) it was reported Resident 10 was independent with toileting.

During an interview with Staff 32 (MT) on 05/01/24 it was reported the resident was independent in toileting and staff did not track the resident's bowel movements.

Resident 10's 03/01/24 through 04/30/24 MARs were reviewed and the following inaccuracies were identified:

* Milk of magnesia give daily, as needed, for constipation lacked resident specific parameters and instructions to determine when the medication should be given;

* Loperamide as needed, for diarrhea;

* The MARs were missing initials for who administered scheduled Tylenol 500 mg caplets on four occasions; and

* The MARs were missing initials for who administered scheduled Ibuprofen on four occasions.

The need to ensure MARs included resident specific parameters and instructions for PRN medications and had initials of the person who administered the medications was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/01/24. They acknowledged the findings.

1.What actions will be taken to correct the rule violation?

a.All current resident's MARs will be audited and reviewed for resident specific parameters and identify/determine missing initials/signatures.  The community will obtain signed order clarifications for every resident.

i.Resident 8: MAR reviewed for accuracy to ensure administration parameters for PRN medications are accurate and interventions are in place.

ii.       Resident 9: MAR reviewed and inaccuracies were corrected to include resident specific paremeters and intruction for PRN medication administration updated.

iii.      Resident 10: MAR reviewed and inaccuracies were corrected to include resident specific parameters and instruction for PRN medication administration updated.

2.How will the system be corrected so this violation will not happen again?

a.Med staff will receive training in required MD order components and policy on requesting order clarifications and proper signatures/initials for dispensing by June 1, 2024.

3.How often will the area needing correction be evaluated?

a.Audits will be conducted by Memory Care Director, RN or designee weekly and results reviewed at weekly QA ongoing to sustain substantial compliance.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#3) who was prescribed psychotropic medications. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 08/2021 with diagnoses including vascular dementia with behavioral disturbance.

Review of Resident 3's MAR, dated 07/01/23 through 08/06/23, and physician orders revealed the following:

Resident 3 was prescribed PRN olanzapine for severe agitation on 06/20/23, and it was documented as administered to the resident on 12 occasions between 07/01/23 and 08/06/23.

The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medication for 11 of the 12 administrations.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       On 08/11/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN). They acknowledged the findings.

1. Facility will ensure through staff retraining that non-pharmacological interventions  are attempted and documented to be ineffective prior to administering psychotropic medications.

2. Prior to administering psychotropic medications, Med Tech staff will assess for documentation of non-pharmacological interventions having been pursued

3. Before each psychotrpic med pass.

4. Med Techs, Lead Med Tech, Memory Care Director, Memory Care Coordinator

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#1) who was prescribed psychotropic medications. This is a repeat citation. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 01/2021 with diagnoses including Alzheimer's disease and Type II diabetes.

Review of Resident 1's MAR, dated 11/01/23 through 11/27/23, and physician orders revealed the following:

* The record indicated s/he had orders for PRN clonazepam for "anxiety" and "agitation";

* The PRN clonazepam was administered on two occasions;

* No specific reasons for the use of the psychotropic medication including signs and symptoms of agitation or anxiety and parameters for when unlicensed staff could consider administering the medication;

* The MAR lacked non-pharmacological interventions to attempt with documented ineffective results prior to administering the medication; and

* On two occasions, unlicensed staff administered the medication without non-drug interventions attempted with ineffective results prior to administering the medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     On 12/07/23 at 10:15 am, Staff 21 (Connections for Living Coordinator) confirmed that there was  no documented evidence staff  had attempted non-pharmacological interventions with ineffective results prior to administering the medication.

On 12/07/23, Resident 1's record was reviewed with Staff 1 (ED), Staff 21 and Staff 27 (MCC Director). They acknowledged the findings.

"C 330:  OAR 411-054-0055 (6) Systems: Psychotropic Medication

1.Direct care staff will receive training on non-pharmacological interventions.  Med staff will receive training on documentation of non-pharmacological interventions.  Resident's service plan will be updated to include interventions.

a.Resident 1: MAR reviewed and updated with non-pharmacological interventions. Facility staff provided with updated training on person-centered  non-pharmacological interventions and documentation policy.

2.Direct care staff will receive training on non-pharmacological interventions.  Med staff will receive training on documentation of non-pharmacological interventions.

3.Daily and as needed.

4.DHS, ED, CFLD, CFLC, or designee

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications, and as needed psychotropic medications had specific reasons for use and resident specific parameters  for 1 of 1 sampled resident (#11) who was prescribed an as needed psychotropic medication. This is a repeat citation. Findings include, but are not limited to:

Resident 11 moved into the MCC facility in 03/2023 with diagnoses including dementia and dementia related agitation.

Review of Resident 11's MAR, dated 02/01/24 through 04/30/24 and physician orders revealed the following:

* The resident was prescribed olanzapine 5 mg, as needed, every four hours;

* There were no specific reasons for the use of the psychotropic medication including signs and symptoms of agitation and parameters for when unlicensed staff could consider administering the medication;

* The MAR lacked non-pharmacological interventions to attempt with documented ineffective results prior to administering the medication; and

* On 02/22/24, unlicensed staff administered the medication without non-drug interventions attempted with ineffective results prior to administering the medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     During an interview and review of the electronic record on 04/30/24, Staff 9 (MT/CG) reported there were no progress notes related to an incident on 02/22/24 that would indicate why staff used the PRN medication and the MAR didn't have any instructions regarding non-pharmacological interventions to attempt, but "for [him/her] I would say music and snacks work best." Staff 9 further confirmed there was no documented evidence that non-drug interventions were attempted with ineffective results prior to administering the medication on 02/22/24.

The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications and as needed psychotropic medications had specific reasons for use and resident specific parameters was discussed with Staff 1 (ED), Staff 4 (RN) and Staff 21 (Interim Designated Administrator) on 05/01/24. They acknowledged the findings.

1.What actions will be taken to correct the rule violation?

a.Current residents' records will be updated to include resident-specific reasons for use of the medication, signs and symptoms, non-pharmacological interventions to attempt and their effectiveness prior to administration and clear PRN parameters.

b.Direct care staff will receive training on non-pharmacological interventions.  Med staff will receive training on documentation of the effectiveness of non-pharmacological interventions.  Resident's service plan will be updated to include interventions.

i.Resident 11: MAR reviewed and updated with non-pharmacological interventions. Facility staff provided with updated training on person-centered non-pharmacological interventions and documentation policy.

2.How will the system be corrected so this violation will not happen again?

a.Weekly audits will be completed by Memory Care Director, RN, or designee and results reviewed at QA meeting until sustained substantial compliance.

b.Direct care staff will receive training on non-pharmacological interventions; Med staff will receive training on documentation of non-pharmacological interventions by June 1, 2024.

3.How often will the area needing correction be evaluated?

a.Weekly at QA meeting.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure an Administrator was scheduled to be on-site in the facility at least 40 hours per week. Findings include, but are not limited to:

Survey entered the facility on 12/05/23 at approximately 9:25 am and requested to speak with the Executive Director. Staff 29 (Concierge) reported Staff 1 (ED) was not in the facility. Survey asked to speak to the Memory Care Director. Staff 29 reported she was working in Pavilion, a separately licensed building. When asked who was in charge in the Administrator's absence, she stated she was not sure, but she would call Staff 1.

A tour of the facility on 12/05/23 identified there was no sign posted with the name of the Administrator or designee in charge.

The need to have an Administrator on-site in the facility at least 40 hours per week was discussed with Staff 1 on 12/06/23 at 2:45 pm. She acknowledged the findings.

"C 350:  OAR 411-054-0065 (1-3) Administrator Qualification and Requirements

1.Administrator will be scheduled to be onsite and available 40 hours per week minimum.  Signage will be posted with name of administrator or designee in charge.  Community staff will be in-serviced on location of administrator signage.

2.ED will monitor schedule and signage on a weekly basis.

3.Weekly and as needed.

4.ED or designee.

Based on observation, interview, and record review, it was determined the facility failed to document sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care, and failed to have an accurate and effective Acuity Based Staffing Tool (ABST) that included all required components and defined an appropriate number of caregivers and general staff based on resident acuity and service needs. Findings include, but are not limited to:

The facility was home to 19 residents at the time of the re-licensure survey. During the acuity interview on 08/07/23, the facility identified multiple residents with high ADL care needs, two of which required two direct care staff to assist with transfers.                

The facility's Uniform Disclosure Statement (UDS) was reviewed 08/07/23. The UDS staffing plan showed:

* Day shift: one MT and two CGs;

* Swing shift: one MT and two CGs; and

* Night shift: one MT and one CG.

Observations and interviews conducted during the survey 08/07/23 through 08/09/23 identified the following:

* The staff were not direct caregivers but universal workers. In addition to providing resident care, staff duties included serving food and beverages, cleaning up after meals, doing residents' laundry and assisting with activities and snacks.

The regulation requires that if universal workers are used, the facility must increase the number of staff to maintain adequate resident care and services. The number of staff was not increased to meet resident needs.

During an interview on 08/09/23 Staff 2 (Associate ED) stated there was an error on the UDS. At 10:45 am an updated copy of the UDS was provided. Care giving staff were changed to universal workers, but the staffing numbers remained the same.

The ABST was reviewed with Staff 1 (ED) and Staff 2 on 08/09/23 at 1:45 pm. The tool lacked some of the 22 required components used to determine staffing levels.

The staffing schedule for 08/01/23 through 08/10/23 identified only two staff scheduled during the night shift. Some of the staff scheduled at night were not on the MCC staff list and were identified to the survey team as ALF staff.

Through interviews with multiple MTs and CGs 08/08/23 and 08/09/23 staff stated the MCC only had two staff working at night, one MT and one CG. They stated the MT would at times float over to the ALF and pass medication or help ALF staff, leaving only one direct care staff member on the floor of the MCC for at least part of the night shift.

During an interview on 08/11/23, Staff 1 and Staff 2 acknowledged staff scheduled to work the MCC also worked on the ALF during the overnight shift and verified there were times on the overnight shift where only one direct care staff was present in the MCC.  

The need to ensure the facility provided a sufficient number of direct care staff to meet the 24 hour scheduled and unscheduled needs of residents to include a minimum of two direct care staff who were scheduled and available at all times when a resident required the assistance of two direct care staff, was discussed with Staff 1 and Staff 2 on 08/11/23. They acknowledged the findings and modified the staffing schedule to ensure two direct care staff were scheduled and available at all times.

1. Facility will ensure staffing levels are comensurate with the scheduled and unscheduled staffing needs of residents based off acuity levels. Facility will document training for staff to meet the scheduled and unscheduled needs of residents according to ABST.

2. Facility consultant firm to pursue corrections to ABST in relation to acuity based staffing.

3. Once

4. Executive Director, Regional Director.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

The facility's ABST was reviewed on 08/09/23 and discussed with Staff 1 (ED) and Staff 2 (Associate ED). They reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident.

There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using.

The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 and Staff 2 on 08/10/23. They acknowledged the findings. Staff 1 was referred to the Department's ABST Policy Analyst.

1. Facility to pursue further revision to AL Advantage ABST tool for the purposes of meeting the OAR 411-054-0037 (1-8) Acuity Based Staffing Tool. 22 ADLS to be listed as dictated by OAR.

2. Facility concultant firm to pursue corrections to ABST.

3. Once

4. Executive Director, Regional Director.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 direct care staff (#s 10, 12, 14 and 17) demonstrated satisfactory performance in any assigned duty within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/9/23 and 08/11/23 and revealed the following:

There was no documented evidence Staff 10 (MT), Staff 12 (MT), Staff 14 (CG) and Staff 17 (MT), hired 01/13/23, 04/18/23, 04/06/23, and 02/15/23 respectively, demonstrated satisfactory performance in first aid/abdominal thrust.

The need for direct care staff to demonstrate satisfactory performance in assigned job duties within 30 days of hire was discussed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

1. Immediately audit employee files for completeness. Hold in-service training and competency assessments; document.

2. Facility updated new hire 30-day competency policy and procedure to meet the requirement.

3. At 30-days for each new hire.

4. Hiring manager, DHS, Health Services Assitant, AED.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 direct care staff (#s 24 and 25) demonstrated satisfactory performance in any assigned duty within 30 days of hire. This is a repeat citation.  Findings include, but are not limited to:

Staff training records were reviewed on 12/07/23 and revealed the following:

* Staff 24 (MT), hired 11/04/23, had no documented evidence First aid and abdominal thrust training had been completed within 30 days of hire; and

* Staff 25 (MT), hired 10/18/23, had no documented evidence of abdominal thrust training completed within 30 days of hire.

The need to ensure staff completed all required training as specified in the rules was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings. No other information was provided prior to survey exit.

"C 372:  OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1.Audit of staff training records will be completed for training, first aid and abdominal thrust requirements.  Missing training items to be completed.  

2.Training to be provided to BOM, DHS, CFLD, ALD on proper onboarding processes and training requirements.

3.Weekly

4.BOM/ED or designee

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented in accordance with Oregon Fire Code, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

A review of fire and life safety records provided from 02/2023 through 08/2023 identified the following:

* Lack of documented evidence fire drills were conducted every other month.

* Lack of documented evidence of all required components of fire drills, including:   

    - Location of simulated fire origin;

    - Escape route used;

    - Problems encountered and comments relating to residents who resisted or failed to participate in drills;

    - Evacuation time period needed; and

    - Number of occupants evacuated.  

* Lack of documented evidence fire and life safety instruction was provided to staff on alternate months.

The need to ensure fire drills were conducted and documented in accordance with Oregon Fire Code, and fire and life safety instruction was completed on alternate months was discussed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

1. Facility to ensure schedule and content of fire drills meets requirement. Facility will adequately document fire drills and associated activity which meets the requirement. Facility will ensure all staff are brought up to date on training.

2. Electronic reminder and documentation tool will be updated to ensure regulatory compliance.

3. Once.

4. Director of Environmental Services, AED, ED

Based on interview and record review, it was determined the facility failed to ensure residents were 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. Findings include, but are not limited to:

During an interview on 08/08/23 Staff 6 (Director of Environmental Services) stated there was no current method for providing fire safety training to residents within 24 hours of admission or annually.

The need to ensure residents were trained in fire safety procedures upon admission and at least annually was reviewed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

1. Facility to develop new resident Fire, Life, Safety orientation which meets the requirement. Facility staff will develop training and utilize monthly Town Hall meetings 2x each year to provide ongoing education, to be supplemented by documentation and followup for residents not in attendance.

2. Bi-annual audit of resident education cirriculum, training schedule and documentation.

3. 2x year

4. Director of Environmental Services, AED, ED  

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

Refer to C 231, C 260, C 270, C 280, C 303, C 305, C 330, C 372, C 530, Z 155, Z 142, Z 162, Z 163, and Z 164.

"C 455:  OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

1.Facility will ensure the Plan of Correction is implemented.

2.System reviewed by ED.

3.Status checks will be done daily until substantial compliance is met.

4.ED will ensure corrections are completed/monitored.

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

a. Situations were identified where there was a failure of the facility to comply with the Departments rules that caused or were likely to cause an immediate threat to residents' health and safety. An immediate plan of correction was requested in the following area:

OAR 411-054-0040 (1-2) (C0270) - Change of Condition and Monitoring.

b. Refer to C 156, C 231, C 260, C 270, C 280, C 300, C 305, C 310, C 330, C 455, Z 140, Z 142, Z 162, and Z 163.

1.What actions will be taken to correct the rule violation?

a.Facility will ensure the plan of correction is implemented and progress is monitored at least weekly at QA meeting.

2.How will the system be corrected so this violation will not happen again?

a.System reviewed by QA team weekly with results from audits and progress, updates and changes will be implemented to sustain substantial compliance.

3.How often will the area needing correction be evaluated?

a.Status checks will be performed as described above  until substantial compliance is met.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on observation and interview, it was determined the facility failed to ensure a separate area with closed containers for separate storage and handling of soiled linens and soiled clothing, a one-way flow of soiled laundry to preclude potential contamination, a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory and ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to:

A tour of the laundry facilities and interviews with staff on 08/07/23 revealed the following:

There was no clear one-way flow from dirty to clean laundry.

Multiple care staff were interviewed on 08/07/23 and 08/08/23 regarding the laundry process, and they stated they sometimes rinsed soiled laundry in the resident shower rooms and put the soiled linens in a large metal rolling basket to transport to the laundry room. They stated the machines on the units were used to wash soiled linens as well as resident personal laundry and that they "try to keep the soiled laundry separate." Staff were not aware of any disinfectant chemicals to be added and did not know whether the machines provided a high temperature rinse option.

During an interview on 08/08/23, Staff 6 (Director of Environmental Services) could not confirm whether there was a chemical disinfectant in the detergent or whether the machines being used provided a minimum rinse temperature of 140 degrees F.

The need to ensure a safe and sanitary process for handling soiled laundry was discussed with Staff 1 (ED) and Staff 2 (Associate ED) on 08/10/23. They acknowledged the findings.

1. Facility to deep clean and reorganize laundry room to meet the requirement for one-way flow of soiled and clean items. Facility will remedy sink area to include flushing rim clinical sink with handheld sprayer.

2. Will retrain staff and provide visual direction of flow in-room to ensure ongoing compliance.

3. Monthly audit

4. Memory Care Director, Memory Care Coordinator, Director of Health Services.   

Based on observation and interview, it was determined the facility failed to provide space and equipment to handle soiled linen and soiled clothing processing needs that was separate from regular linens and clothing. This is a repeat citation. Findings include, but are not limited to:

A tour of the laundry facilities and interviews with staff on 12/06/23 and 12/07/23 revealed the following:

Multiple care staff were interviewed on 12/06/23 regarding the laundry process, and they stated they sometimes rinsed soiled laundry/linens in a handwash sink in the laundry room or put the soiled laundry/linens in a bag to transport to the assisted living soiled laundry room [another licensed building attached to the memory care unit] and rinsed out the soiled linen at the flushing rim clinical sink (hopper). Staff then rebagged the soiled linen and transported it back to the memory care unit laundry room.

They stated the machines on the memory care units were used to wash soiled linens as well as resident personal laundry and that they "keep the soiled laundry separate."

The need to provide space and equipment to handle soiled linen and soiled clothing processing needs that was separate from regular linens and clothing was discussed with Staff 1 (ED) and Staff 27 (MCC Director) on 12/06/23 and 12/07/23. They acknowledged the findings.

"C 530:  OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry

1.Facility is pursuing Housekeeping and Laundry facility remodel to comply with OAR.

2.Remodel to be scheduled with the intent to complete by 1/21/2024. Facility staff trained on updated procedures by 1/21/2024.

3.Project manager, DES will schedule and monitor project through to completion with ED oversight.

4.ED will ensure corrections are completed/monitored.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:

During the first revisit to the change of management survey of 08/11/23, conducted 12/05/23 through 12/07/23, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number of repeat citations and additional citations added during the revisit survey.  

Refer to deficiencies in the report.

"Z 140:  OAR 411-057-0140(1) Administration Responsibilities

1.Facility will ensure the Plan of Correction is implemented

2.System reviewed by ED

3.Status checks will be done daily until substantial compliance is met.

4.ED will ensure corrections are completed/monitored.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:

During the second revisit to the change of management survey of 08/11/23, conducted 04/30/24 through 05/02/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number of repeat citations and severity of citations during the second revisit survey.  

1. A situation was identified which constituted immediate jeopardy to residents' health and safety. An immediate plan of correction was requested in the following area:

OAR 411-054-0040 (1-2) (C0270) - Change of Condition and Monitoring.

The facility put an immediate plan of correction in place during the survey and the situation was abated.   

2. Refer to deficiencies in the report.

1.What actions will be taken to correct the rule violation?

a.See C270. Facility will ensure the accepted Plan of Correction is implemented and reviewed at weekday managers meeting and weekly at QA meeting.  

2.How will the system be corrected so this violation will not happen again?

a.The Plan of Correction status will be monitored for compliance daily and at weekly QA meeting until substantial compliance is met. Weekly QA meeting will be utilized ongoing to ensure compliance with OARs is sustained.

3.How often will the area needing correction be evaluated?

a.Daily; then weekly once sustained substantial compliance has been determined.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

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 231, C 295, C 360, C 361, C 372, C 420, C 422, and C 530.

1. Facility Plan of Correction provides compliance actions which meet the licensing rules and Chapter 411, Division 57 pertaining to areas as listed in Statement of Deficiency: C231, C295, C360, C361, C372, C420, C422, and C530.

2. Plan of Correction will be carried out by Facility management.

3. Evaluation period for each SOD listed will be administered by facility management.

4.Persons responsible are listed in the POC for each deficiency listed and will be held acountable for corrections as listed.

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 152, C 154, C 156, C 231, C 350, C 372, and C 530.

"Z 142:  OAR 411-057-0140(2) Administration Compliance

1.A licensed administrator will ensure licensing rule compliance as referenced in C152, C154, C156, C231, C350, C372, C530.

2.Administrator is trained in residential care facility licensing rules.

3.Ongoing; audit 5x per 40-hour period.

4.ED

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

Refer to C 156 and C 231.

1.What actions will be taken to correct the rule violation?

a.See C156 and C231. Facility has retained Elderwise for compliance oversight. ED, AED, MCD, RN or designee will meet and review any concerns, updates and progress with PoC.

2.How will the system be corrected so this violation will not happen again?

a.Elderwise consultant, Clinical management team, and MBK Regional management team will work together to ensure compliance with licensing rules is sustained.

3.How often will the area needing correction be evaluated?

a.Weekly

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed for 4 of 4 newly hired staff (#s 7, 12, 13 and 14), demonstrated competency in assigned duties within 30 days of hire for 4 of 4 newly hired direct care staff (#s 10, 12, 14 and 17), and a total of 16 hours of in-service training completed annually, including six hours related to dementia care topics for 3 of 3 long-term direct care staff (#s 11, 15 and 18). Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (ED), Staff 2 (Associate ED) and Staff 3 (Connections for Living Director) on 08/9/23 and 08/11/23.

1. Training records for Staff 7 (Wellness Program Assistant), Staff 12 (MT), Staff 13 (CG) and Staff 14 (CG), hired 05/25/23, 04/18/23, 07/17/23, and 04/06/23 respectively, identified the following:

a. Staff 7, 12, 13 and 14 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in the areas of:

* Resident rights and values of community based care;

* Abuse reporting requirements; and

* Infectious disease prevention.

b. Staff 7, 12, 13 and 14 lacked documented evidence pre-service dementia training was completed prior to independently providing care and services to residents.

2. Staff 10 (MT), 12, 14 and 17 (MT), hired 01/13/23, 04/18/23, 04/06/23, and 02/15/23 respectively, lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in the following required areas:

* Changes associated with normal aging; and

* General food safety, serving, and sanitation.

3. Staff 11 (MT), Staff 15 (CG) and Staff 18 (MT), hired 05/12/21, 08/25/16 and 05/20/21 respectively, lacked documented evidence of completion of 16 hours of annual in-service training which included annual infection control training and at least six hours of dementia care training.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 2, Staff 3 and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

1.Facility immediately audited staff files for training and documentation. Any staff member found to be lacking training and or documentation were provided with required training to bring them into compliance.

2. Associate Executive Director created a new process through which each new-hire will be assessed and tracked for pre-service trainings and documentation prior to being schceduled to work. Exisitng staff CEUs/ongoing training will be tracked in an updated system to ensure ongoing compliance.

3. At onset of new-hire for pre-service training, at 30-days for competency evaluation; monthly and annual trainings ongoing.

4. Associate Executive Director.

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation and dementia training completed for 4 of 4 newly hired staff (#s 22, 24, 25 and 26), demonstrated competency in assigned duties within 30 days of hire for 2 of 2 newly hired direct care staff (#s 24 and 25), and overseeing the training of staff  have experience and knowledge in the care of individuals with dementia. This is a repeat citation. Findings include, but are not limited to:

On 12/07/23, training records were reviewed with Staff 27 (MCC Director). The following deficiencies were identified.

1. Staff 22 (MT), Staff 24 (MT), Staff 25 (MT) and Staff 26 (MT), hired on 11/14/23, 11/04/23, 10/18/23, and 11/01/23 respectively, identified the following:

a. Staff 22 and Staff 26 lacked documentation in the following areas:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures;

* Food handler's certificate;

* A written job description;

* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging person dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food and fluids, preventing wandering, and use of person-centered approach;

* Environmental factors that are important to a resident's well-being;

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change on the resident's condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

b. Staff 24 and Staff 25 lacked documentation in the following areas:

* Infectious disease prevention;

* Food handler's certificate;

* A written job description;

* Environmental factors that are important to a resident's well-being;

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change on the resident's condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

Additionally, Staff 24 lacked documentation the following:

* Resident rights and values of CBC care; and

* Abuse reporting requirements.

2. Staff 24 and Staff 25 lacked documented evidence of competency demonstration within 30 days of hire in the following required areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

Additionally, Staff 25 lacked competency demonstrated in medication administration training.

3. Review of the facility's annual training system with Staff 27 revealed they "just discussed" the areas for annual training. Staff 27 reported the care staff were in charge of their annual training since 10/10/23 due to turnover of the management team. Staff 27 acknowledged the facility failed to have a person in a supervisory role to oversee the staff training program.

The need to ensure newly-hired staff completed all required training prior to beginning their job duties, documented methods to determine competency of direct care staff, on-going required of annual training and the overseeing the training of staff experienced and knowledgeable in the care of individuals with dementia was reviewed  Staff 1 (ED) and Staff 27 on 12/07/23. They acknowledged the findings.

"Z 155:  OAR 411-057-0155(1-6) Staff Training Requirements

1.Audit of staff training records will be completed for training and skills requirements.  Missing training items to be completed.  Skills demonstration checklists to be completed with oversight of ED, DHS, CFLD.

2.Training to be provided to BOM, DHS, CFLD, CFLC, on proper onboarding processes and training requirements.

3.Weekly

4.BOM/ED

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 270, C 280, C 282, C 303, C 305 and C 330.

1. Facility Plan of Correction provides compliance actions which meet the licensing rules and Chapter 411, Division 57 pertaining to areas as listed in Statement of Deficiency: C252, C260, C270, C280, C282, C303, C305, and C330.

2. Plan of Correction will be carried out by Facility management.

3. Evaluation period for each SOD listed will be administered by facility management.

4.Persons responsible are listed in the POC for each deficiency listed and will be held acountable for corrections as listed.

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

Refer to C 260, C 270, C 280, C 300, C 303, C 305, C310 and C 330.

1.Z 162:  OAR 411-057-0160(2b) Compliance with Rules Health Care

2.A licensed administrator will ensure licensing rule compliance as referenced in C260, C270, C280, C300, C303, C305, C310, C330.

3.Administrator DHS, CFLC to be involved in service planning, weekly QA & clinical meetings.

4.Ongoing; audit 5x per 40-hour period.

5.ED, DHS, CFLD, CFLC, RN or designee.

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. This is a repeat citation. Findings include, but are not limited to:

a. Situations were identified where there was a failure of the facility to comply with the Departments rules that caused or were likely to cause an immediate threat to residents' health and safety. An immediate plan of correction was requested in the following area:

OAR 411-054-0040 (1-2) (C0270) - Change of Condition and Monitoring.

b. Refer to C 260, C 270, C 280, C 300, C 305, C 310 and C 330.

1.What actions will be taken to correct the rule violation?

a.See C260, C270, C280, C300, C305, C310, C330. Facility has retained Elderwise for compliance oversight; Administrative support, and RN support. ED, AED, MCD, RN or designee will meet and review any concerns, updates and progress with PoC.

2.How will the system be corrected so this violation will not happen again?

a.Administrator, AED, MCD and RN to be involved in service planning, weekday managers meeting, and weekly QA meetings.  

3.How often will the area needing correction be evaluated?

a.Daily and weekly results, follow up and updates will be reviewed weekly at QA meetings and results reviewed at weekly QA ongoing to sustain substantial compliance.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

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 the service plan for 1 of 3 sampled residents (# 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3 moved in to the facility 08/09/21 with diagnoses including vascular dementia with behavioral disturbance, hypertension and pre-diabetes.

The resident's service plan was reviewed on 08/08/23. There was no documented information related to nutrition and hydration status and needs of the resident. During an interview with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23, no additional information was provided.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 2, Staff 3 and Staff 5 on 08/11/23. They acknowledged the findings.

1. Facility will review resident assessments and service plans for completeness and supplement information to ensure residents'nutrition and hydration needs are documented so they can be met by staff.

2. Resident nutrition and hydration needs reviewed and documented at pre-admission evaluation. Document in AL Advantage to ensure service plan reflects needs.

3. At initial assessment and subsequent resident assessments as required- 3 day and quarterly.

4. Director of Memory Care, Memory Care Coordinator, Director of Health Services

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 2 sampled residents (#s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 and 6's current service plans were reviewed during survey. Both service plans lacked information and staff instructions related to individualized nutrition and hydration preferences and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (ED), Staff 5 (LPN) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

"Z 163:  OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

1.Nutritional assessment to be completed for every resident and reflect in service plan.  All physician ordered diets to be reflected on service plan and special diet list as applicable.

a.Resident 5: Resident assessed for individualized nutrition and hydration. Service plan updated and readily available to facility staff.

b.Resident 6: Resident assessed for individualized nutrition and hydration. Service plan updated and readily available to facility staff.

2.Nutritional needs to be evaluated upon move-in, quarterly assessments and changes effecting nutritional needs.

3.Monthly, quarterly, and/or as changes occur.

4.ED, DHS, CFLD, CFLC, or designee

Based on observation, 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 2 of 3 sampled residents (#s 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 9 and 10's current service plans were reviewed during survey. Both service plans lacked information and staff instructions related to individualized nutrition and hydration preferences and needs. Resident 9 and 10 had a history of weight loss and were observed during the survey to need cueing and redirection during meal times.

The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (ED) and Staff 21 (Interim Designated Administrator) on 05/01/24. They acknowledged the findings.

1.What actions will be taken to correct the rule violation?

a.Current residents records will be reviewed and audited for a nutritional assessment and be reflected in individualized resident service plans.  

b.All physician ordered diets to be reflected on service plan and special diet list.

i.Resident 9: Resident assessed for individualized nutrition and hydration. Service plan updated and readily available to facility staff.

ii.Resident 10: Resident assessed for individualized nutrition and hydration. Service plan updated and readily available to facility staff.

2.How will the system be corrected so this violation will not happen again?

a.Nutritional needs will be evaluated upon move-in, 30-day and quarterly assessments, when significant change of condition occurs.

b.Audit will be completed weekly and reviewed at QA meeting until determined a sustained substantial compliance.

3.How often will the area needing correction be evaluated?

a.Monthly, quarterly, and/or as changes occur.

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

a.Memory Care Director, Director of Health Services, Executive Director, Associate Executive Director, or designee.

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

Resident 1, 2 and 3's evaluations, service plans and "The Story of a Lifetime" documents were reviewed. The facility's evaluation failed to address the following

* Emotional and social needs and patterns;

* Adaptations necessary for participation; and

* Activities that could be used as behavioral interventions.

There was no documented evidence an individualized activity plan based on the evaluation had been completed for Residents 1, 2 and 3.

The need to develop individualized activity plans which were based on an evaluation of the resident's interests, abilities and needs was discussed with Staff 2 (Associate ED), Staff 3 (Connections for Living Director) and Staff 5 (LPN) on 08/11/23. They acknowledged the findings.

1. Facility will audit resident files for the presence of individualized activities plans for each. Facility will create and document individualized activities plans for resdients who do not have such a plan.

2. Activities staff will meet with management pre-admission to begin creating activities plan. Activities staff will meet with resident & responsible party to create and document individualized activities plan.

3. At move-in for each new resident and at ongoing assessments.

4. Memory Care Director, Memory Care Wellness Program Coordinator.  

Based on interview and record review, it was determined the facility failed to develop an individualized activity plan for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 5 and 6) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 and 6's evaluations and service plans reviewed. The evaluations failed to address one more of the following components:

* 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.

There was no documented evidence an individualized activity plan based on the evaluation had been completed for Residents 5 and 6.

The need to develop individualized activity plans which were based on an evaluation of the resident's interests, abilities and needs was discussed with Staff 1 (ED), Staff 5 (LPN) and Staff 27 (MCC Director) on 12/07/23. They acknowledged the findings.

*Z 164:  OAR 411-057-0160(2d) Activities

1.Activities assessments completed for every resident and service plans updated.

a.Resident 5: Resident assessed, and service plan updated with detailed person-centered individualized activities plan.

b.Resident 6: Resident assessed, and service plan updated with detailed person-centered individualized activities plan.

2.Activities assessments to be completed upon move-in and during changes in condition as needed.

3.Upon move-in and changes of condition as needed

4.ED, CFLD, CFLC, DHS or designee

Based on interview and record review, it was determined the facility failed to ensure resident behaviors which negatively impacted themselves or others were evaluated and included in the service plan for 1 of 1 sampled resident (#6), who was reviewed with challenging behaviors. Findings include, but are not limited to:

Resident 6 moved into the facility in 03/2023 with diagnoses including dementia with behavioral disturbance.

Resident 6's most recent updated service plan, narrative charting notes dated 10/10/23 through 11/29/23 and occurrence reports were reviewed. The following behaviors were documented:

* 10/09/23: Resident to resident altercation;

* 10/13/23: Verbally threatening physical harm;

* 10/22/23: Aggressive towards staff and residents all shift;

* 10/22/23: Wandering and sleeping in another resident room, when redirected by staff, the resident called staff derogatory names and threw shoes at them; and

* 11/09/23: Resident to resident altercation.

There were no interim service plans for the above behaviors. The service plan failed to include the following:

* A description of the resident's behaviors (as noted above); and

* Resident specific interventions or approaches for staff to utilize for each type of behavior.

The facility failed to evaluate the resident's behaviors and update the service plan.

On 12/07/23, the need to ensure behaviors which negatively impacted the resident and others in the community were evaluated and the service plan updated was discussed with Staff 1 (ED) and Staff 27 (MCC Director). The findings were acknowledged.

*Z 165: OAR 411-057-0160(e) Behavior

1.Utilize MBK Behavior Management policies.  Identify residents requiring ongoing daily behavior monitoring.  Behavior tracking reviewed weekly QA meeting or more often as applicable per resident needs.  Provide behavior training to direct care staff including identification of changes, reporting/documenting and how to provide care.

a.Resident 6: Assessment and service plan updated to include behavior related monitoring, tracking, and care support attributes.

2.Behavior training provided to direct care staff.  Ongoing monitoring of behaviors at weekly QA meeting.  Changes in service plan to be made as needed.

3.Weekly and as changes occur.

4.ED, CFLD, CFLC, DHS or designee