The findings of the change of ownership survey, conducted 09/20/21 through 09/23/21, 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 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
A situation was identified which represented an immediate threat to residents' health and safety and required an immediate plan of correction in the following area:
OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule.
The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety and the situation was abated.
The findings of the first revisit to the change of ownership survey of 09/23/21, conducted 03/08/22 through 03/09/22, 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 re-visit to the change of ownership survey of 03/08/22 through 03/09/22, conducted on 12/01/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.
Based on observation, interview and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision and training of staff. Findings include, but are not limited to:
During the change of ownership survey, conducted 09/20/21 through 09/23/21, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.
1. A situation was identified which represented an immediate threat to residents' health and safety and required an immediate plan of correction in the following area:
OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule.
The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety and the situation was abated.
2. Refer to deficiencies in the report.
Please refer to each citation's plan of correction.
2. Resident 3 was admitted to the facility in July 2021 with diagnoses including dementia.
Review of Resident 3's 07/15/21 through 09/20/21 progress notes, 07/15/21 service plan, incident investigations, interviews with staff and observations of the resident revealed the resident experienced multiple skin injuries during the time frame reviewed, which included the following:
* Progress note dated 07/31/21 indicated the resident had a "large red abrasion that is the size of a large sticky note." No location was identified;
* Progress note dated 08/05/21 indicated the resident had a "large sticky note and small sticky note sized abrasion on the back of his left bicep."; and
* Progress note dated 08/08/21 indicated the resident had "quarter-size skin tear located on the left elbow".
During an interview with Staff 1 (Executive Director) and Staff 2 (LPN/ Memory Care Coordinator) on 09/22/21 at 3:50 pm, they reported the injuries were not investigated at the time the injuries were identified to rule out abuse and had not been reported to the local SPD office as injuries of unknown cause.
On 09/22/21, survey requested the RN complete a skin audit to determine the status of Resident 3's wounds. The RN skin audit was provided during the meeting with Staff 1 and 2 on that date. Review of the document revealed the RN identified the following additional skin injuries:
*0.4 cm dark, hard scab to the lateral aspect top of the right foot; and
* Seven dark, hard scabs on the resident's left lower extremity which varied in size from 0.2 to 0.7 cm.
During an interview with Resident 3 on 09/22/21 at 11:15 am, multiple scabs were observed on both lower extremities below the level of the resident's shorts.
There was no documented evidence the additional injuries had been investigated to rule out abuse at the time the injuries occurred or were reported to the local SPD office as injuries of unknown cause. Survey requested the facility report all of the injuries of unknown cause noted above to the local SPD office on 09/23/21. An email confirmation of the report was provided prior to exit.
The need to ensure all injuries of unknown cause were investigated to rule out abuse and reported to the local SPD when abuse was not able to be reasonably ruled out was discussed with Staff 1 and Staff 2 on 09/22/21 and 09/23/21. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure investigations were completed for incidents involving residents to rule out abuse or reported to the local SPD office if abuse could not reasonably be ruled out for 2 of 4 sampled residents (#s 3 and 4) who had documented unwitnessed falls and injuries of unknown cause. Findings include, but are limited to:
1. Resident 4 was admitted to the facility in June 2021, with diagnoses including rheumatoid arthritis and dementia.
Clinical records including evaluations, service plans and temporary service plans, incident reports/investigations and progress notes were reviewed during survey and indicated the following:
Resident 4's evaluation and service plans dated 06/24/21, 08/2/21 and 8/27/21 indicated the resident displayed memory loss, had a history of falls, required staff assistance for ADLs (transfers, toileting grooming dressing) and instructed staff to provide hourly "safety checks when in bed".
The following unwitnessed falls were documented in incident reports/investigations:
08/19/21- Staff found the resident lying on his/her left side next to the bed at approximately 12:15 am. The report stated "the last time care staff assisted the resident was at 10 pm when care staff were doing rounds".
09/3/21- Staff found the resident sitting on the floor next to his/her bed with "blood dripping down the resident's face and on the floor" at 12:15 am. The report stated "the last time care staff assisted the resident was at approximately 10:15 pm when care staff were doing shift change rounds". The resident was sent to the ER and returned with five staples to a laceration on the back of the head.
09/9/21- Staff found the resident lying on the floor in his/her apartment at 4:00 am. The report stated " the last time care staff assisted the resident was at 2:00 am when toileting assistance was provided".
09/14/21- Staff found the resident lying on the floor in his her apartment at 4:10 am. The report stated " the last time care staff assisted the resident was at 2:00 am when RA was doing rounds".
Incident reports/investigations dated 8/19, 9/3, 9/9 and 9/14 indicated staff had not completed hourly safety checks, as directed by the service plan. There was no documented evidence the incidents had been reported to the local SPD office.
Resident 4 was service planned to require hourly checks. The resident experienced four falls and the investigations noted the hourly checks had not been completed. Therefore, abuse and neglect could not reasonably be ruled out and the facility failed to notify SPD.
The need to ensure a thorough investigation was completed for incidents involving residents, which documented abuse/neglect was ruled out, or reporting the incident to the local SPD office if abuse could not reasonably be ruled out was discussed with Staff 1 (ED) an Staff 2 (LPN/Memory Care Coordinator) on 09/21/21. No further documentation related to hourly safety checks was provided. The facility reported the incidents to the local SPD, per the survey team request, confirmation was provided on 09/23/21.
1. Regarding Resident 4: Incident reports/investigations dated 8/19, 9/3, 9/9 and 9/14 indicated staff completed approximate 2 hour safety checks but had not completed hourly safety checks, as directed by the service plan. Administrator self- reported these 4 incidents to APS on 09.22.2021. Documentation was provided to the surveyor on 9.23.2021.
Resident 3' s injuries of unknown cause were monitored through alert charting but incident reports were not completed. These injuries of unknown cause were reported to APS on 9.23.2021 and email confirmation was provided to the surveyor.
2. Documented training was conducted with staff and the LPN/ Memory Care Coordinator (Administrator) on the following topics: Abuse Investigation, reporting and documentation training, Fall Investigation training, and Root Cause Analysis for falls and/or abuse investigations on 10.15.2021. Documented training also performed with staff to thoroughly read and follow service plans, including the importance. Follow up inservice will be done within compliance date. Staff will complete an incident report for all injuries of unknown cause so that a thorough investigation can be completed and abuse can be ruled out. Administrator and/or Designee will determine whether staff followed service plan appropriately when completing an investigation for all incident reports and report to local SPD office when abuse or neglect can not be reasonably ruled out.
3. and 4. Administrator will be responsible to ensure that staff are completing incident reports for any injuries of unknown cause and intervene appropriately as needed. Administrator and/or Designee will monitor and evaluate this through alert charting and then at time of chart review when performing quarterly evaluation. Administrator will be responsible to ensure that all investigations are done thoroughly and if abuse or neglect can not be reasonably ruled out then incident will be reported to local SPD office.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The kitchen was observed in an unsanitary condition which posed a situation that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:
1. Observation of the kitchen on 9/20/21 at 2 pm revealed the following areas in need of cleaning:
* Floors throughout the kitchen and coved moldings along the perimeter had extensive build-up of black matter and grease, often obscuring the flooring below;
* Legs of tables, shelves, rolling carts, appliances at floor level had a build-up of dense black matter;
* Stove burners, grill and side of stove had a dense build-up of grease and food debris/splatters/spills. The floor near the stove had an extensive accumulation of food debris, grease and thick, black build-up of trash behind;
* Extensive build-up of black matter/dirt/food debris was observed on floor of the dry storage room. Open metal shelving had areas where rust had developed.
* Ceiling tiles, light fixtures, vents and fans above food preparation and storage areas had build up of black matter, food splatters and dangling gray matter;
* An uncovered open vent above the entry to the walk-in cooler showed a very thick, heavy build up of black matter;
* There was water on the floor behind the ice machine with an area of dense black matter and a build-up of brown matter/food splatters was on the interior seal next to the ice;
* Storage containers of flour and sugar were stored in close proximity to areas where rust had developed on the ice machine;
* Multiple buckets used for sanitization solution were observed to have build up of black/brown matter on their interior;
* Multiple food and dish storage carts had brown/black matter, spills/splatter and food debris on their surfaces;
* The meat slicer and industrial mixer had extensive splatter of food matter on their surfaces;
* Cabinets doors, drawers and shelves and free standing shelves had build-up of food splatters and debris particles;
* Floors in the walk-in cooler and freezer had dense accumulation of trash, black matter and debris;
* There was a puddle of liquid on the floor of the walk-in cooler;
* Shelves in the walk-in cooler had build-up of food splatters and drips;
* Walls, doors, light switches and thermostats throughout the kitchen had build up of food splatters/spills/smears/smudges and gray/brown matter;
* Extensive build up of black matter was noted on the pipes, walls, gauges, drain and flooring behind/underneath the dish machine and under/behind three compartment sink; and
* The approximately one foot high mop sink in the utility closet had dense build up of black matter and debris in the sink and on the walls behind it.
2. The following areas were noted to be needing repair:
* Disintegrating and missing ceiling tiles with exposed ventilation pipes were observed above food storage and preparation areas in the kitchen and adjacent coffee/juice room;
* The ice machine had areas where rust had developed which were near the opening to the machine;
* Two bolts were observed to be missing from the dish machine;
* The coved flooring had pulled away from the exterior of the walk-in cooler exposing a gap where dirt/debris and black matter had accumulated;
* Doors and walls throughout the kitchen showed diffuse areas with chipped paint; walls additionally had gouges and holes with exposed drywall visible.
* Rust had developed on the floor of the walk-in cooler;
* Vinyl-covered shelves in the walk-in cooler had areas where the vinyl was missing and rust had developed;
* The caulk behind the hand washing sink by walk-in had pulled away from wall and black matter had developed;
* The caulk behind the triple sink and the hand washing sink near the entrance had areas with missing caulk and discolored areas.
* The caulk on the pipes behind the dish machine had black matter that had developed;
* The fire sprinkler head in the walk-in cooler was dislodged from the ceiling and white matter from the area above was dangling down into the food storage area and was dripping;
* Flooring throughout the kitchen showed multiple cracks and areas where the flooring was worn through to the cement below. The vinyl flooring was not continuous under appliances and steam table with exposed concrete visible;
* The industrial mixer had areas where paint had peeled and the covering to the motor was ajar;
* The seal on the memory care refrigerator door was broken and the door did not stay closed; and
* An approximately one foot area of the coved floor molding in the memory care kitchen was broken off.
3. Possible rodent droppings were observed in one of the corners of the dry storage room.
At approximately 2:45 pm, the observations were discussed with the Team Coordinator of the survey team. At that time, she toured the kitchen and confirmed the findings.
At 3:30 pm, the surveyor contacted the Community Based Care Supervisor and shared concerns about the unsanitary condition of the kitchen. A decision was made to close the kitchen until the unsanitary condition was rectified.
At 4:20 pm, the surveyor, Team Coordinator and Staff 1 toured the kitchen. Staff 1 acknowledged the above areas needed to be cleaned and repaired. Staff 1 said the kitchen had recently had a difficult time keeping staff and that the corporate office had recently toured the facility to identify items that needed to be replaced. She also reported that a recent visit from a pest control company confirmed the kitchen had mice and had treated the area. She provided documentation from the pest control company.
The facility submitted a plan of correction on 09/20/21 at 5:15 pm which was approved by the survey team the same day.
On 9/23/21 at 2:45 pm, the facility requested a re-inspection of the kitchen. The surveyor observed the kitchen and found the unsanitary conditions had been corrected. The facility was informed they could re-open the kitchen and the situation was abated.
1. Several examples were given in the summary statement of deficiencies for the kitchen. A plan of correction was submitted and approved on 09.20.2021. All items listed in example 1 were cleaned by Servpro on 09.21.2021, by our staff on 09.22.2021, our staff on 09.23.2021, by Servpro again on 10.05.2021, and 10.11.2021 by Dor to Door Cleaning Services.
The following actions were taken in correlation to items listed in Example 1:
*Open metal shelving in dry storage room were replaced.
*All vents were cleaned and covered prior to exit of survey team. One vent being replaced.
*Stove burners, grill, and side of stove were all cleaned. Stove burners will be replaced.
*Ice machine removed and replacement ordered.
*Closed storage containers were emptied. Containers were cleaned and replaced with new product and labeled, placed in dry storage area.
*Immediate Sanitization Training and deep cleaning training was provided to staff related to carts and overall cleaning of surfaces and areas on 9.22.2021. Follow up sanitization training was done on 10.14.2021.
*Utility carts were thoroughly cleaned and training completed on 9.22.2021 as mentioned above. Some utility carts were discarded and replaced. Stainless steel carts have been purchased.
*Meat slicer and industrial mixer were not in use and were discarded prior to survey team's exit. Both items were purchased and are on order.
*Area of stainless steel shelving system and cabinetry needs further repair and requires replacement. Plan in process.
*Walk-in cooler and freezer floors were cleaned as stated above. Areas need replacement, quote received for whole unit replacement, and plan in process.
*Leak identified in walk in cooler to be from condensation. Leak was fixed on 09.23.2021 prior to survey team's exit. Electrician performed further resolution and replaced lighting on 09.28.2021.
*Shelving in cooler was cleaned per dates listed above. Plan in process to replace shelving system.
*Plan in process to replace all flooring, walls, and floor drains throughout kitchen. These areas have been cleaned per cleaning dates listed above.
*Plan in process to replace mop sink. This utility area was cleaned per dates listed above.
Several examples were listed in Example 2 that were noted to be needing repair. The following actions have been taken (some actions noted in example 1):
*All ceiling tiles replaced and all ventilation piping is covered in ceiling. Completed by 09.23.2021 and shown to survey team.
*Ecolab came onsite and replaced 2 bolts on dishwasher. Shown to survey team prior to exit.
*Merrill Gardens plan in process to replace flooring throughout kitchen and walk in cooler and freezer unit, including shelving system.
*Chipped paint repaired. Plan in process to replace doors and walls. Exposed drywall areas have been temporarily covered until walls are replaced.
*Caulking was cleaned and replaced in affected areas. Shown to survey team prior to exit.
*Fire sprinkler, located in walk-in cooler not directly above food, was repaired and shown to survey team prior to exit. Leak details above.
*Memory Care Kitchen fridge replaced prior to survey team's exit.
*Coved flooring molding in memory care kitchen repair: quote has been received and plan to repair as soon as possible but no later than 11.22.2021.
Example 3: Rodent droppings observed. As stated in summary of deficiencies, recent visit from pest control company (Orkin) confirmed area had been treated, monitored, and plans to provide ongoing oversight until resolved as documentation was provided.
2., 3., and 4. The dining services director and the administrator will be responsible for ensuring this rule violation is corrected and ongoing compliance. The dining services director will ensure that the cleaning schedule is completed on a weekly basis with daily oversight from the cooks. The administrator or designee will walk through and evaluate on a weekly basis, intervening where necessary. A cleaning company has been hired to come in every two weeks to thoroughly clean the kitchen and maintain until kitchen remodel is completed. Merrill Gardens has plan in process to replace several items referenced throughout this plan of correction in a "remodel". Due to several factors including delays of delivery/shipments and various shortages beyond our control, Merrill Gardens requests extension to complete this remodel. If obstacles arise of which is beyond our control, explanation will be given and further extension will be requested.
A registered dietician performed a kitchen consultation and audit on 10.16.2021. The results will be shared with APD Safety, Oversight & Quality of Oregon DHS, progress reports will be reported to them until compliance is achieved. A registered dietician from Crandall will continue to audit quarterly.
Due to the facility requesting an extension, the plan of correction date was extended to 03/31/22 for the facility kitchen areas. The facility remains out of compliance.
Please see our plan of correction approved on 10.19.2021 for C 240 with extension approval.
Update to items provided and approved by DHS on 1.31.22 for extension through 3.31.2022:
1.*Stove burners, grill, and side of stove were all cleaned. Stove burners will be replaced.- pending replacement.
2.*Meat slicer and industrial mixer were not in use and were discarded prior to survey team's exit. Both items were purchased and are on order. Several delays in shipping occurred. Meat slicer was cancelled as we do not need. Mixer is still on it's way since October. We should be in compliance here because old equipment was removed.
3.*Area of stainless steel shelving system and cabinetry needs further repair and requires replacement. Plan in process - estimate approved and are waiting on vendor to invoice to pay 50% down.
4.*Walk-in cooler and freezer floors were cleaned as stated above. Areas need replacement, quote received for whole unit replacement, and plan in process.- paid 50% deposit as required by vendor and are awaiting on manufacturer. Manufacturer required 12 weeks to begin installation. When we last checked in with manufacturer, they stated they are drawing the plans.
5.*Shelving in cooler was cleaned per dates listed above. Plan in process to replace shelving system in cooler.- paid 50% down and are awaiting manufacturer see item 4 above. lead time 12 weeks to installation.
6.*Plan in process to replace all flooring, walls, and floor drains throughout kitchen. These areas have been cleaned per cleaning dates listed above. - this has to be done after the cooler as it is connected to the ceiling and walls.
7.*Plan in process to replace mop sink. This utility area was cleaned per dates listed above.- Plan in process - estimate approved and are waiting on vendor to invoice to pay 50% down.
8.*Merrill Gardens plan in process to replace flooring throughout kitchen and walk in cooler and freezer unit, including shelving system.- 50% paid for walk in cooler and freezer as required, awaiting manufacturer, and have to wait for this to be done until flooring can be done.
9.*Chipped paint repaired. Plan in process to replace doors and walls. Exposed drywall areas have been temporarily covered until walls are replaced. - Walls will get done after walk in cooler is done as walk in cooler is connected to walls as stated above. Doors have been paid for and are waiting on manufacturer as they have been delayed based on supplies.
Merrill Gardens has plan in process to replace several items referenced throughout this plan of correction in a "remodel". Due to several factors including delays of delivery/shipments and various shortages beyond our control, Merrill Gardens requests a consideration to extend the completion of compliance to complete this remodel. Based on the manufacturer's required lead time of 12 weeks, we are asking for consideration to be given to achieve replacement of the items listed above through 3.31.2022.
Update 3.25.2022: Please see attached letter from Bargreen Ellginson of whom is performing this remodel. Due to obstacles outside of our control as Bargreen described, we are asking for an extension through 07.15.2022.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations included all required components for 1 of 1 sampled resident (# 4) whose move-in evaluation was reviewed. Findings include but are not limited to:
Resident 4 was admitted to the facility in June 2021, with diagnoses including rheumatoid arthritis and dementia.
Resident 4's move-in evaluation was reviewed during the survey. The evaluation lacked information related to the following required components:
* Effective non drug interventions for behaviors;
* Decision making ability;
* Pain including non-drug interventions;
* Emergency evacuation needs;
* Environmental factors which impact behaviors; and
* Personality and how the person copes with change.
The need to ensure move-in evaluations included information for all required elements was discussed with Staff 1 (ED) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. They acknowledged the findings.
1. These missing components have been evaluated and documented for Resident 4.
2. A specific resident evaluation form is used to do all move in evaluations. This form has been updated to include effective non drug interventions for
behaviors, decision making ability, pain including non-drug interventions, emergency evacuation needs, environmental factors which impact behaviors, and personality and how the person copes with change. Documented training has been completed on 10.18.2021.
3. and 4. Administrator or Designee to ensure the designee(s) completing the move in evaluation completes all components of the evaluation form.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and provided clear direction to staff for 3 of 4 sampled residents (#s 2, 3 and 4) and were updated within 30 days of admission as appropriate for 1 of 1 sampled resident (#3) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in January 2019 with diagnoses including dementia.
Review of Resident 2's 06/25/21 service plan, interviews with staff and interview and observations of the resident revealed the resident's service plan was not reflective of the resident's current status and care needs in the following areas:
* Difficulty/confusion managing utensils;
* Use of 4 WW; and
* Assistance with dressing and grooming.
Resident 2 was observed on 09/21/21 during the breakfast meal to pick fruit up with his/her fingers and put it on his/her fork and during the lunch meal that day attempted to pick up potato chips with a fork. The resident did not attempt to eat the food from the fork.
During and interview with Staff 12 (CG) on 09/21/21, he reported the resident does better with food s/he can pick up with his/her hands.
The need to ensure service plans were reflective of the resident's current status and care needs was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. They acknowledged the findings.
2. Resident 3 was admitted to the facility in July 2021 with diagnoses including dementia.
Review of the 07/15/21 service plan, interviews with caregiving staff and interviews with and observations of the resident revealed the service plan had not been updated as appropriate within 30 days of admission, was not reflective of the resident's current status and care needs and did not provide clear direction to staff in the following areas:
* Skin tears and scabs;
* Frequency of staff assist for emptying catheter bag;
* Level of assistance provided for ambulation and transfers; and
* Hearing aids.
The need to ensure service plans were reflective of the resident's current status and provided clear instruction to staff was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. No further information was provided at that time.
3. Resident 4 was admitted to the facility in June 2021, with diagnoses including rheumatoid arthritis, dementia and diabetes.
Clinical records including the current and temporary service plans, progress notes dated 06/23/21 - 09/19/21, physician orders and communications and incident reports were reviewed during survey and indicated Resident's 4's current service plans were not reflective and/or did not provide clear direction to staff in the following care areas:
* The resident's history of poor meal intake;
* Orders for a nutritional supplement; and
* Fall prevention and safety checks.
The need to ensure service plans were reflective of the resident's care needs and provided clear direction to staff was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. They acknowledged the findings.
1. Resident 2, 3, 4's service plan were updated based on current needs.
2. Staff training completed re: reviewing service plans and reporting changes of condition. Administrator and LN will provide re-training to staff as needed and update careplans to reflect current needs.
3. and 4. Administrator and LN will monitor process of how changes are communicated by ensuring staff are utilizing this system per community procedures quarterly.
There are no detail notes for this visit.
3. Resident 3 was admitted to the facility in July 2021 with diagnoses including urinary retention and placement of a suprapubic catheter.
Resident 3's 07/15/21 move-in evaluation and service plan, progress notes dated 07/15/21 through 09/20/21, incident investigations and physician communications were reviewed.
a. Resident 3's 07/15/21 service plan identified the resident as a high fall risk and identified fall prevention interventions. Review of progress notes and fall investigations revealed the resident experienced seven non-injury falls between 07/16/21 and 08/4/21.
On 08/11/21, Resident 3 called staff to his/her room to inform them s/he had fallen in the bathroom. No injuries were noted at the time of the injury. On 08/16/21, during subsequent monitoring of the resident following the fall, a "large bruise to (his/her) left hip and thigh" was noted. The 08/16/21 investigation related to the bruise attributed it to the resident's fall on 08/11/21.
Resident 3 experienced three additional non-injury falls on 08/23/21, 08/26/21 and 09/2/21.
On 09/10/21, Resident 3 experienced a fall with injuries identified as abrasions to his/her right forearm and right shin.
There was no documented evidence the facility monitored the effectiveness of fall prevention interventions identified on the service plan after the initial fall or following subsequent falls or determined and documented new interventions to prevent future falls. The resident continued to fall and experienced the injuries noted above.
During an interview with Resident 3 on 09/22/21 at 11:15 am, multiple scabs were observed on both lower extremities below the level of the resident's shorts.
The need to ensure fall prevention interventions were monitored for effectiveness when the resident fell and that actions and interventions were determined and documented to prevent further falls, communicated to staff on all shifts and added to the service plan was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator). No further documentation was provided.
b. On 07/15/21, Resident 3 was placed on alert charting for placement of a suprapubic catheter on 07/02/21.
Progress notes reviewed between 07/16/21 and 07/25/21 included the following comments related to the catheter:
* 07/16/21: "Moderate amount of thick odorous yellow drainage";
* 07/19/21: "Yellow/green discharge. Split bandage has some noted blood";
* 07/20/21: "Suprapubic cath site is red/pink with noted yellow/green drainage"
* 07/22/21: "Moderate amount of thick yellow drainage from cath with a scant amount of blood"
* 07/23/21: "Moderate amount of thick yellow drainage from cath with a scant amount of blood" and
* 07/24/21: "Moderate amount of thick yellow drainage from cath with a scant amount of blood"
In an RN progress note on 07/26/21, she noted "thick whitish yellow drainage present ...redness noted at the stoma ...slight odor". The RN indicated she thought the resident should be seen by the urologist.
Review of Resident 3's urologist visit summary dated 07/27/21 indicated the suprapubic catheter site was "concerning for infection, erethyma and purulent drainage". Antibiotics were ordered to treat the resident's condition.
There was no documented evidence the facility determined and documented what additional actions and interventions were needed between 07/16/21 and 07/26/21 when the wound showed possible signs of infection.
c. Review of Resident 3's 07/15/21 through 9/20/21 progress notes revealed the resident experienced the following short-term changes of condition related to skin injuries for which the facility failed to determine and document what actions and interventions were needed for the resident, communicate them to staff on all shifts, update the service plan and monitor the changes at least weekly through resolution:
* Skin tear left forearm;
* "Large sticky note and small sticky note sized red/yellow abrasion on the back of his left bicep";
* Two scabs on left upper arm;
* Skin tear left elbow; and
* Thigh/ hip bruise.
The need to monitor residents related to their evaluated needs, determine and document what actions and interventions were necessary for the resident, communicate them to staff on all shifts and update the service plan when the experienced short-term changes of condition related to skin and suprapubic catheter infection was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator on 09/22/21 and 09/23/21. They acknowledged the findings.
4. Resident 2 was admitted to the facility in January 2019 with diagnoses including dementia.
Review of Resident 2's 06/25/21 service plan and quarterly evaluation, 06/23/21 through 09/18/21 progress notes and fall investigations, and interviews with staff revealed the following:
* Resident 2's 06/25/21 service plan and quarterly evaluation identified the resident to have a history of falls, be at high risk for future falls and identified fall prevention interventions.
* Progress notes and incident investigations identified that Resident 2 experienced non-injury falls on 08/30/21 and 09/1/21.
There was no documented evidence the facility monitored the effectiveness of existing fall prevention interventions, determined and documented what actions and interventions were necessary for the resident, communicated them to staff on all shifts and updated the service plan when the resident experienced the falls.
The failure of the facility to monitor the effectiveness of fall prevention interventions, determine and document what actions and interventions were needed for the resident, communicate them to staff on all shifts and update the service plan was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/23/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined when residents experienced short term changes of condition, the facility failed to ensure resident specific actions or interventions were determined, documented, communicated to staff and monitored for effectiveness and ensure each resident was monitored consistent with his or her evaluated needs and service plan for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced changes of condition requiring interventions and monitoring. Resident 3 and Resident 4 experienced multiple falls with injury. Findings include, but are not limited to:
1. Resident 4 was admitted to the facility in June 2021, with diagnoses including rheumatoid arthritis and dementia.
Resident 4's evaluations and service plans dated 06/24/21, 08/2/21 and 8/27/21 indicated the resident displayed memory loss, had a history of falls, required staff assistance for ADLs (transfers, toileting grooming, dressing) and instructed staff to provide hourly "safety checks when in bed".
Clinical records including evaluations, service plans and temporary service plans, incident reports, hospital records and progress notes were reviewed during survey.
a. Clinical records and interviews with staff revealed the facility failed to determine, document, and monitor fall prevention interventions when Resident 4 experienced the following unwitnessed falls:
* 07/17/21- Staff found the resident sitting on the floor in the bathroom of his/her apartment;
* 07/25/21- Staff found the resident leaning on his/her right side with his/her back against the bed;
* 08/03/21- Staff found the resident sitting on the floor near his/her bed;
* 08/08/21- The resident fell during toileting. The caregiver "was cleaning up the resident's apartment and did not witness the actual fall." The report stated on 8/9/21 the resident had complaints of pain of the right wrist pain and was taken to urgent care clinic and diagnosed with a wrist sprain;
* 08/14/21- Staff found the resident sitting on the floor near his/her bed;
* 08/19/21- Staff found the resident lying on his/her left side next to his/her bed;
* 08/27/21- Staff found the resident kneeling next to his/her bed, leaning on a wheelchair;
* 09/01/21- Staff found the resident sitting on the floor near the bathroom with his/her back against a wheelchair;
* 09/03/21- Staff found the resident sitting on the floor next to his/her bed with "blood dripping down the resident's face and on the floor". The resident was sent to the ER and returned to the facility with five staples to a laceration on the back of the head; and
* 09/09/21- Staff found the resident at 4:00 am, lying on the floor near his/her bed.
On 09/09/21, staff found the resident sitting on the floor in the bathroom of another resident's room at 1:13 pm. Resident 4 was sent to the ER for evaluation and returned to the facility with a diagnosis of left clavicle fracture. Multiple fall interventions were implemented upon the resident's return from the hospital.
Resident 4 was observed during the survey, to require staff assistance with transfers, mobility and toileting.
The facility failed to ensure Resident 4 was monitored consistent with his/her evaluated and serviced planned needs related to fall risk and safety checks. Additionally, the facility failed to determine, document and monitor fall prevention interventions when Resident 4 experienced repeated unwitnessed falls. Resident 4 continued to experience unwitnessed falls resulting in injuries which required medical treatment at the hospital and urgent care clinic.
b. Progress notes on 07/30/21 stated Resident 4 returned to the facility following a hospitalization related to diagnosis of "encephalopathy with med changes". Hospital records dated 07/28/21 indicated Resident 4 was hospitalized related to acute encephalopathy, acute cystitis and functional gait abnormality.
Alert charting was initiated by the facility upon the resident's return but did not provide clear direction to staff as to what staff should monitor related to resident specific medication changes and diagnoses of acute encephalopathy, acute cystitis and functional gait abnormality.
The need to ensure, when residents experienced short term changes of condition, resident specific actions or interventions were determined, documented, communicated to staff and monitored for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/21/21. They acknowledged the findings.
2. Resident 1 was admitted to the facility in June 2018, with a diagnosis including dementia.
Clinical records including progress notes 08/16/21 - 09/19/21, current service plans and incident reports indicated the following:
Resident 1 was dependent on staff assistance for most ADLS including transfers, wheelchair mobility, incontinent care, dressing and grooming.
An incident report dated 09/02/21, stated staff discovered Resident 1 in bed with a skin tear on the right elbow. The report stated the facility completed an investigation and concluded Resident 1's mattress often shifted position, exposing the metal bed frame and the resident bumped his/her arm resulting in the skin tear.
There was no documented evidence the facility determined necessary interventions to address the determined cause of the skin tear.
The need to ensure, when residents experienced short term changes of condition, resident specific actions or interventions were determined, documented, communicated to staff and monitored for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/21/21. They acknowledged the findings.
1. Resident 4: Staff monitored Resident 4 throughout alert charting after each fall mentioned in the survey report. On 09/09/2021, multiple fall interventions were implemented upon the resident's return from the hospital. Thereafter, resident has been monitored and interventions have been evaluated and changed as needed.
Resident 1: Interventions were documented through service plan on 09.24.2021 to address the determined cause of the skin tear.
Resident 3: Fall risk, skin breakdown interventions were reviewed. Updated service plan.
Resident 2: Reviewed fall risk interventions and updated service plan.
2. The community will monitor residents who experience short term change of conditions, implement interventions, updating service plan as needed. Staff training performed on 10.15.2021. Follow up training will be completed within compliance date.
3. and 4. LN and/or Designee to review upon incident investigation, change of condition, and quarterly evaluation and service plan update. LN and/or designee to review upon incident investigation, change of condition, quarterly evaluation and service plan update.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 3 sampled residents (#3) who received services from an outside provider. Findings include, but are not limited to:
Resident 3 was admitted to the facility in July 2021 with diagnoses including urinary retention and had a suprapubic catheter.
The resident's 07/15/21 through 09/20/21 progress notes and outside provider visit summaries were reviewed.
In a 07/27/21 visit summary, the resident's urologist indicated the "suprapubic catheter site concerning for infection, erythema, and purulent drainage" and to "keep follow-up (appointment) on 07/30/21."
During an interview with Staff 2 (LPN/Memory Care Coordinator) on 09/22/21, she reported she did not have documentation from the follow up visit.
The need to ensure the facility coordinates care with outside providers in order to ensure continuity of care was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. They acknowledged the findings.
1. Administrator requested documentation and received on 10.05.2021.
2. Communication to be given in writing to all responsible parties or designees to state that we must receive all outside provider visit summaries to ensure continuity of care.
3. and 4. Administrator will review appointment schedules quarterly and ensure visit summaries from outside providers have been received.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure the physician was notified when a resident refused consent to an order for 1 of 1 sampled resident (#1) who had documented medication refusals. Findings include but are not limited to:
Resident 1 was admitted to the facility in June 2018 with diagnoses including dementia, major depressive disorder, hypothyroid, hypertension and edema.
Resident 1's current physician orders and MARs dated 07/01/21 - 09/19/21 were reviewed and showed the resident refused the following medications on numerous occasions during the dates reviewed:
*Memantine (for dementia);
*Metoprolol Tartrate (for blood pressure);
*Mucinex ER (for congestion);
*Olanzapine (for major depressive disorder);
*Sertraline (for major depressive disorder);
*Cranberry (for UTI prevention);
*Furosemide (for hypertension);
*Levothyroxine (for hypothyroidism); and
*Potassium (for supplement).
There was no documented evidence the facility notified the physician of the refusals.
The need to ensure the physician was notified if a resident refused consent to an order was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. They acknowledged the findings. No further documentation was provided.
1. Resident 1's Provider was notified of all refusals. Received order to notify Provider of refusals on 09.30.2021.
2. Staff training completed re: notify Provider of medication refusals unless otherwise directed by Provider order/preference.
3. and 4. LN will evaluate medication administration records monthly for refusals.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an accurate Medication Administration Record (MAR) was maintained for all medications administered by the facility and included resident specific parameters and instructions for PRN medications for 1 of 4 sampled residents (# 4) whose MARS were reviewed. Findings include but are not limited to:
Resident 4 was admitted to the facility in June 2021 with a diagnoses including dementia.
Resident 4's physician orders and MARs dated 07/01/21 - 09/19/21 were reviewed and indicated the following:
On 07/05/21 the facility received an order to administer a nutritional supplement drink three times a day as needed related to the resident's poor meal intake.
The MARs did not include resident specific parameters to instruct staff as to when staff should administer the drink to the resident.
The need to ensure an accurate MAR was maintained for all medications administered by the facility and included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. They acknowledged the findings.
1. Received clarification for nutritional supplement order from PRN to twice daily routine.
2. All medication administration records will be reviewed by compliance date 11.22.2021 to ensure accuracy is maintained for all medications administered by the facility, including resident specific parameters and instructions for PRN medications. Staff training to ensure that appropriate parameters are given for each applicable PRN physician order.
3. and 4. LN will review quarterly to ensure that PRN physican orders have appropriate parameters.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behavior had clear, written, resident-specific parameters and reasons for use for 1 of 1 sampled resident (#2) whose psychotropic medications were reviewed. Findings include, but are not limited to:
Resident 2 was admitted in January 2019 with diagnoses including dementia and was identified during the acuity interview to receive hospice services.
Review of Resident 2's 09/1/21 through 09/20/21 MAR and 04/17/21 physician orders revealed the following:
* Halperidol was ordered for delirium. Instructions on the MAR indicated evidence of delirium included: "hitting, kicking attempts to bite, pinching, yelling, cursing, throwing items".
* Lorazepam was ordered for anxiety. Instructions on the MAR indicated evidence of anxiety included: "hitting, yelling, crying, shaking, pacing, stomach upset".
The MAR lacked clear parameters and reasons for use to enable staff to distinguish anxiety from delirium to select the appropriate medication.
The need to ensure PRN psychotropic medications used to treat a resident's behavior had clear, written, resident-specific parameters and reasons for use was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. They acknowledged the findings.
1. These two orders were updated to include clear, written resident-specific parameters and reasons for use to distinguish anxiety from delirium to select the appropriate medication.
2. All medication administration records will be reviewed by 11.22.2021 to ensure any PRN psychotropic medications used to treat a resident's behavior have resident-specific parameters and reasons for use. Staff training to ensure resident specific parameters and reasons for use are given for each applicable PRN psychotropic order.
3. and 4. LN will review MARs quarterly to ensure that all PRN psychotropic orders have clear, written resident specific parameters and reasons for use.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC). Findings include, but are not limited to:
Fire drill records for March through August 2021, were reviewed during survey.
The following required components were not consistently documented in fire drill records:
* The escape route used;
* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time period needed; and
* Number of occupants evacuated.
The need to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC) was discussed with Staff 1 (Executive Director) on 09/23/21. She acknowledged the findings. No further documentation was provided.
1. Fire Drill was completed on 10.08.2021 to include missing components mentioned.
2. Documented training completed with staff to ensure all components of the Fire Drill form are completed at time of drill.
3. and 4. Fire Drills will be turned into Administrator to ensure completion of corrections as Administator and Maintenance Director will be responsible to ensure ongoing compliance.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the general exterior of the building was maintained in good repair and the outdoor perimeter fencing was secured to prevent exit. Findings include, but are not limited to:
The exterior of the facility was toured on 09/21/21. The following was identified:
a. Drop-offs, up to three inches in depth, were observed along the edges of the concrete pathways of the facility's two resident use outdoor courtyards which created a possible tripping hazard for residents. The concrete pathways of the larger external courtyard had areas covered with plant and tree debris creating a possible tripping hazard for residents.
b. Screens were missing or in disrepair on windows of several resident rooms and common use areas. Several of the screens in disrepair had a build up of cobwebs and insects in between the screens and windows.
c. A light fixture in the internal courtyard was not securely attached and was missing the cover.
d. The fencing around the perimeter of the external courtyard had two gates locked with pad locks which could prevent building occupants from exiting in the event of a fire or other emergency. On 09/21/21 Staff 1 (ED) stated the pad locks would be removed for fire safety and the courtyard would remain closed until repairs were made.
The exterior areas of the facility were reviewed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/21/21 and 09/23/21. They acknowledged the areas in need of repair.
1. Concrete pathways were cleared and mulch is scheduled to be applied on 10.22.2021 in drop off areas.
Screens were repaired and/or placed back on resident apartment windows and windows were cleaned prior to surveyors leaving on 09.23.2021.
Light fixture is being repaired contigent on arrival of parts.
Locks: Received exception for locks on gates from DHS Licensing Policy Analyst with plan to unlock in case of emergencies.
2. Maintenance personnel will perform weekly walk throughs, evaluating for repairs and cleaning needs. Staff training to ensure that they report any needed repairs through work orders in which maintenance or housekeeping will respond appropriately to.
3. and 4. This correction will be evaluated by Administrator who will review such items on a monthly basis and will ensure ongoing compliance and corrections are completed.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were maintained in clean and in good repair. Findings include, but are not limited to:
The facility was toured on 09/21/21. The following was identified:
a. Doors and door frames had areas of chipped, peeling or gouged paint in the following locations:
*The door leading from the living room to the corridor to resident rooms;
*An office door located in the corridor between the dining and living rooms; and
*Resident rooms #s 15, 17, 18, 20 and 21.
b. The overhead light fixtures in a resident use activity room had a buildup of insect debris.
The areas in need of cleaning and/or repair were reviewed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/23/21. They acknowledged the findings.
1. All paint of doors and door frames in mentioned affected areas have been fixed with touch up paint. The overhead light fixture in a resident use activity room was cleaned.
2. Maintenance personnel will perform weekly walk throughs, touching up paint and cleaning lighting as needed. Staff training to ensure that they report any chipped paint, light debris build up, or any other needed repairs through work orders in which maintenance will receive and respond appropriately to.
3. and 4. This correction will be evaluated by Administrator who will review such items on a monthly basis and will ensure ongoing compliance and corrections are completed.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure a manually operated emergency call system was provided in each toilet and bathing facility used by residents and visitors and an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exited the building. Findings include but are not limited to:
The facility was toured on 09/21/21. The following was identified:
a. Common use bathrooms were not equipped with a manually operated emergency call system.
b. The doors leading to the internal courtyard were not equipped with an exit door alarm or other acceptable system to alert staff staff when residents exited the building.
The need to ensure a manually operated emergency call system was provided in each toilet and bathing facility used by residents and visitors and an exit door alarm or other acceptable system was provided to alert staff when residents exited the building was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/23/21. They acknowledged the findings.
1. Emergency call system pull cords have been ordered for common use bathrooms.
Exit door alarms have been ordered for internal courtyard exit doors.
2. Equipment has been ordered for permanent placement so that this violation will not happen again.
3. and 4. These areas will be evaluated by the staff who are monitoring these pull cords and alarms through resident use. Staff will report any future repairs through work order. Maintenance Director and Administrator will be responsible for ongoing compliance and completion of corrections.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C 150, C 231, C 240, C 420, C 510, C 513 and C 555.
Refer to plan of correction for C 150, C 231, C 240, C 420, C 510, C 513, C 555.
Based on interview and record review, it was determined the facility failed to provide health care services in accordance with OARs 411 Division 54 for Assisted Living and Residential Care Facilities. Findings include, but are not limited to:
Refer to C 240.
See POC for C 240.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly-hired staff (#s 13 and 14) completed all required pre-service dementia training and 30-day competency demonstrations. Findings include, but are not limited to:
Staff 13 (CG), hired 06/29/21, and Staff 14 (CG), hired 06/15/21, lacked documented evidence of completion of the following pre-service orientation training topics:
* 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 persons with dementia in meaningful activities;
* Specific aspects of dementia care and ensure safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; and
* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan.
Staff 13 and Staff 14 lacked documentation of competency within 30 days of the following:
* 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; and
* Conditions that require assessment, treatment, observation and reporting.
The need to ensure newly-hired staff completed all required pre-service dementia training before providing personal care or other services and demonstrated competency in all required areas was discussed with Staff 1 (Executive Director) on 09/23/21. She acknowledged the findings.
1. Obtained Staff 13's "Pre-Service Dementia Care Training for Direct Care Staff" Certificate from Oregon Care Partners dated 02.15.2020 and updated file. Staff 14 completed their "Pre-Service Dementia Care Training for Direct Care Staff" Certification through Oregon Care Partners on 09.26.2021.
Staff 13 and Staff 14 completed their competencies, through evaluation and demonstration, immediately prior to providing any further direct care.
2. Community will ensure that documentation is obtained for competency in which is evaluated and demonstrated within 30 days of hire for all care staff.
3. and 4. Administrator will ensure that this documentation is complete and competency is demonstrated and evaluated within 30 days of hire for all new care staff. Administrator will ensure ongoing compliance and corrections are completed by auditing employee files quarterly.
There are no detail notes for this visit.
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, C270, C 290, C 305, C 310 and C 330.
Refer to plan of correction for C 252, C 260, C 270, C 290, C 305, C 310 and C 330.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure each resident's activity evaluation included information which addressed all required MCC components for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity evaluations were reviewed. Findings include, but are not limited to:
Activity evaluations for Resident's 1, 2, 3 and 4 were reviewed during survey. The evaluations lacked information related to the following MCC required components:
*Current abilities and skills;
*Physical abilities and limitations; and
*Adaptations necessary for the resident to participate.
The need to ensure each resident's activity evaluation included information which addressed all required MCC components was discussed with Staff 1 (Executive Director) and Staff 2 (LPN/Memory Care Coordinator) on 09/22/21. They acknowledged the findings.
1. Evaluation was performed to include missing components for Resident 1, 2, 3, and 4. Missing components include: current abilities and skills, physical abilities and limitations; and adaptations necessary for the resident to participate.
2. Evaluation form is being updated to include these missing components.
3. and 4. Administrator will be responsible to ensure ongoing compliance and will evaluate quarterly.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height and outdoor furniture was sufficient in weight to prevent resident injury or aid in elopement. Findings include, but are not limited to:
The facility was toured on 09/21/21. The following was identified:
a. Sections of fencing surrounding the perimeter of the outdoor recreation area did not meet the six foot height requirement. The surveyor measured several sections of the fence. Measurements included 65 inches, 67 inches and 70 inches in height.
b. Several outdoor patio chairs were not sufficient weight and could be easily moved, which created a potential safety and/or elopement risk.
The need to ensure fences surrounding the perimeter of the outdoor recreation were no less than six feet (or 72 inches) in height and outdoor furniture was sufficient weight to prevent resident injury or aid in elopement was discussed with Staff 1 (Executive Director) on 09/21/22. Staff 1 reported the courtyard was rarely used by residents and would remain closed until the repairs could be made.
1. Lattice was added to the fence to ensure outdoor courtyard is no less than six feet in height.
Affected outdoor chairs were removed.
2. In process of receiving quotes to purchase new courtyard seating to replace outdoor seating that was removed.
3. and 4. Administrator will evaluate the two courtyard areas at least monthly and ensure ongoing compliance and intervene as necessary.
There are no detail notes for this visit.