The findings of the change of ownership survey conducted 05/23/22 through 05/24/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the change of ownership survey of 05/24/22, conducted 08/03/22 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.

2. Resident 1 was admitted to the facility in April 2022 with diagnoses including dementia.

Observations of the resident on 05/23/22 and 05/24/22, interviews with staff, and review of the resident's current service plan, dated 05/13/22, were conducted during the survey.

The service plan was not reflective of the resident's status, lacked clear instructions to staff and/or was not followed in the following areas:

* Diet texture;

* Bed sensor alarm; and

* Half side rails on the bed.

The need to ensure service plans were reflective of the resident's current status, provided clear instructions for staff and were followed was discussed with Staff 1 (Administrator) on 05/24/22. She acknowledged the findings.

3. Resident 3 was admitted to the facility in June 2019 with diagnoses including dementia and Parkinson's disease.

Observations of the resident on 05/23/22 and 05/24/22, interviews with staff, and review of the resident's current service plan, dated 03/18/22, were conducted during the survey.

The service plan was not reflective of the resident's status, lacked clear instructions to staff and/or was not followed in the following areas:

* Post surgical hip precautions;

* Modified diet texture and thickened liquids;

* Pad in wheelchair seat;

* Toileting and assistance needed; and

* Transfer status.

The need to ensure service plans were reflective of the resident's current status, provided clear instructions for staff and were followed was discussed with Staff 1 (Administrator) on 05/24/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of current care needs for 3 of 3 sampled residents (#s 1, 2 and 3), failed to provide clear instructions for staff, and were not followed for 2 of 3 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the memory care community in 07/2019, with diagnoses including congestive heart failure, cerebral hemorrhage, and dementia.

Review of Resident 2's service plan, dated 04/14/22 determined the service plan was not reflective of the resident's current status or care needs in the following areas:

* Transfer status;

* Oral/denture care;

* Toileting/incontinence; and

* Anticoagulant status.

The need to ensure service plans were reflective of the resident's current status and care needs was discussed with Staff 1 (Administrator) on 05/24/22. She acknowledged the findings.

Hawthorne House of Salem will implement the following:

1. All residents assessments/evals and service plans will be entered into our new system, Point Click Care utilizing the new assessment/evaluation form that addresses all necessary requirements of the OAR's.

2. Caregivers will be responsible for reviewing, signing and following the care plans. They will also be trained on signing off on the tasks after they've completed them.

3. All staff will receive additional training at the next in-service on how to read the care plans and to notify management if any of the residents care needs have changed.

4. Task Manager will be implemented by July 1st.

5. The Executive Director and/or RN will review and monitor to ensure that the care plans are being reviewed and signed and that the proper care is being delivered. The Executive Director and/or Assistant Executive Director will pull reports to ensure that tasks are signed off on each week.

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.

See POC for C260

Based on observation and interview, it was determined the facility failed to ensure person centered activities were available during waking hours, which included a selection of structured and unstructured activities for the residents in the memory care community. Findings include, but are not limited to:  

Extensive observations were made in the MCC's common areas during the survey. While several residents were encouraged to engage in small activities (such as a puzzle or game), the calendar lacked an organized selection of structured and unstructured daily activities.

During the survey, several residents in the MCC were observed sitting quietly for much of the day. With the exception of the example below, staff did not initiate any group activities.

On 05/24/22 at 9:45 am, several residents were observed in a "ball toss" game, led by a staff member. This was the only organized group activity observed during the survey.

In an interview on 05/23/22 Staff 3 (MT/Universal Worker) stated "We just set up individual activities when we can, but we don't have a designated staff person for that".

On 05/24/22 the need to ensure person centered activities were available during residents' waking hours, which included a selection of structured and unstructured activities was discussed with Staff 1 (Administrator). S/he acknowledged the findings.

Hawthorne House of Salem will implement the following:

1. Each resident's evaluation will include:

(i) Past and current interests;

(ii) Current abilities and skills;

(iii) Emotional and social needs and patterns;

(iv) Physical abilities and limitations;

(v) Adaptations necessary for the resident to participate; and

(vi) Identification of activities for behavioral interventions

2. Activity calendar will specify the time of day that the primary activities will take place. Additional activities, to be done as time allows, and will be listed as well.

3. An individual activity plan will be included in the evaluation.

4. The Universal Caregivers will be responsible for ensuring that the activities are done.

5. The Universal Caregivers will be responsible for completing the activity log and specifying who participated and who refused participation.

6. If the none of the Universal Caregivers are able to lead the activity due to emergency, resident care, etc. they will notify the Executive Director and/or designated supervisor so that they can arrange for coverage and/or perform the activity.

7. All staff will be trained at the next in-service on the new procedures for implementing and tracking activities.

8.The Executive Director will be responsible for reviewing the activity logs weekly.