The findings of the change in ownership survey, conducted 02/05/24 through 02/08/24, 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, and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the change of ownership survey of 02/08/24, conducted on 05/30/24, are documented in this report. The survey was conducted to determine compliance with 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 the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the change of ownership survey of 02/08/24, conducted on 07/18/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Observations of the facility kitchen, food storage areas, food preparation, and food service on 02/05/24, between 9:10 am and 12:50 pm, revealed the following:

* Upper cabinet doors to the left of the stove had brown matter around the cabinet pulls;

* Multiple cabinet shelves had chipped paint, creating an uncleanable surface;

* The stainless steel backsplash of the stove had grease/food splatter;

* There were no test strips available to staff to use for the sanitizing buckets;

* Opened/undated food items were observed in the cabinetry; and

* Scoops were observed in the sugar and cereal bins.

The areas in need of cleaning and repair were reviewed with Staff 1 (ED) on 02/06/24 at 2:20 pm. She acknowledged the findings.  

Immediate actions of correction:  

oNew cabinets and shelving were installed. Completion date on 2/11/2024

oTraining provided to kitchen staff on use of open/date stickers. Completion date 2/12/2024

oTest strips re-ordered and present in the kitchen as of 2/12/2024

oChanges containers with use of scoop with containers that can be poured from as of 2/12/2024

oReviewed the deep cleaning plan with kitchen staff as of 2/12/2024

Systems implemented for continuous improvement and correction:

oKitchen audit by Administrator will be completed every month. This system will include a checklist that includes to check and monitor for the following, but not limited to: presence of cleanable surfaces, absence of visible grease/food splatter, food items have open and date stickers, and food items are stored in containers without spoons inside.

oOwner: Administrator

oDone every month until 3 consecutive inspections with no issues, then moving to every quarter.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services, included a written description of who should provide the services and what, when, how, and how often the services should be provided for 3 of 6 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2023 with diagnoses including dementia, depression, and mild cognitive impairment.

Observations of the resident, staff interviews, and review of the service plan, dated 01/28/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* How the resident exhibited agitation;

* Interventions to redirect when becoming agitated;

* The resident's routine relating to carrying a book and having his/her hat on; and

* Shower routine.

Resident 3 was observed wearing a hat each day during the survey. Observations were made of the resident when an unsampled resident attempted to touch him/her. The resident shook his/her head and stated, "No." When Resident 3 attempted to return to his/her unit, the unsampled resident tried to follow. Staff intervened and redirected the unsampled resident.

The need to ensure service plans were reflective of the residents' status and included clear instructions for staff for providing care and services was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/07/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's, dementia with behavioral disturbance, depression, and post traumatic stress disorder.

Observations of the resident, staff interviews, and review of the service plan, dated 01/28/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Cueing for activities;

* How the resident exhibits anxiety and agitation;

* The use of a psychotropic;

* Mobility device;

* Trust-building with the resident;

* Toileting assistance needed;

* Usual daytime clothing, including the resident's routine relating to wearing a mask, carrying a word find book, and having his/her hat on;

* Shower routine;

* Housekeeping routine; and

* Laundry routine.

Resident 4 was observed wearing a medical grade mask during different times of the survey. Staff 2 (Administrator) verified the resident making statements of having "COVID since 1970" and the preference to wear a mask at times.

The need to ensure service plans were reflective of the residents' status, and included clear instructions for staff for providing care and services was discussed with Staff 1 (ED) and Staff 2 on 02/08/24. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including advanced dementia and failure to thrive.

Observations of the resident, staff interviews, and review of the service plan, date 11/10/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Vocalization with ADL cares;

* Repositioning assistance;

* Toileting assistance;

* Dressing assistance;

* Alternating pressure mattress use; and

* Hospice.

The need to ensure service plans were reflective of the residents' status and included clear instructions for staff for providing care and services was discussed with Staff 2 (Administrator) on 02/07/24. She acknowledged the findings.

Immediate actions of correction:  

oAdministrator, LPN reviewed OAR 411-054-0036 (1-4), for re- training on the rules for service planning on 2/12/2024

oReviewed the tool used by the community and proposed revisions to ensure the template has the specific parts to create a service plan to comply with the OAR. Done on 2/12/2024

Systems implemented for continuous improvement and correction:

oRN and LPN, Administrator, re-created service plan tool to ensure areas include and specify the individualized instructions on: What the resident does/prefers. What the staff should do, When staff provides assistance, and Who provides the assistance.

oProcess improvement included scheduling a pre-meeting with caregivers and medication techs, to review care plans, and collaboratively develop and update care plans to the most accurate information specific to the residents.

oOwner: Administrator

Done at every 30 days and quarterly, and when significant changes of condition of residents.   

4. Resident 3 was admitted to the facility in 09/2023 with diagnoses including dementia, hypertension, and mild cognitive impairment.

The resident's 01/01/24 through 02/05/24 MARs and physician's orders were reviewed. The following inaccuracy was identified:

* The resident had a physician's order for metoprolol (for high blood pressure). There were no parameters for the staff to hold the medication relating to the blood pressure readings.

The need to ensure MARs were accurate and included clear parameters for staff was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/07/24. They acknowledged the findings.

5. Resident 4 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's, dementia with behavioral disturbance, and hypertension.

The resident's 01/01/24 through 02/05/24 MARs, physician's orders, and progress notes, dated 12/10/23 through 02/04/24, were reviewed. The following inaccuracies were identified:

* Resident 4 returned from the hospital on 01/11/24 with the following new medications:

- Atorvastatin (for lowering cholesterol);

- Donepezil (for agitation and dementia);

- Fluticasone-Salmeterol (for asthma); and

- Olanzapine (for agitation/clear thoughts).

Progress notes dated 01/11/24 through 01/15/24 reflected the resident did not receive the above medications due to the facility not having them to administer.

Staff initialed the MAR, documenting the medications had been administered on 01/11/24, 01/13/24, 01/14/24, and 01/15/24.

* Physician's orders directed staff to hold the metoprolol (for heart failure) for "systolic [blood pressure] less than 110 or heart rate less than 55."

The parameters were not transcribed on the resident's MAR.

The need to ensure MARs were accurate and included clear parameters for staff was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/08/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for 4 of 6 sampled residents (#s 2, 3, 4, and 5) and contained reasons for use for 3 of 6 sampled residents (#s 1, 2, and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease. Resident 2's signed physicians orders, dated 12/12/23, and MARs were reviewed from 01/01/24 through 02/05/24, and the following was noted:

a. Resident 2 had a physician's order for PRN acetaminophen 325 mg every six hours as needed for pain.  There was also an order for morphine sulfate 20 mg/ml SOLN 0.25 ml (5 mg) by mouth or under tongue every 15 minutes as needed for pain.

There were no resident-specific parameters regarding which PRN should be used first.

In an interview with Staff 4 (MA) on 02/07/24, at 10:15 am, it was confirmed that the electronic MAR did not contain any additional information for staff as to which PRN pain medication to use first.

b. Multiple medications on the MAR lacked a reason for use.

On 02/07/24, the surveyor and Staff 4 reviewed the electronic MAR and confirmed the electronic MAR contained no additional information versus the printed MAR.

The need to ensure MARs included reasons for use and all PRN medications had resident-specific parameters was discussed with Staff 1 (Administrator) on 02/07/24. The findings were acknowledged.

2. Resident 5 was admitted to the facility in 12/2023 with diagnoses including dementia and cervical disc disorder. Resident 5's signed physician orders, dated 12/19/23, and MARs were reviewed from 01/01/24 through 02/05/24, and the following was noted:

a. Resident 5 had a physician's order for PRN acetaminophen 325 mg, two tablets every six hours as needed for pain.  There was also an order for oxycodone-acetaminophen 5-325 mg, one to two tablets every six hours as needed for pain.

There were no resident-specific parameters for staff regarding which PRN should be used first.

In an interview with Staff 4 (MA) on 02/05/24, it was confirmed the electronic MAR did not contain any additional information for staff as to which PRN to administer first.

b. Multiple medications on the MAR lacked a reason for use.

On 02/05/24 at 10:24 am, the surveyor and Staff 4 reviewed the electronic MAR and confirmed the electronic MAR contained no additional information versus the printed MAR.

The need to ensure all medications on the MAR had reasons for use and included resident-specific instructions for PRN medications was discussed with Staff 1 (Administrator) on 02/07/24. The findings were acknowledged.

3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including advanced dementia. Resident 1's signed physician orders, dated 12/27/23, and MARs were reviewed from 01/01/24 through 02/05/24, and the following was noted:

* Fluoxetine HCL 40 mg, one capsule once daily lacked a reason for use.

On 02/05/24 at 10:28 am, the surveyor and Staff 4 (MA) reviewed the electronic MAR and confirmed the electronic MAR contained no additional information versus the printed MAR.

The need to ensure all medications on the MAR included reasons for use was discussed with Staff 1 (Administrator) on 02/07/24. The findings were acknowledged.

Immediate actions of correction:  

oAdministrator, LPN and RN reviewed OAR 411-054-0055 (2), for re- training on the rules for Medication Administration on 2/12/2024

oReviewed MARs to identify and correct any orders needing parameters, specific instructions for use, indications, and accuracy per physician's orders. Done on 2/12/2024

Systems implemented for continuous improvement and correction:

oRN and LPN, Administrator, implemented a process to do a focused review on MARs versus Physician orders quarterly when service plans are due. During the review, parameters and specific indications will be audited to ensure presence on the MAR.

oOwner: LPN

Done at quarterly service plans when due, and when significant changes of condition of residents.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in to the facility, no less than quarterly, and with significant changes of condition. Findings include, but are not limited to:

On 02/06/24, the ABST was reviewed with Staff 1 (ED) and Staff 2 (Administrator). The following was identified:

* The three newest admissions had not been added to the ABST;

* Admission dates were verified with the facility, but the resident data had not been inputted for 15 to 27 days after admission;

* Twenty out of the thirty-six residents had not been updated at least quarterly; and

* One resident who had a verified significant change of condition had not been updated in the system.

The need to ensure the facility updated the ABST before a resident moved in to the facility and no less than quarterly was discussed with Staff 1 and Staff 2 on 02/06/24. They acknowledged the findings.

Immediate actions of correction:  

oAdministrator, LPN and RN reviewed OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool, for re- training on the rules for Acuity-Based staffing tool on 2/12/2024

Systems implemented for continuous improvement and correction:

oAdministrator, implemented a process to include the ABST update in the checklist of tasks to do at the time of evaluation of a new resident, at the time of their 30-days review of service plan and at significant change of condition. A calendar digital alarm has also been made to alert for quarterly to remind the update of ABST tool.

oOwner: Administrator

oDone at initial evaluation, 30 days, quarterly calendar due dates, and when significant changes of condition of residents.    

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) no less than quarterly for 2 of 2 sampled residents (#s 7 and 8) and to use the tool to develop the facility's staffing plan. This is a repeat citation. Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 2 (Administrator) at 1:20 pm on 05/30/24. The following was identified:

a. Resident 7's ABST did not show evidence of being updated with the service plan dated 05/01/24, and Resident 8's ABST showed the last update was 11/01/23.

b. During an interview at 1:20 pm on 05/30/24, Staff 1 stated she included non-direct care staff when using the tool to determine appropriate staffing levels for the facility.

The need to ensure each resident's ABST was updated no less than quarterly and the results were used to develop the facility's staffing plan was discussed with Staff 1 on 05/30/24. She acknowledged the findings.

Immediate actions of correction:

oThe facility administrator received comprehensive training about the ABST process last 06/04/24. This training, conducted by Ms. Katie Gaffney, ABST Policy Analyst from the Safety, Oversight, and Quality Unit of the Oregon Department of Human Services, covered the importance of timely updates, the correct use of the ABST, and the exclusion of non-direct care staff in staffing level calculations.

oThe ABST for all Residents were immediately reviewed and updated. (Completed on 6/11/24)

Systems implemented for

continuous improvement and

correction:

oInitial/30-day/Significant Change of Condition and Quarterly ABST Review Schedule: A schedule and alerts have been established to review and update the ABST for all residents quarterly, every 30 days, and in the event of a significant change of condition. This schedule aligns with the service plan updates required by OAR 411-054-0034.

oCheckpoints and Audits: Monthly audits will be conducted by the administrator to ensure compliance with ABST updates. The audits will include verifying that each resident's ABST is current and accurately reflects their needs.

oDocumentation Process: All ABST updates will be documented and logged in an ABST spreadsheet record. This log will be reviewed quarterly or whenever there is an update by the facility administrator to ensure that no updates are missed.

Owner: Administrator

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months and document all required elements for fire drills in accordance with Oregon Fire Code (OFC) requirements. Findings include, but are not limited to:

Review of fire drill records dated 08/15/23, 10/15/23, and 12/19/23 revealed a lack of documentation of one or all of the following required fire drill components:

* Time of day of the fire drill;

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

* Evacuation time period needed.

Additionally, there was no documented evidence alternate exit routes were used during the fire drills.

During an interview on 02/06/23, Staff 2 (Administrator) confirmed the fire drills and fire and life safety instruction to staff had not occurred on alternate months consistently over the last six months.

The need to provide fire and life safety instruction to staff on alternate months and to document all required elements for fire drills as required by the OFC was discussed with Staff 1 (ED) and Staff 2 on 02/06/24. They acknowledged the findings.

Immediate actions of correction:  

oAdministrator, LPN and RN reviewed OAR 411-054-0090 (1-2) Fire and Life Safety: Safety, for re- training on the rules on 2/14/2024

Systems implemented for continuous improvement and correction:

oAdministrator, re-created the form used for Fire and Life safety drills to ensure the tool prompts to capture information needed to comply with the rule that includes: time and date of the drill, problems encountered and comments related to the drill, evacuation time needed, and documentation of alternate exit routes.

oElectronic calendar prompts were added to alert fire drills due scheduled on alternate months and alternating shifts to cover different times of the day.

oOwner: Administrator

oDone at every other month when calendar alerts are due

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

Refer to C 361 and Z 142.

Immediate actions of correction:

oImmediate steps were taken to address and correct the identified deficiencies (C 361 and Z 142) by revising procedures and processes to ensure compliance with the Department's requirements. All corrective actions were subsequently verified to ensure proper implementation and that the deficiencies noted in the survey were effectively addressed.

oThe facility administrator received comprehensive training about the ABST process last 06/04/24. This training, conducted by Ms. Katie Gaffney, ABST Policy Analyst from the Safety, Oversight, and Quality Unit of the Oregon Department of Human Services, covered the importance of timely updates, the correct use of the ABST, and the exclusion of non-direct care staff in staffing level calculations.

oThe ABST for all Residents were immediately reviewed and updated. (Completed on 6/11/24)

Systems implemented for

continuous improvement and

correction:

oInitial/30-day/Significant Change of Condition and Quarterly ABST Review Schedule: A schedule and alerts have been established to review and update the ABST for all residents quarterly, every 30 days, and in the event of a significant change of condition. This schedule aligns with the service plan updates required by OAR 411-054-0034.

oCheckpoints and Audits: Monthly audits will be conducted by the administrator to ensure compliance with ABST updates. The audits will include verifying that each resident's ABST is current and accurately reflects their needs.

oDocumentation Process: All ABST updates will be documented and logged in an ABST spreadsheet record. This log will be reviewed quarterly or whenever there is an update by the facility administrator to ensure that no updates are missed.

Owner: Administrator

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

Observations of the facility on 02/05/24 and 02/06/24 revealed the following:

* Multiple resident rooms, common bathrooms, and laundry room had scraped doors and/or jambs;

* The armrest of a chair outside the nurse's office was missing;

* Multiple overhead florescent light fixtures contained dead insects;

* A vent outside of Room #29 had dust and debris;

* An outdoor vent near the entry to the building had dust and debris;

* An outdoor vent in the interior courtyard had dust and debris; and

* The hallway entry to the left of the main entrance had scraped paint and baseboards.

The surveyor toured the environment with Staff 2 (Administrator) on 02/06/24. She acknowledged the above areas needed to be cleaned and repaired.

Immediate actions of correction:  

oAdministrator, scheduled the services for repair and cleaning for 3/15/2024.

Systems implemented for continuous improvement and correction:

oAdministrator, recreated a monthly audit walkthrough audits for repair and cleaning. The tool audit will prompt items needing for repair and cleaning to ensure the interior and exterior are kept clean and in good repair.

oOwner: Administrator

oDone at every other month

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

On 02/05/24 and 02/06/24, the surveyor measured water temperatures in occupied resident unit bathrooms and common bathrooms throughout the building. Water temperatures were below 110 degrees F.

During an interview on 02/06/24 at 2:35 pm, Staff 2 (Administrator) stated the facility had ongoing issues with water temperatures, especially when dishwashing and laundry tasks were performed simultaneously.

The need to ensure hot water temperatures were monitored and maintained within a range of 110 - 120 degrees F was discussed with Staff 2 on 02/06/24. She acknowledged the findings.

Immediate actions of correction:  

oAdministrator, scheduled the services for repair of water tank and temperature regulation on 2/14/2024.

Systems implemented for continuous improvement and correction:

oRepair completed.

oAdministrators included a water temperature check on the monthly building walkthrough audit to ensure no repairs or maintenance is needed.

oOwner: Administrator

oDone at every other month

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

Refer to C 240, C 361, C 420, C 513, and C 545.

Immediate actions of correction:  

oAdministrator, reviewed licensing rules for the facility and Chapter 411, Division 57 on 2/14/2024.

Systems implemented for continuous improvement and correction:

oChecklists, forms, retraining and electronic calendar alerts were implemented to address compliance on the tags: C 240, C 361, C 420, C 513, and C 545.

oOwner: Administrator

oDone at every other month and quarterly use of systems

Based on 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 361.

Immediate actions of correction:

Steps to immediately address and correct the identified deficiency (C 361) were created and established. This included revising procedures and processes to ensure compliance with the Department's licensing rules for Residential Care and Assisted Living Facilities.

oThe facility administrator received comprehensive training about the ABST process last 06/04/24. This training, conducted by Ms. Katie Gaffney, ABST Policy Analyst from the Safety, Oversight, and Quality Unit of the Oregon Department of Human Services, covered the importance of timely updates, the correct use of the ABST, and the exclusion of non-direct care staff in staffing level calculations.

oThe ABST for all Residents were immediately reviewed and updated. (Completed on 6/11/24)

Systems implemented for

continuous improvement and

correction:

o Initial/30-day/Significant Change of Condition and Quarterly ABST Review Schedule: A schedule and alerts have been established to review and update the ABST for all residents quarterly, every 30 days, and in the event of a significant change of condition. This schedule aligns with the service plan updates required by OAR 411-054-0034.

oCheckpoints and Audits: Monthly audits will be conducted by the administrator to ensure compliance with ABST updates. The audits will include verifying that each resident's ABST is current and accurately reflects their needs.

oDocumentation Process: All ABST updates will be documented and logged in an ABST spreadsheet record. This log will be reviewed quarterly or whenever there is an update by the facility administrator to ensure that no updates are missed.

Owner: Administrator

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 and C 310.

Immediate actions of correction:  

oAdministrator, reviewed licensing rules for the facility and OAR 411-057-0160(2b) Compliance with Rules Health Care on 2/14/2024.

Systems implemented for continuous improvement and correction:

oChecklists, forms, retraining and electronic calendar alerts were implemented to address compliance on the tags: C 260, and C 310.

oOwner: Administrator

oDone at every other month and quarterly use of systems

Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs, that was individualized and documented in the resident's service or care plan, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, 4, 5, and 6's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.

The need to develop a daily meal program for nutrition and hydration based on the resident's preferences and needs and documented in the resident's service or care plan was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/07/24 and 02/08/24. They acknowledged the findings.

Immediate actions of correction:  

oAdministrator, LPN reviewed 411-057-0160(2)(c)(A)(B) Nutrition and Hydration, for re- training on the rules for service planning on 2/12/2024

oReviewed the tool used by the community and proposed revisions to ensure the template has the specific parts to create a service plan to comply with the OAR. Done on 2/12/2024

Systems implemented for continuous improvement and correction:

oRN and LPN, Administrator, re-created service plan tool to ensure areas include and specify the individualized instructions on the individualized nutritional plan.

Process improvement included scheduling a pre-meeting with caregivers and medication techs, to review care plans, and collaboratively develop and update care plans to the most accurate information specific to the residents' meal plans.

oOwner: Administrator

oDone at every 30 days and quarterly, and when significant changes of condition of residents.  

Based on observation, interview, and record review, it was determined the facility failed to evaluate and develop individualized activity plans and provide a meaningful activity program for 2 of 6 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2023 with diagnoses including dementia, depression, and mild cognitive impairment.

Although there was some information related to activities Resident 3 may want to participate in, the documentation lacked the following components:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

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

Resident 3's Life Enrichment Plan identified arts, crafts, and music for his/her preferred activities. The resident's service plan identified arts, crafts, card games, knitting, music, reading, television shows, and walking for his/her preferred activities.

Per interview with Staff 3 (MA) on 02/07/24 at 10:44 am, the resident preferred Bingo and watching movies. Although Resident 3 carried a book with him/her, Staff 3 reported the resident was no longer able to focus on reading.

Resident 3 was observed during the survey to be in a quiet common area, watching movies.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/07/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's, dementia with behavioral disturbance, depression, and post traumatic stress disorder.

Although there was some information related to Resident 4's current interests, the documentation lacked the following components:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

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

Resident 3's Life Enrichment Plan identified music, word puzzles, and word search for his/her preferred activities. The resident's service plan identified arts, crafts, knitting, music, praise and worship, and television shows for his/her preferred activities.

Per interview with Staff 3 (MA) on 02/08/24 at 9:24 am, the resident preferred Elvis Presley music, and thought Resident 4 shared the same birthday with Elvis. She reported s/he would play the "air guitar" and dance when Elvis Presley music was being played in the facility.

Resident 4 was observed listening to Staff 13 (MA/Activities) talk about Elvis' life in a group setting and join another group where Staff 13 was talking about Dr. Martin Luther King, Jr.

The lack of an activity evaluation and individualized activity plan was discussed with Staff 1 (ED) and Staff 2 (Administrator) on 02/08/24. They acknowledged the findings.

Immediate actions of correction:  

oAdministrator, LPN reviewed OAR 411-057-0160(2d) Activities, for re- training on the rules for service planning on 2/12/2024

oReviewed the tool used by the community and proposed revisions to ensure the template has the specific parts to create a service plan to comply with the OAR. Done on 2/12/2024

Systems implemented for continuous improvement and correction:

oRN and LPN, Administrator, re-created service plan tool to ensure areas include and specify the individualized activity plan developed for each resident based on their activity evaluation. The plan will reflect the resident ' s activity preferences and needs.

oProcess improvement included scheduling a pre-meeting with caregivers and medication techs, to review care plans, and collaboratively develop and update care plans to the most accurate information specific to the residents' meal plans.

oOwner: Administrator

Done at every 30 days and quarterly, and when significant changes of condition of residents.

4. Resident 4 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's and dementia with behavioral disturbance.

Review of the resident records and staff interviews during the survey revealed Resident 4 had eloped from the facility three times between 12/24/23 and 01/06/24.

The current service plan, dated 01/11/24, and "Life Enrichment Plan" lacked resident-specific information which included how the resident would exhibit agitation and individualized interventions for staff to try when responding to Resident 4's agitation.

The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 1 (ED) and Staff 2 (Administrator) on 02/08/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure behavioral symptoms which negatively impacted the resident and others in the community were evaluated and/or included on the service or care plan for 4 of 5 sampled residents (#s 1, 2, 4, and 6) who had challenging behaviors in the MCC. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease.

Review of the resident records and staff interviews during the survey revealed Resident 2 frequently exhibited escalated verbal behavior, including yelling at residents, when agitated and feeling like others were "in [his/her] space."

The current service plan, dated 01/12/24, lacked resident-specific information that informed staff of the specific behaviors of concern and lacked individualized interventions for staff to try when responding to the behaviors.

The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 2 (Administrator) on 02/07/24. She acknowledged the findings.

2. Resident 6 was admitted to the facility in 08/2023 with diagnoses including dementia with behavioral disturbance.

Review of the "Life Enrichment Plan" stated that Resident 6 should be provided with activities that were "tactile and also offers small snacks" as an intervention to Resident 6's behavior of scratching his/her skin. The current service plan, dated 01/20/24, lacked interventions for the behavior of scratching his/her skin.  

The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 2 (Administrator) on 02/07/24. She acknowledged the findings.

3. Resident 1 was admitted to the facility in 10/2023 with diagnoses including advanced dementia.

Review of the resident's "Life Enrichment Plan" identified that "care staff should always talk to [him/her] first before transferring," as an intervention to Resident 1's behavior of yelling loudly when being touched or transferred. The current service plan, dated 11/10/24, lacked that intervention.

The need to ensure the facility developed an individualized behavior plan for residents who exhibited behavioral symptoms which negatively impacted the resident and others in the community was reviewed with Staff 2 (Administrator) on 02/07/24. She acknowledged the findings.

Immediate actions of correction:  

oAdministrator, LPN reviewed OAR 411-057-0160(e) Behavior, for re- training on the rules for service planning on 2/12/2024

oReviewed the tool used by the community and proposed revisions to ensure the template has the specific parts to create a service plan to comply with the OAR. Done on 2/12/2024

Systems implemented for continuous improvement and correction:

oRN and LPN, Administrator, re-created service plan tool to ensure areas include and specify the individualized behavioral symptoms which negatively impact the resident and others in the community, reflected in the care plan

oProcess improvement included scheduling a pre-meeting with caregivers and medication techs, to review care plans, and collaboratively develop and update care plans to the most accurate information specific to the residents' meal plans.

oOwner: Administrator

Done at every 30 days and quarterly, and when significant changes of condition of residents.  

Based on observation, interview and record review, it was determined the facility failed to ensure the fence surrounding the perimeter of the outdoor recreation area was constructed to reduce the risk of resident elopement. Findings include, but are not limited to:

The outdoor secured courtyard was toured on 02/05/24 at 9:25 am. The following was observed:

The fencing surrounding the perimeter of the outdoor recreation area was constructed of chain link material with slats placed through the gaps in the chain links. The slats placed were flexible and not constructed to reduce risk of resident elopement.

Resident 4 was admitted to the facility in 12/2023 with diagnoses including dementia with behavioral disturbance.

Progress notes, dated 12/10/23 through 02/04/24, were reviewed. The resident eloped from the facility by scaling the fence located in the outdoor secured courtyard area on the following dates:

* 12/23/23;

* 01/04/24; and

* 01/06/24.

During an interview on 02/06/24 at 2:30 pm, Staff 2 (Administrator) confirmed the fence construction could potentially aid in resident elopement.

A tour of the outdoor recreation area was completed with Staff 2 on 02/06/24.  She acknowledged the findings.

Immediate actions of correction:  

oAdministrator, scheduled the services for repair with safety fence cover added for 3/5/2024.

Systems implemented for continuous improvement and correction:

oRepair completion will address the isuue.

oOwner: Administrator

on 3/5/2024