The findings of the Change of Ownership survey, conducted 11/27/23 through 11/30/23, 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.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit to the re-licensure survey of 11/30/23, conducted 02/21/24 through 02/22/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-to-resident altercations and injuries of unknown cause were promptly investigated to rule out abuse and neglect, and reported to the local SPD office when required, for 3 of 5 sampled residents (#s 3, 4, and 8). Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 06/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 09/27/23 service plan, 09/05/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident required one staff assistance for ADLs and cueing. The resident spent most of his/her day wandering the halls throughout the unit or napping in different locations of the facility. The resident did not consistently initiate or direct his/her own care and needs were frequently anticipated by staff. The resident was able to ambulate and transfer on his/her own.

Review of the resident's records showed the following:

* A progress note dated 09/08/23 indicated the resident was discovered in another resident's room during staff rounds. Resident 8 was in his/her brief and was "petting" the other resident's head while s/he laid in bed covered with a blanket. Resident 8 was escorted from the room by staff.

There was no other information about the incident located in the resident's record. No investigation was completed, and the incident was not reported to the local SPD office.

In an interview on 11/29/23, Staff 1 (ED), Staff 2 (Health Services Director/LPN) and Staff 3 (RN) indicated they were not aware of the incident and no investigation was completed. Staff 1 stated she would report the incident to the local SPD office. The staff were unaware of any similar incidents occurring between Resident 8 and any other residents. Staff 2 indicated it was not uncommon for Resident 8 to wander into the hall in only a brief/underwear but there had been no indication it was sexually oriented.

The incident was reported to the local SPD office on 11/29/23 and a confirmation of the report was provided to the survey team prior to exit.

The need to ensure incidents were investigated promptly to rule out abuse and neglect, and reported to the local SPD office when required, was discussed with Staff 1, Staff 2, and Staff 3 on 11/29/23. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in 08/2023 with diagnoses including central nervous system degenerative disease (dementia), asthenia (physical weakness), and history of pelvic, femur, and hip fractures. The resident was evaluated at admission to be a fall risk.

Between 09/22/23 and 11/27/23, the record indicated Resident 3 was found on the floor on six occasions. In particular, Resident 3 fell on 11/05/23 and sustained a small laceration to the bridge of the nose and fell again on 11/10/23.

On 11/16/23, Staff 2 (Health Services Director/LPN) documented the resident had "large scattered bruises in various stages of healing covering back/hip and chest. Resident also has yellowing bruising under both eyes [related to] prior fall."

There was no documentation in the record of previous bruising to the back, hips, or chest from prior falls. Therefore, these bruises would be considered injuries of unknown cause that needed to be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concluded and documented that the physical injuries were not the result of abuse.

Though Staff 1 (ED) and Staff 2 stated in an interview with this surveyor on 11/30/23 they believed the bruises were the result of previous falls, they acknowledged they had not documented that they investigated and reasonably concluded the bruises were not the result of abuse or neglect.

The need to ensure the facility conducted an immediate investigation and documented how it reasonably concluded an injury of unknown cause was not the result of abuse or neglect, or reported the injury to the local SPD office as suspected abuse, was reviewed with Staff 1 and Staff 2 on 11/30/23. They acknowledged the findings.

2. Resident 4 was admitted to the MCC in 02/2020 with diagnoses including dementia without behavioral disturbances and major depressive disorder.

A review of the resident's charting notes and incident investigations from 09/01/23 through 11/27/23 identified:

* 09/16/23 Charting note - "Resident is on alert for slapping and yelling at another resident today at dinner."

There was no documented evidence the incident was immediately reported to the local SPD office.

* 10/13/23 Charting note - "[Resident 4] was on the floor on [his/her] bottom with [his/her] back up against [room number]. [Resident 4] was complaining about [another resident] and wanted [him/her] to go away. Care staff stated [Resident 4] had punched the other resident in the chest and then [resident name] hit [ Resident 4] with a wheelchair and knocked [him/her] down on the ground."

There was no documented evidence the altercation had been investigated in a timely manner. The facility reported the altercation to the local SPD office on 11/08/23, 26 days after the event.

* 11/10/23 Charting note - "[Resident 4] ran over another resident with his wheelchair, and the situation got confrontational."

There was no documented evidence the incident was immediately reported to the local SPD office.

* 11/17/23 Charting note - "Another resident was being loud [resident room number],when [Resident 4] had gone up behind the resident. [Resident 4] grabbed the coat off the back of [the resident's chair] and had it around [the resident's] neck and was trying to choke [him/her] with it. Care staff rushed over to [resident name]. The resident had [his/her] hands on [his/her] neck saying [Resident 4] was trying to kill me."

There was no documented evidence the altercation had been investigated in a timely manner. The facility reported the altercation to the local SPD office on 11/20/23, three days after the event.

On 11/29/23, Staff 2 (Health Services Director/LPN) was asked to report the 9/16/23 and 11/10/23 altercations to the local SPD office. Verification the incidents had been reported was received on 11/30/23.

The need to ensure all resident-to-resident altercations were reported to the local SPD office was discussed with Staff 1 (ED) and Staff 2 on 11/30/23. They acknowledged the findings.

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

Investigating Abuse-Other Action

Facility failed to ensure resident-to-resident altercations and injuries of unknown cause were promptly

investigated to rule out abuse and

neglect, and reported to the local SPD

office when required.

Resident 8's and Resident 4's and Resident 3's incidents were reported to SPD when report was made known. No other residents effected by this practice.

All staff were inserviced on what would consitute a reporting of potential abuse and proper pocedures.  

RN, RCC, and Administrator were inserviced on timely reporting of potential abuse cases. And reviewing 24 hour reporting process.  

LN and Administrator will report all potential abuse cases to SPD within 24 hours of the incident.  

System will be audited 3 times weekly for two months by reviewing  daily charting by LN or designee.

Any cases found will be brought to QA for further review.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff, and were consistently implemented by staff for 6 of 8 sampled residents (#s 1, 3, 4, 5, 6, and 8) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 03/2023 with diagnoses including dementia and congestive heart failure.

Observations of the resident, interviews with staff,  and review of the resident's 10/31/23 service plan, 08/29/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident required two staff assistance for all ADL care. The resident could answer simple questions, but was unable to fully direct his/her own care. The resident used a tilt-in-space wheelchair for mobility and had right-sided weakness.

The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff in the following areas:

* Grooming;

* Handroll/washcloth to right hand;

* Call light placement and use;

* Finger foods and health shakes;

* Toileting, incontinence care, how and where to change;

* Low bed and air mattress;

* Non-skid footwear during transfers; and

* Recliner vs. bed use.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 11/29/23. The staff acknowledged the findings.

2. Resident 8 was admitted to the facility in 06/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 09/27/23 service plan, 09/05/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident required one staff assistance for ADL and cueing. The resident spent most of his/her day wandering the halls throughout the unit or napping in different locations of the facility. The resident did not consistently initiate or direct his/her own care and needs were frequently anticipated by staff. The resident was able to ambulate and transfer on his/her own.

The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not consistently implemented by staff in the following areas:

* Shower assistance;

* Resident romantic relationship;

* Urinating in inappropriate areas;

* Entering common areas/halls partially clothed;

* Resident-to-resident altercations;

* Shower and dressing assistance;

* Toileting assistance and incontinence care;

* Wandering and entrance into other apartments; and

* Activities related to wandering.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 11/29/23. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in 08/2023 with diagnoses including central nervous system degenerative disease (dementia), asthenia (physical weakness), and history of pelvic, femur, and hip fractures. The resident was evaluated at admission to be a fall risk.

Observations of the resident, interviews with staff, and review of the resident's 08/31/23 and 09/28/23 service plans, 08/31/23 through 11/27/23 temporary service plans, progress notes, and incident reports were completed.

The resident had been admitted to hospice services on 11/17/23, following a significant decline which included a series of falls resulting in a hip fracture and other injuries, as well as testing positive for COVID-19. Since then, the resident was bedbound, had been sleeping most of the days or was only minimally responsive, and was declining most food and beverages offered by staff. Hospice ordered oxygen to be administered as needed at a rate of 2 liters per minute (LPM).

a. The current service plan was not reflective of the resident's status or lacked a written description of who should provide the services and what, when, how, and how often the services should be provided in the following areas:

* Instructions to provide food and beverages at every meal, and what to do if the resident was asleep to ensure adequate intake;

* Specific instructions for how to provide meals including, but not limited to, the most current food texture order, providing a covered cup/glass, and use of a straw for beverages; and

* Instructions for administering and monitoring the PRN oxygen.

b. Resident 3's current service plan was not implemented in the following areas:

* Two-hour checks for incontinence;

* Repositioning the resident very two hours; and

* Providing liquids and applying ointment to the resident's lips every one to two hours.

The need to ensure Resident 3's service plan was reflective, included clear instructions for providing services, and was implemented was reviewed with Staff 1 (ED) and Staff 2 on 11/30/23. They acknowledged the findings.

4. Resident 5 was admitted to the facility in 12/2021 with diagnoses including dementia, Type 2 diabetes mellitus, and chronic pain syndrome.

Observations of the resident, interviews with staff, and review of the resident's 09/25/23 service plan, 08/29/23 through 11/27/23 temporary service plans, progress notes, physician communications, and outside provider notes were completed.

The resident was admitted to hospice services on 11/06/23. The resident required two staff to transfer him/her into and out of his/her new Flex-Tilt wheelchair using a mechanical Hoyer lift. The resident was being treated for several recurring pressure ulcers on his/her bottom. The resident required staff to physically feed him/her.

a. The current service plan was not reflective of the resident's care needs in the following areas:

* Use of the Hoyer lift;

* Hospice was now providing bathing; and

* The resident needed physical feeding assistance.

b. Resident 5's current service plan was not implemented in the following areas:

* Observations on 11/28/23 and 11/29/23 indicated the facility was not repositioning and providing incontinence care every two hours as instructed in the service plan.

The need to ensure Resident 5's service plan was reflective, included clear instructions for providing services, and was implemented was reviewed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged the findings.

5. Resident 1 was admitted to the MCC in 11/2023 with diagnoses including type 2 diabetes, obesity, and depression.

The current service plan, dated 10/31/23 and Temporary Service Plans (TSPs) from 11/01/23 to 11/27/23 were reviewed, and observations and interviews with staff and Resident 1 were completed during the survey. The following was identified:

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Preferred to stay in their apartment during the day;

* Episodes of tearfulness and anxiety;

* Level of assistance required for ADLs and use of gait belt with transfers;

* Decreased appetite;

* Meal and hydration assistance; and

* Nutritional shakes.

The need to ensure service plans were reflective of residents' status and included clear directions to staff was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged the findings.

6. Resident 4 was admitted to the MCC in 2/2020 with diagnoses including dementia without behavioral disturbances and major depressive disorder.

Interviews with care staff and observations of Resident 4 during the survey revealed s/he was dependent on staff for ADL care and was unable to use the call light to request assistance.

Resident 4's service plan, dated 10/26/23, was not reflective of the resident's needs and lacked clear direction to staff in the following areas:

* Level of assistance required for hygiene, dressing, toileting/incontinence care, ambulation and transfers;

* Recent falls and current interventions to minimize falls;

* Resident-specific instructions for providing meal assistance; and

* Ability to use call light.

The need to ensure the service plan was reflective of Resident 4's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged the findings.

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

Facility failed to ensure service plans

were reflective of residents' needs,

provided clear direction for staff, and

were consistently implemented by staff

for 6 of 8 sampled residents (#s 1, 3, 4,

5, 6, and 8) whose service plans were

reviewed.

Resident 6,8,3,5 and 1's service plans were updated to reflecting specific staff for directions of care.

All other residents servcies plans were reviewed for clear direction for care needs.

All staff inserviced on the imporatance of reading TSPs and checking care plans. And reporting needed changes to service plans.

All staff inserviced on the imporantace of following the service plans.

IDT inserviced on resident centered care plans with more detail including written detail on who shall provide services,and what when and how those services will be provided. IDT inserviced on signifcant change of condition and updating the service plan to reflect the signifcant change.

Residents with signifcant change of conditions will have service plans updated as needed to reflect the change of condition. LN will audit weekly

All Service plans have been reviewed by RCC, ED and LN and updated as needed to reflect change of conditions.

Service plans will be audited as they come due for 3 months by LN or designee.

Audits will be brought to QA for review of the IDT team for 3 months.

3. Resident 6 was admitted to the facility in 03/2023 with diagnoses including dementia and congestive heart failure.  

Observations of the resident, interviews with staff, and review of the resident's 10/31/23 service plan, 08/29/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident required two staff assistance for all ADL care. The resident could answer simple questions, but was unable to fully direct his/her own care. The resident used a tilt-in-space wheelchair for mobility and had right-sided weakness.

a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or there was a lack of resident-specific directions to staff in the following areas:

* Multiple medication changes;

* Injury and non-injury falls;

* Increased episodes of agitation with physical aggression;

* Bruising to lower extremities and face; and

* Extremity swelling/edema.

b. The resident experienced ongoing severe weight loss between September 2023 and November 2023. The weight loss was not reported to the RN for completion of a significant change of condition assessment.

The need to ensure documentation of short-term changes was noted at least weekly to resolution, clear, resident-specific instructions provided to staff, and significant changes were reported to the RN was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 11/30/23. The staff acknowledged the findings.

4. Resident 8 was admitted to the facility in 06/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 09/27/23 service plan, 09/05/23 through 11/27/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident required one staff assistance for ADL and cueing. The resident spent most of his/her day wandering the halls throughout the unit or napping in different locations of the facility. The resident did not consistently initiate or direct his/her own care and needs were frequently anticipated by staff. The resident was able to ambulate and transfer on his/her own.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or there was a lack of resident-specific directions to staff in the following areas:

* Wandering into other apartments, partially clothed.

The need to ensure documentation of short-term changes was noted at least weekly to resolution and clear, resident-specific instructions provided to staff was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 11/29/23. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 08/2023 with diagnoses including central nervous system degenerative disease (dementia), asthenia (physical weakness), and history of pelvic, femur, and hip fractures. The resident was evaluated at admission to be a fall risk.

Between 09/22/23 and 11/27/23, the record indicated Resident 3 was found on the floor on six occasions.

a. Following each of the falls, the facility failed to monitor the resident for changes in mobility to determine if the service plan needed to be updated to provide additional assistance with transfers or other fall prevention interventions.

b. The facility documented the resident sustained the following injuries:

* 11/16/23 - Bruising to the chest, back, and both hips; and

* 11/17/23 - Swelling and discoloration to the left forehead/eyebrow area.

The facility failed to document on the progress of these conditions at least weekly until the injuries resolved.

The need to ensure the facility had a process for monitoring a resident following a fall or an injury was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition, communicate resident-specific instructions to staff on each shift, document weekly progress until the condition resolved, and/or refer significant changes of condition to the facility RN for 4 of 8 sampled residents (# 3, 4, 6, and 8) who had changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the MCC in 02/2020 with diagnoses including dementia without behavioral disturbances and major depressive disorder.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 10/26/23, and charting notes dated 09/01/23 through 11/27/23 were completed.

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

* 09/16/23 - Resident-to-resident altercation;

* 10/13/23 - Fall in bathroom with injury;

* 10/24/23 - Return from ER;

* 11/05/23 - Swelling to right leg; and

* 11/10/23 - Resident-to-resident altercation.

The need to ensure short-term changes of condition had actions or interventions determined and documented in the resident record and were communicated to staff on all shifts was discussed  with Staff 1 (ED) and Staff 2 (Health Services Director) on 11/30/23. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of

Condition and Monitoring

Facility failed to determine and document

what actions or interventions were

needed for changes of condition,

communicate resident-specific

instructions to staff on each shift,

document weekly progress until the

condition resolved, and/or refer

significant changes of condition to the

facility RN for 4 of 8 sampled residents

(# 3, 4, 6, and 8) who had changes of

condition.

Resident 3, 4, 6, and 8 were assessed by the RN and LN for change of conditions and service plans were updated as needed.

All residents reviewed. No other residents effected by this practice.

Administrator, RN, LN and RCC and Med techs were all inserviced on Change of condition requirements and Alert charting, and weights with significant changes.

RCC completing 24 hour audit report sharing results with LN and ED to ensure all Temporary Service Plans are in place to direct staff on resident specific instructions and interventions and LN/RN as been notified.

Change of conditions will be monitored 2x a week by LN or designee for two months.

All findings will be brought to QA for review for two months.

2. Resident 6 was admitted to the facility in 03/2023 with diagnoses including congestive heart failure, edema, and dementia.

Progress notes, temporary service plans, and physician communications dated 08/29/23 through 11/27/23 indicated the resident was independent with meals. The resident required finger foods to encourage independence. The resident had experienced a change of condition in late September 2023 with a suspected stroke, multiple falls, and increased care needs. The resident was admitted to hospice on 09/29/23.

Weight records, dated 08/01/23 through 11/29/23, indicated the resident experienced the following:

* An 8.51 pound weight loss between 09/01/23 and 09/30/23, which constituted a 7.26% severe loss in a month;

* A 4.5 pound weight gain between 09/30/23 and 10/01/23, which constituted a 4.14% gain in one day; and

* An additional 13.5 pound weight loss occurred between 10/01/23 and 11/01/23, which constituted a 11.94% severe weight loss in one month.

The resident continued to fluctuate between 100 pounds and 104 pounds between 11/03/23 and 11/27/23. The resident's weight on 11/29/23 was 103 pounds.

Observations of the resident between 11/27/23 and 11/29/23 showed the resident up in a tilt-in-space wheelchair in common areas, as well as in his/her recliner in his/her bedroom. The resident was observed to eat 50-100% of the meals provided during six meal observations. The resident drank 100% of fluids provided during meals and snacks, as well as eating 50% of the snacks observed.

The resident was not interviewable. Interviews with staff between 11/27/23 and 11/29/23 showed the following:

Staff 14 (CG), Staff 13 (CG), Staff 9 (MT) and Staff 6 (CG) indicated the resident required two staff assistance for transfers and toileting. The resident could answer simple questions about his/her needs. The staff indicated the resident could eat independently with finger food, but had a more difficult time with silverware. Staff 9 indicated the resident was on daily weights due to his/her edema and had a medication in place to help with fluid retention.

Staff 4 (RCC) indicated the resident did well at meals with the finger foods and was able to drink from a regular cup without issue. Staff 4 stated all residents were offered snacks twice a day and Resident 6 ate most of what was provided.

Staff 2 (Health Services Director/LPN) and Staff 3 (RN) indicated the resident was weighed daily related to congestive heart failure and fluid retention. Staff 3 indicated the resident had ongoing weight fluctuations which were reported to the physician when weight change was greater than three pounds in a day or five pounds in a week. The staff indicated the resident required more assistance and had increased weakness since the falls and suspected stroke in September 2023 and being placed on hospice. The staff stated the resident typically ate very well with the finger foods. Staff 2 indicated the resident additionally received health shakes three times a day. Staff 3 (RN) stated she was unaware of the significant losses between September and November 2023 and had not completed a significant change assessment.

The facility failed to ensure an RN assessment was completed for the weight loss from September 2023 to November 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (ED), Staff 2, and Staff 3 on 11/29/23. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the facility RN assessed all residents with a significant change of condition for 2 of 6 sampled residents (#s 5 and 6) with documented changes of condition requiring assessment. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 12/2021 with diagnoses including dementia, Type 2 diabetes mellitus, and chronic pain syndrome.

The record indicated Resident 5 was receiving home health services to treat a wound on the back side of the leg. A home health visit note dated 09/26/23 read: "New wounds: [Right] upper buttocks: Stage 2 pressure injury...Sacrum Stage 2 pressure injury..." On 10/03/23, home health documented "New pressure injury @ buttocks" and identified an open wound to the "[left] medial buttocks."

Documentation of a stage 2 or greater pressure wound represented a significant change of condition, for which an assessment was required by the facility RN. There was no documented evidence the facility RN completed an assessment of the resident which included findings, resident status, and interventions made as a result of the assessment.

The need to ensure the facility RN completed and documented an assessment when a resident experienced a significant change of condition was reviewed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 11/30/23. They acknowledged no assessment had been completed. No additional documents were provided.

OAR 411-054-0045 (1)(a-f)(A)(C-F)

Resident Health Services

F acility failed to ensure the facility RN

assessed all residents with a significant

change of condition for 2 of 6 sampled

residents (#s 5 and 6) with documented

changes of condition requiring

assessment.

Resident 5, and 6, were reviewed by RN for wounds and weight loss.

No other residents effected by this practice.

ADM, LN and RCC inserviced about what the RN needs to for review.

LN or designee will notify RN immediately of any change of condition.

All weights and wounds reviewed to ensure proper RN oversite by LN or Designee 2 times a week for 4 weeks.  

Audits of weights and wounds to reviewed monthy and all weights outside of parameters to be brought to QA monthly.

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

During observations conducted 11/27/23 thru 11/29/23, the following areas were found to be in need of cleaning:

* Main and small dining room floor, table bases, and chair legs/frames;

* Main dining room kitchenette cabinet doors and sides, hardware, and cabinet laminate;

* Main dining room kitchenette garbage receptacles;

* Small dining room refrigerator had three uncovered, unlabeled, and undated beverages;

* Small dining room refrigerator had two uncovered, unlabeled, and undated food products;

* Main living room arm chairs;

* Sections of baseboard throughout the facility corridors, dining rooms, common spaces, and common restrooms;

* Walls throughout facility corridors, dining rooms, common spaces, and common restrooms; and

* Multiple ambulatory assistive devices (wheelchairs, walkers, canes).

During observations conducted 11/27/2023 and 11/28/2023, the following were observed to need repair:

* Chair bases/frames throughout the facility were gouged, dinged, and scratched;

* Sections of wooden handrails under hand sanitizer dispensers throughout the facility;

* Transitions bordering Living Room (three separate transitions);

* Unit 18 C/D shared restroom had a large section of wallpaper behind the toilet peeling off the wall;

* Unit 18 C/D shared restroom had exposed nails in the wall;

* Unit 17 and 18 C/D restrooms had no transition between shower and restroom floor;

* Three communal shower rooms had no transition between shower stall and restroom floor;

* Broken picture frame in TV Lounge located across the hallway from unit 18;

* One of the industrial drying machines was not operable;

* In the laundry room, six of six light fixtures had missing, broken, or cracked coverings, one cabinet door was missing, and one cabinet door had a missing hinge;

* Unit 17's door handle had a broken key entry point; and

* The caulking in the common area restroom, between the small dining room and kitchen, was in need of repair.

Between 11/27/23 and 11/29/23, the interior of the facility was observed to have persistent/continuous unpleasant urine odor identified in the following areas:

* Upon entry to the main residential common area;

* At the entry of the corridor leading to the small dining room;

* Common area restroom/shower room near the medication station; and

* In unit 16, bed B had a heavy urine odor.

On 11/27/23 and 11/29/23, the above noted findings were pointed out to and discussed with Staff 1 (ED) during tours of the facility.

On 11/29/23 at 2:15 pm Staff 1 witnessed and acknowledged the heavy urine odor in unit 16 and determined a new mattress was needed.

The need to ensure the facility was clean and in good repair was discussed with Staff 1 on 11/27/23, 11/29/23, and 11/30/23. She acknowledged the findings.

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

Elevators, Odors

Facility failed to ensure the indoor environment was kept clean and in good repair.

All identified areas of concerns were addressed.

No other areas identified.

All housekeeping and plant operations were inserviced on upkeep of common areas.

Plant operations or Designee auditing furniture, walls, and handrails weekly and repairing as needed.

Schedule made for Caregivers on the overnight shift to clean all wheelchairs, canes, and walkers. Audit of this will be completed weekly by RCC or Designee

Housekeeping schedule updated to have focus day on facility common area furniture.

Housekeeping schedule updated to clean specific apartments and bathrooms daily to elimate unpleasent urine odor

All service plan updated to reflect toileting needs on all shifts to elimate unpleasent urine odor.  

Cleaning schedule updated for Kitchen staff to clean and audit both dining rooms daily.

Cleanliness audits will be conducted by Administrator, Plant operations or designee 1 weekly for 8 weeks.

Audits will be brought to QA for review by the IDT team for 2 months.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in resident units and common areas were maintained within a range of 110°F to 120°F. Findings include, but are not limited to:

On 11/28/23 and 11/29/23 the following water temperatures were observed:

* Apartment 18 A/B bathroom sink - 102°F;

* Apartment 18 C/D bathroom sink - 101.6°F;

* Apartment 18 D private sink - 101.6°F;

* Apartment 17 - 103.7°F;

* Apartment 16 - 107.6°F;

* Apartment 8 - 103.5°F;

* Community restroom across from kitchen - 108°F; and

* Community restroom at entry of 20's hall - 108°F.

On 11/28/23 at 12:45 pm and 11/29/23 at 12:05 pm, survey informed Staff 1 (ED) of the low water temperatures. Staff 1 stated she would contact a plumber.

The need to ensure hot water temperatures were maintained between 110°F and 120°F was discussed with Staff 1 on 11/30/23. She acknowledged the findings.

Water temps have been repaired to maintain temps  from 110-120 degrees.

Plant opeations was inserviced on taking water temps thoughout the building to ensure proper temps.

Audits are conducted 1 weekly for 8 weeks by plant operations or designee to ensure proper temps.

All temps outside of normal range will be brought to QA for review by IDT team for two months.

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 C231, C513, and C545.

McMinnville Memory care will be in compliance with both Memory Care Communitie Administrative Rules and REsidential Care Facilities Rules. See plan of correction for C231, C513, and C545.

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 C260, C270, and C280.

McMinnville Memory care will be in compliance with both Memory Care Communitie Administrative Rules and REsidential Care Facilities Rules. See plan of correction for C260, C270, and C280.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked out of or inside their rooms at any time. Findings include but are not limited to:

Observations were made between 11/27/23 and 11/29/23 of multiple sampled and unsampled residents being locked out of their apartments.

* One resident attempted to open their apartment door; when the door would not open, the resident searched his/her purse, looked up and down the hallway, walked to the dining room and looked around, then returned to his/her apartment and attempted to open the door again.

* On 11/27/23 and 11/28/23, the door of Unit 22 was observed to have two rolled up towels propping the door open. The resident stated s/he had been locked out of his/her apartment and using towels was how they knew they wouldn't get locked out. The resident also stated when they had been locked out in the past, they would sit at the end of the hall and wait for staff assistance.

* On 11/29/23 multiple residents were observed attempting to open their apartment doors but were unable to because they were locked (apartments 9, 17, 23, and 26).

The need to ensure residents were not locked out of or inside their rooms at any time was discussed with Staff 1 (ED) on 11/29/2023. She acknowledged the findings.

All resident room doors  identified with incorrect locking ablility not allowing them to enter there room if pushed correctly have been identified and replacement door handles have been ordered.  

No other residents effected by this practice.

A complete building audit was conducted to ensure all door locks are proper.

Training done with plant operations for proper locks.

Audit to be done monthly for 1 month.

Any locks identified will be brought to QA for review.