The findings of the initial licensure survey conducted 03/04/24 through 03/06/24 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 re-visit survey to the initial survey on 03/06/24, conducted 09/09/24 through 09/11/24, 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 and OARs 411 Division 57 for Memory Care Communities.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 03/06/24, conducted 12/30/24 through 01/02/25, 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.

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

MCCMemory 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 third re-visit to the re-licensure survey of 03/06/24, conducted 04/16/25 through 04/17/25, 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.

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 fourth revisit to the re-licensure survey of 03/06/24, conducted 06/23/25 through 06/24/25, 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, OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:

During the first re-visit of the initial survey, conducted 09/09/24 through 09/11/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity, scope and number of citations.

Refer to deficiencies in report.

C 150: OAR 411-054-0025 (1) Facility Administation: Operation:

1. Immidiate actions taken to correct this rule violation are as follows:

a) Effective immediately a mandatory daily clinical meeting is conducted where the Memory Care Administrator and/or designee and clinical team will review all residents care and services to ensure quality of care and services are adequate.

b) Effective immediately Memory Care Administrator and/or designee and/or clinical leadership are attending shift changes with caregiving staff to review daily residents' care and services.

c) Effective immediately, a daily log of clinical meeting outcomes is maintained and reviewed by Memory Care Administrator and/or designee and/or clinical leadership to ensure follow-through on all identified resident care needs.

d) Memory Care Administrator and/or designee will audit all staff records to ensure staff training records meeting the rules.

e) Please refer to other action plan to correct deficiencies in this report.

2.System will be corrected so this violation will not happen again:

a)Ongoing monitoring mentioned in #1 will be documented, and any identified issues will be addressed promptly with corrective actions tracked.

b)Memory Care Administrator and Executive Director will attend 40 hours ALF/RCF Administrator training on 10/14-10/18/2024.

3.The areas needing correction in #1 will be evaluated daily, monthly and quarterly.

4.Memory Care Administrator, Executive Director, Wellness Director and/or designee will be responsible for corrections that are to be completed/maintained.

5. Facility Alleges Compliance: October 26, 2024 except for the following:

a) All Med Techs will undergo mandatory medication administration training via the Relias platform, with a completion deadline of October 15, 2024. This training will cover proper procedures for administering medications, documentation protocols, and strategies for avoiding medication errors. Documentation of completed training will be submitted to the state surveyor no later than October 16, 2024.

b) All Staff will undergo mandatory "Elder Abuse Prevention, Investigation and Reporting" training via the Relias platform with a completion deadline of October 15, 2024. Documentation of completed training will be submitted to the state surveyor no later than October 26, 2024.

c) Nursing team will undergo mandatory Root Cause Analysis training with a completion deadline of October 15, 2024. Documentation of completed training will be submitted to the state surveyor no later than October 26, 2024.

d)Nursing Team, Memory Care Administrator, and Executive Director sign up Nurselearn.com for training on Care Planning, Change of Condition, Physician Orders

e) Chelsea Tudela (Memory Care Administrator), Kenric Thompson (RN) and Tiana Jackson (Executive Director) have enrolled in CBC Nurse Standard Program @Nurselearn

f)Kenric Thompson (Clinical Support Specialist, RN) will attend the Role of the Nurse in CBC @OHCA 10/8-10/10

g) Laurie Polneau, (Wellness Director, RN) is currently in CBC Nurse Enhanced Program Cohort @ Nurselearn

h) Laurie Polneau (Wellness Director, RN) will attend the Role of the Nurse in CBC @OHCA on 12/9-12/12

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

During the third re-visit survey, conducted 04/16/25 through 04/17/25, the quality improvement plan to ensure adequate resident care, services, and satisfaction was found to be ineffective.

Refer to the deficiencies in the report.

C156 - OAR 411-054-0025 (9) - Facility Administration: Quality Improvement

1.What actions will be taken to correct the rule violation for each example/resident?

The facility acknowledges the cited deficiency related to not developing and conducting an ongoing quality improvement plan that evaluates resident services, staff performance, resident outcomes, and resident satisfaction. Immediate corrective actions include:

oImplementing a Memory Care-centered Quality Improvement Plan.

oThe plan will be monitored through regularly scheduled QAPI (Quality Assurance and Performance Improvement) meetings.

oThe QAPI team will review the plan after three months of implementation, and quarterly thereafter to assess effectiveness and make ongoing adjustments.

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

The system will be corrected by:

oEmbedding the quality improvement plan as a standing agenda item in QAPI meetings.

oAssigning clear roles and accountability for data collection, analysis, and follow-up related to resident services, outcomes, and satisfaction.

oIncorporating performance improvement metrics and tracking into regular staff performance reviews and service delivery audits.

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

oThe Quality Improvement Plan will be evaluated monthly for the first three months following implementation, and then quarterly thereafter as part of the ongoing QAPI cycle.

4.Who will be responsible to ensure that the corrections are completed and monitored?

oThe Memory Care Administrator, Wellness Director, Wellness Nurse, Executive Director, and/or designee will be responsible for completing and monitoring the corrective actions.

5.Date facility alleges compliance:

oThe facility alleges compliance by May 17, 2025.

Based on interview and record review, it was determined the facility failed to ensure investigations of resident incidents included all required documentation for 1 of 1 sampled resident (#5) with documented incidents. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 08/2023 with diagnoses including Alzheimer's disease and was identified in the acuity interview as having recent falls.

The resident's 05/10/24 service plan, a facility incident report dated 07/10/24, an investigation dated 07/11/24, and progress notes and short-term observations (STOs) dated 05/13/24 through 09/08/24 were reviewed. Interviews with staff were conducted. The following was identified:

The resident experienced an injury fall on 07/10/24 with "abrasion/bruise/swelling to forehead, skin tear/pain to right knee, right second digit discoloration and 'pins and needles' generalized pain."

The facility investigation of the fall revealed a lack of the following:

* Individuals present at the time of the fall; and

* Administrator review.

Survey requested the 07/10/24 fall be reported to the local SPD, and confirmation was received at 2:26 pm on 09/11/24.

The need to ensure all incidents of abuse or neglect were reported to the local SPD office unless an immediate investigation reasonably ruled out abuse or neglect was discussed with Staff 1 (Executive Director), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24. They acknowledged the findings.

C 231: OAR 411-054-0028 (1-3)

Reporting & Investigation Abuse - Other Action

1.The immediate actions taken to correct this rule violation are as follows:

RESIDENT 5:

a) Incident report for an injury fall on 7/10/2024 for an injury fall with abrassion/bruise/swelling to forehead, skin tear/pain to right knee, right second digit discoloration and "pins and needles" generalized pain has been revised to including individuals present at the time of the fall and review by Memory Care Administrator.

b) 7/10/24 fall was reported to APS on 9/11/2024.

2. To ensure the system will be corrected so this violation will not happen again:

a) All Staff will undergo mandatory "Elder Abuse Prevention, Investigation and Reporting" training via the Relias platform with a completion deadline of October 15, 2024. Documentation of completed training will be submitted to the state surveyor no later than October 16, 2024. This training will cover abuse reporting, staff reporting, facility reporting, law enforcement agency, and injury of unknow cause.

b) All Staff will be undergo mandatory incident investigation training including immediately reporting abuse or suspected abuse to APS or the law enforcement agency and investigation documentation to include time, date, place and individuals present; description of the event as reported; response of staff at the time of the event; follow-up action; and Administrator's review.

c) Incident reports are reviewed at daily clinical stand up meeting.

3. This area will be reviewed on a daily basis at the daily clinical stand-up.

4. The Memory Care Administrator, Wellness Director (RN) and/or designee will be responsible for ensuring the system is corrected and monitored.

5. Faility Alleges Compliance by October 26, 2024.     

3. Resident 9 moved in to the facility in 11/2024 with diagnoses including Alzheimer's disease and tremors. Resident 9 was not interviewable.

During the acuity interview on 12/30/24, the resident was identified as sustaining a "laceration" on his/her "head".

Resident 9's medical records were reviewed and staff were interviewed and the following was identified:

On 12/25/24, a Short Term Observation (STO) for Fall was implemented, directing staff to monitor him/her as, "Resident was seen in front of [his/her] door with blood on [his/her] face, laceration on right upper eyebrow."

On 12/26/24, staff documented, "Resident is on alert for back from hospital/fall, head injury."

There was no documented evidence the facility investigated the incident to rule out abuse or that the incident was reported to the local SPD office.

Survey received documentation that the incident was reported on 12/31/24 at 10:48 am.

The need to ensure all injuries of unknown cause were immediately investigated, and reported to the local SPD office if suspected abuse could not be ruled out was discussed with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN), and Staff 27 (Regional VP of Operations) on 01/02/25 at 12:40 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all incidences of abuse or suspected abuse were immediately reported to the local SPD and promptly completed an investigation with all required components, and/or report an injury of unknown cause to the local SPD office, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, for 3 of 6 sampled residents (#s 1, 7 and 9). This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved in to the facility in 11/2024 with diagnoses including vascular dementia and dysphagia.

The resident's 11/29/24 service plan, incident reports and/or investigations, progress notes and Short Term Observations (STOs) dated 11/01/24 to 12/30/24 were reviewed, and interviews with staff were conducted. The following was identified:

*11/10/24: Resident-to-resident physical contact;

*11/12/24: Resident-to-resident altercation;

*12/02/24: Resident-to-resident physical contact; and

*12/08/24: Provided incorrect diet texture with subsequent difficulty swallowing.

There was no documented evidence the facility had completed an investigation with all required components and or immediately reported the above incidents to the local SPD office. Survey requested the above incidents be reported and verification was received by 01/02/25.

The need to ensure all facility employees immediately reported abuse or suspected abuse to the local SPD and promptly completed an investigation with all required components was reviewed on 01/02/25 at 1:30 pm with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN) and Staff 27 (Regional Vice President of Operations). They acknowledged the findings, and no additional information was provided.

2. Resident 1 moved in to the facility in 11/2023 with diagnoses including Alzheimer's disease and Parkinson's disease.

The resident's 11/18/24 service plan, incident reports and/or investigations, progress notes and Short Term Observations (STOs) dated 10/26/24 to 12/30/24 were reviewed, and interviews with staff were conducted. The following was identified:

*11/03/24: Resident-to-resident altercation;

*12/11/24: Resident-to-resident altercation; and

*12/22/24: Resident-to-resident altercation.

There was no documentation the above incidents were immediately reported to the local SPD office. The 12/11/24 incident was not reported until 12/19/24. There was no documentation an investigation was completed for the incidents on 11/03/24 and 12/22/24. The investigation completed for the 12/11/24 incident did not include all required components, including follow-up and administrator review. Survey requested the incidents on 11/03/24 and 12/22/24 be reported, and verification was received on 12/31/24.

The need to ensure the facility immediately reported abuse or suspected abuse to the local SPD and promptly completed an investigation with all required components was reviewed on 01/02/25 at 1:30 pm with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN) and Staff 27 (Regional Vice President of Operations). They acknowledged the findings, and no additional information was provided.

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

1.What actions will be taken to correct the rule violation for each example/resident?

The facility acknowledges the cited deficiency of not investigating and reporting abuse allegations in a timely manner. The immediate actions taken to correct this rule violation are as follows:

1.APS self-reports were submitted for the following residents:

a.Resident 1 - Reported to APS - 12/31/2024

i.11/03/24: Resident-to-resident altercation;

ii12/11/24: Resident-to-resident altercation; and

iii.12/22/24: Resident-to-resident altercation

b.Resident 7 - Reported to APS - 12/31/2024

i.11/10/24: Resident-to-resident physical contact;

ii.11/12/24: Resident-to-resident altercation;

iii.12/02/24: Resident-to-resident physical contact; and

iv.12/08/24: Provided incorrect diet texture with subsequent difficulty swallowing.

c.Resident 9 - APS report - 12/31/2024

i.12/25/24: Injury of Unknown Cause

2.The service plan for residents involved in resident to resident altercations have been updated and revised to include supervision strategies and behavioral interventions.

3.Care coordination with Hospice nursing and social services implement to help the resident involved with resident to resident physical contact to receive additional support services as needed.

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

All staff will be trained on the following:

1.Recognizing and responding to inappropriate sexual behaviors and timely reporting /escalation of events to leadership

2.Additional training on the importance of adhering to service plans and diet orders

3.Proper documentation practices and the identification of reportable events.

4.Importance of timely and accurate reporting to ensure resident safety and regulatory compliance.

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

a.Incident reports will be reviewed daily during daily stand up meeting to identify events needing investigation and possible regulatory reporting.

b.The Memory Care Administrator, Wellness Director (RN), Wellness Nurse (RN), and/or designee will conduct random audits of progress notes weekly for three months to ensure compliance with this process

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

a.The Memory Care Administrator, Wellness Director (RN), Wellness Nurse (RN) and/or designee will be responsible for ensuring the system is corrected and monitored.

5.Date facility alleges compliance.

a.Facility Alleges Compliance by February 1, 2025.     

Based on interview and record review, it was determined the facility failed to ensure all incidences of abuse or suspected abuse were promptly investigated, included all required components, and necessary measures were taken to protect residents and prevent the reoccurrence of abuse, and/or report to the local SPD office, for 1 of 1 sampled resident (# 13) who had multiple unwitnessed falls resulting in injury. This is a repeat citation. Findings include, but are not limited to:

Resident 13 moved into the memory care facility in 11/2023 with diagnoses including late onset Alzheimer's disease.

Observation of the resident from 04/16/25 to 04/17/25 noted the resident ambulated around the facility without an assistive device with a steady gait.

Following observation and interview, the resident demonstrated difficulty accurately recalling and reporting incidents.

The resident's 02/05/25 service plan indicated the resident was at high fall risk and directed staff to "remind resident to use the call light" or "...the call light is within reach and working."

The resident's 02/05/25 service plan, incident reports and/or investigations, progress notes and Short Term Observations, dated 02/01/25 to 04/16/25, were reviewed, and interviews with staff were conducted. The following was identified:

* 02/09/25: Injury fall, including an abrasion on the chin and a bleeding upper lip;

* 02/27/25: Injury fall, resulting in right wrist pain and bruising around the right eye;

* 03/18/25: Injury fall, causing a bump on the head; and

* 03/24/25: Injury fall, causing an abrasion on the right knee.

There was no documented evidence the facility had completed an investigation with all required components including measures taken to protect the resident and prevent the reoccurrence and/or reported the above incidents to the local SPD office.

Survey requested the above incidents be reported and verification was received by 04/17/25.

The need to ensure all incidences of abuse or suspected abuse were promptly investigated, included all required components, necessary measures were taken to protect residents and prevent the reoccurrence, and/or report to the local SPD office was reviewed on 04/17/25 at 3:20 pm, with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director, RN), Staff 28 (Wellness Nurse, LPN) and Staff 29 (Administrator). They acknowledged the findings.

C231 - OAR 411-054-0028 (1-3): Reporting & Investigating Abuse - Other Action

1.What actions will be taken to correct the rule violation for each example/resident?

The facility acknowledges the cited deficiency regarding failure to investigate abuse incidents in accordance with required components, including implementing appropriate measures to protect residents and prevent recurrence. Immediate corrective actions include:

A. APS self-reports were submitted for the following incidents involving Resident #13:

o2/9/25 - Unwitnessed fall resulting in injury

o2/27/25 - Unwitnessed fall resulting in injury

o3/18/25 - Unwitnessed fall resulting in injury

o3/24/25 - Unwitnessed fall resulting in injury

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

a. All facility staff will complete the "Elder Abuse Prevention, Investigation, and Reporting" training available through Oregon Care Partners (www.oregoncarepartners.com). Staff who do not complete the training by May 23, 2025, will be removed from the schedule until training is completed.

b. Medication Managers have received training on completing incident reports and reporting all incidents to leadership, as documented in an in-service conducted by the Wellness Nurse no later than May 17, 2025.

c. All staff are scheduled to complete "Alzheimer's Dementia with Behaviors" training on May 8 and/or May 9, 2025. Staff who do not attend will be removed from the schedule until training is completed.

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

a. A manager on duty will review all incident reports seven days a week to ensure timely reporting and follow-up.

b. Incident reports and investigations will be reviewed at QAPI meetings monthly for the first three months, then quarterly thereafter.

4.Who will be responsible to ensure that the corrections are completed and monitored?

oThe Memory Care Administrator, Wellness Director, Wellness Nurse, Executive Director and/or designee will be responsible for ensuring compliance and monitoring corrective actions.

5.Date facility alleges compliance:

oThe facility alleges compliance by May 17, 2025

2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including dementia with paranoia and delusions and Type 2 diabetes.

Review of the resident's quarterly evaluation dated 11/28/23, revealed the following:

* Evaluation was not performed quarterly; and

* The most recent quarterly evaluation with documented change of condition updates was not in the resident's current record or available to staff.

On 03/06/24 at 11:20 am, the need to ensure evaluations were performed at least quarterly and documented change of condition updates were in the resident's current record and available to staff was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and evaluations were performed at least quarterly, to correspond with the quarterly service plan updates, for 2 of 3 sampled residents (#1 and 2) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility on 11/21/23 with diagnoses including Alzheimer's disease and Parkinson's disease.

The resident's 11/21/23 move-in evaluation was reviewed and there was no documented evidence the following elements were addressed:

* Mental health issues including presence of depression, thought disorders or behavioral or mood problems, history of treatment and effective non-drug interventions;

* Cognition including confusion and decision making ability; and

* Recent losses.

The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/05/24. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation

RESIDENT 1

1. Actions taken to correct rule violations include:

a) Initial evaluation will be updated for resident 1 addressing:

*Mental health issues including presence of depression, thought disorders or behavioral or mood problems, history of treatment and effective non-drug interventions;

*Cognition including confusion and decision making; and

*Recent losses.

2. Initial evaluation will be reviewed by Memory Care Administrator, Wellness Director (RN), Executive Director, or designee to ensure every initial evaluation must address the elements above.

3. System will be evaluated prior to resident move in, to  ensure initial evaluation addresses the elements above.

4. Memory Care Administrator, Wellness Director (RN), Executive Director, or designee will be responsible for ensuring corrections that are to be completed and monitored.

RESIDENT 2

1. Actions taken to correct rule violations include:

a) Quarterly evaluation has been performed in March 2024 to correspond with the late February 2024 quarterly service plan for resident 2. Next quaterly evaluation is scheduled on May 2024 to get back on track with quarterly evaluation cycle.

2. Quarterly evaluation list will be reviewed at the beginning of the month by the Memory Care Administrator, Wellness Director (RN), Executive Director or designee to ensure resident evaluations are performed quarterly after the resident moves in to the facility.

3. System will be evaluated monthly to ensure resident evaluations are performed at least quarterly.

4. Memory Care Administrator, Wellness Director (RN), Executive Director, or designee will be responsible for corrections that are to be completed and monitored.

RESIDENT 2

1. Actions taken to correct rule violations include:

a) The most recent quarterly evaluation, with documented change of condition updates in the resident's current record and available to staff.

2. Quarterly evaluation spreadsheet will be created to track and ensure the most recent quarterly evaluation is  in the resident's current record and available to staff.

3. System will be evaluated weekly to ensure the most recent quarterly evaluation is in the resident's current record and available to staff.

4. Memory Care Administrator, Wellness Diretor (RN), Executive Director, or designee will be responible for corrections that are to be completed and monitored.

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

Resident 2 was admitted to the facility in 08/2023 with diagnoses including dementia with paranoia and delusions, and Type 2 diabetes.

a. Observations of the resident, interviews with staff, review of the 11/28/23 service plan, temporary service plans dated 02/13/24 through 02/21/24, and "Observation" notes dated 12/21/23 through 02/23/24 identified Resident 2's service plan was not reflective of his/her needs and preferences, lacked clear direction to staff, and/or was not implemented in the following areas:

* Assistive/Adaptive Devices;

* Mobility/Ambulation;

* Grooming;

* Dressing;

* Toileting;

* Psychosocial interventions;

* Bed mobility;

* Transfers;

* Bathing; and

* Wellness checks.

b. The handwritten updates to the temporary service plans did not include the date or initials of the staff who made the changes to the service plan.

On 03/06/24 at 11:20 am, the need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, and that the services were implemented was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator). They acknowledged the findings.

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

RESIDENT 2

1. Action taken to correct the rule violation will include:

a) Resident 2's service plan will be updated to reflect his needs and preferences, provide clear direction to staff, and implement the following areas:

*Assistive/Adaptive Devices

*Mobility/Ambulation

*Grooming

*Dressing

*Toileting

*Psychosocial interventions

*Bed mobility

*Transfers

*Bathing

*Wellness checks

2. The system will be corrected, so this violation does not happen again by ensuring that all service plans are reviewed and updated to reflect the above elements in terms of residents' needs and preferences, provide clear direction to staff, and implement them accordingly.

3. The area needing correction will be evaluated quarterly. Changes of service plans will be reviewed daily in Clinial Stand Up meeting to ensure accurarcy and appropriateness and make changes as needed.

4.

a) Memory Care Administrator, Wellness Director (RN), Executive Director, or designee will be responsible for corrections that are to be completed and maintained.

b) Memory Care Administrator, Wellness Director (RN), Executive Director, or designee will be responsible for ensuring service plans are reflective of residents' needs and preferences.

c) Memory Care Administrator, Wellness Director (RN), Executive Director, or designee will be responsible for ensuring service plans provide clear direction to staff.

d) Memory Care Administrator, Wellness Director (RN), Executive Director, or designee will be responsible for ensuring the implementation of services.

RESIDENT 2:

1. Action taken to correct the rule violation will include:

a) Temporary service plans will be dated and initialed by staff who make the changes to the service plan.

2. The system will be corrected, so this violation does not happen again by ensuring that all temporary service plans are dated and initialed.

3. System will be evaluated daily to ensure temporary service plans are dated and initialed.

4. Memory Care Administrator, Wellness Director (RN) or designee will be responsible for corrections that are to be completed and monitored.

2. Resident 4 was admitted to the facility in 03/2024 with diagnoses including frontotemporal dementia.

The resident's current service plan dated 06/16/24 was reviewed, observations were made, and interviews with the resident's family and caregivers were conducted between 09/09/24 and 09/11/24. Resident 4's service plan was not reflective, did not provide clear instruction to staff, and/or was not implemented in the following areas:

* Home health services provided;

* Fall risk interventions;

* Toileting;

* Showering; and

* Dining.

The need to ensure service plans were reflective of the identified needs of the resident, provided clear direction regarding the delivery of services, and were implemented was discussed with Staff 1 (ED), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24 at 5:05 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, and were implemented for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 08/2023 with diagnoses including Alzheimer's disease.

The resident's 08/09/24 service plan and 05/13/24 through 09/08/24 observation notes and short term observations (STOs) were reviewed, interviews with staff were conducted, and observations of the resident were made. The resident's service plan was not reflective of current needs and/or did not provide clear direction to staff in the following areas:

* Assistive devices;

* Fall interventions;

* Showers;

* Dressing;

* Mobility;

* Dietary needs;

* Toileting; and

* Personal hygiene.

The need to ensure service plans were reflective and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24 at 3:45 pm. They acknowledged the findings.

C260: OAR 411-054-0036 (1-4) Service Plan: General

1. Actions taken to correct the rule violation are as follows:

RESIDENT 5: service plan has been updated to reflect current needs and/or provide clear direction to staff and implement the following areas:

*Assistive Devices

*Fall interventions

*Showers

*Dressing

*Mobility

*Nurtition and Hydration

*Toileting

*Personal hygiene

RESIDENT 4: service plan has been updated to reflect the needs and preferences and provide clear instruction to staff and implement the following areas:

*Home Health Services Provided

*Fall Risk Interventions

*Toileting

*Showering

*Nutrition and Hydration

2. The system will be corrected, so this violation does not happen again by:

a) Completed review service plan for 8 residents with high acuity.

b) Review all service plans for 24 residents to reflect of their current needs and provide clear direction to staff by 9/30/2024

3.The area needing correction will be evaluated:

a) Quarterly or during significant change of condition.

b) Changes to service plans will be reviewed daily in Clinial Stand Up meeting to ensure accurarcy and appropriateness and make changes as needed.

4. Memory Care Administrator, RN, Executive Director, or designee will be responsible for corrections that are to be completed and maintained.

5. Faility Alleges Compliance by October 26, 2024.     

2. Resident 13 moved into the facility in 11/2023 with diagnoses including late onset Alzheimer's without behavioral disturbance.

The resident's clinical record, including the service plan, dated 02/05/25, progress notes, dated 02/01/25 through 04/16/25, Short Term Observation documents, and incident reports were reviewed. Resident 13 was observed and staff were interviewed. 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:

* Fall risks including person centered interventions;

* Behaviors including a resident to resident altercation and the cause of the altercation; and

* Person centered behavior interventions relating to the history of disliking specific residents or individuals.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), and Staff 29 (Administrator) on 04/17/25 at 2:50 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences and provided clear direction regarding the delivery of services for 3 of 3 sampled residents (#s 2, 13, and 15) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 15 moved into the facility in 09/2023 with diagnoses including mild cognitive impairment.   

The resident's clinical record, including the service plan, dated 02/24/25, progress notes, dated 02/01/25 through 04/15/25, Short Term Observation documents, were reviewed. Resident 15 was observed and staff were interviewed. 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:

* Favorite foods and beverages;  

* Person centered behavior interventions relating to the "need for meaning and purpose, self expression, security and affection, identity";

* What triggers Resident 15 for resident to resident altercations; and

* Interventions for resident to resident altercations.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25. They acknowledged the findings.

3. Resident 2 moved into the facility in 08/2023 with diagnoses including late onset Alzheimer's Dementia and type 2 diabetes.

The resident's clinical record, including the service plan, dated 02/24/25, progress notes, dated 02/01/25 through 04/16/25, and Short Term Observation documents, were reviewed. Observations were made and staff were interviewed, the following was identified:

The service plan did not provide clear direction to staff in the following areas:

* The time-of-day staff were to assist the resident with toileting needs, incontinent care, safety checks, and nighttime wellness checks.

The need to ensure service plans provided clear direction to staff was reviewed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25 at 4:01 pm. They acknowledged the findings.  

C260 - OAR 411-054-0036 (1-4): Service Plan - General

1.What actions will be taken to correct the rule violation for each example/resident?

The facility acknowledges the cited deficiency for not ensuring resident service plans were comprehensive, person-centered, and reflective of resident needs and preferences. Immediate corrective actions taken include:

a. Resident #15 - Service plan updated to include:

oFavorite foods and beverages

oPerson-centered behavior interventions

oIdentified triggers for resident-to-resident interactions

oInterventions to prevent and address altercations

b. Resident #13 - Service plan updated to reflect:

oFall risk and related person-centered interventions

oResident-to-resident altercation history

oSpecific behavioral triggers and preferences, including aversions to particular residents or individuals

c. Resident #2 - Service plan updated to include:

oSpecific times of day for toileting assistance, incontinent care, safety checks, and nighttime wellness checks

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

a. The Facility Memory Care Administrator will enroll in and complete the Role of the RCC course by OHCA at the next available session in August 2025.

b. All current service plans will be reviewed to ensure they are person-centered and reflect each resident's needs and preferences.

c. The facility will utilize and refine its auditing checklist to ensure full compliance with OAR requirements.

d. The Facility Memory Care Administrator and Wellness Nurse will complete the "Role of a Service Plan" training provided by Oregon Care Partners by May 17, 2025.

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

oThe service planning process and accuracy of plans will be reviewed in QAPI meetings monthly for the first three months, and quarterly thereafter to ensure sustained compliance.

___________________________

Amended POC-C260 (3): How frequently will this area need to be evaluated to ensure service plans are reflective while considering the service plan change could be triggered by a significant change of condition, a new resident move-in, etc.

?A service plan will be created prior to the resident's move-in and will be reviewed for updates or necessary changes within 30 days of the move-in.

?Service plans will be reviewed and updated at least quarterly to ensure they remain aligned with the resident's current needs and conditions.

?Residents identified with a significant change of condition will be re-assessed and their service plan will be revised within 48 hours to reflect any new care needs.

?To ensure continuous compliance and timely updates, the Wellness Nurse or designee will do a monthly review of all quarterly evaluations due for the month. They will also conduct a daily review during daily clinical meetings to identify any resident changes that would prompt a significant change of condition evaluation.

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

oThe Memory Care Administrator, Wellness Director, Wellness Nurse, Executive Director and/or designee will be responsible for oversight and monitoring of service plan updates and compliance.

5.Date facility alleges compliance:

oThe facility alleges full compliance by May 17, 2025.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had changes of condition had resident-specific instructions or interventions determined and documented and/or the conditions were monitored at least weekly through resolution for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2023 with diagnoses including Alzheimer's disease.

The resident's current service plan dated 02/21/24, progress notes dated 11/28/23 through 01/13/24, and after visit summary dated 11/24/23 were reviewed.  

The following short term changes of condition lacked resident-specific actions or interventions needed for the resident and/or weekly progress noted through resolution.

*11/24/23 barrier cream twice daily for rash on the buttock area; and

*11/28/23 alert charting for change in medications.

During an interview on 03/04/24 at 1:57 pm, Staff 10 (MT/CG) stated she had not observed a rash to the resident's buttocks area.

In an interview on 03/05/24 at 2:10 pm, Staff 8 (CG) stated the rash had healed.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, and the changes of condition were monitored at least weekly through resolution was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/05/24. They acknowledged the findings.

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

The resident's current service plan dated 11/28/23, progress notes dated 12/21/23 through 02/23/24, and weight records were reviewed.

a.  Resident 2's weight records noted the following:

*12/06/23 182.4 pounds; and

*01/25/24 172.2 pounds.

Between 12/2023 and 01/2024 Resident 2 lost 10.2 pounds or 5.6 % of his/her body weight resulting in a significant weight loss.

There was no documented evidence specific actions or interventions were identified nor was the resident monitored weekly through resolution.

At the time of the survey, 03/05/24, Resident 2 weighed 169.9 pounds.  Resident 2 was observed to eat independently greater than 95% of his/her meal on 03/04/24 and 03/05/24.

b. Resident 2's progress notes indicated the following:

*02/15/24 "...found a dime size wound on the middle of [genitals]...two hour toileting checks in place...."

*02/22/24 "...found a dime size wound on the middle of [genitals]..."

During an interview on 03/06/24 Staff 3 (Wellness Director, LPN) stated she observed Resident 2's perineal area and stated there were no open areas to the resident's skin and noted, "...[genitals] had some slight abrasion the the left medial side...."

Resident 2 had a change of condition related to skin breakdown and there was no documented evidence the wound was monitored weekly through resolution.

c. Resident 2's progress note dated 02/21/24 noted the resident was put on alert charting for a non-injury fall.  A temporary service plan and alert charting were initiated however there was no documented evidence the resident was monitored weekly through resolution.

Resident 2 experienced short term changes of condition related to weight, skin and a fall.  There was no documented evidence resident-specific actions or interventions were determined, documented, and the changes of condition were monitored, at least weekly, through resolution.

Changes of condition were discussed with Staff 1 and Staff 2 on 03/06/24 at 11:30 am. Staff acknowledged the findings.

2. Resident 3 was admitted to the MCC in 10/2023 with diagnoses including Alzheimer's disease.

Staff were interviewed and the resident's record was reviewed, to include progress notes dated 01/03/24 through 03/03/24 and service plan dated 02/13/24.

Weights provided by the facility were as follows:

*12/06/23: 130.2 lbs.; and

*02/22/24: 119 lbs.

Between 12/22/23 and 02/22/24 Resident 3 lost 11.2 lbs or 8.6% of his/her body weight representing a significant change of condition. There was no documented evidence the weight loss was referred to the facility RN for assessment and no evidence actions/interventions were developed with weekly monitoring through resolution.

At the time of the survey, 03/05/24 the resident weighed 112.5 lbs. The resident was observed to eat less than 50% of the breakfast and lunch meals on 03/05/24 and 03/06/24.

Interviews with staff noted the resident was offered snacks between meals and often refused.

Resident 3 was admitted to hospice effective 02/05/24 and spent much of 01/2024 and 02/2024 in and out of the hospital with a diagnosis of diverticulitis of the large intestine. Resident had chronic nausea which impacted her/his ability to eat.

The need to ensure the facility had a process for determining what actions or interventions were needed for a resident and monitoring the resident following a change of condition was reviewed with Staff 1 (Senior Executive Director), Staff 2 (Administrator) and Staff 3 (Wellness Director, LPN) on 03/06/24. They acknowledged the findings.

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

RESIDENT 1

1. Action taken to correct the rule violation will include:

a) Discontinue barrier cream as of 2/20/2024 with physician's order.

2. The system will be corrected so this violation does not happen again by ensuring that a short-term change of condition will be:

a) documented on what actions or interventions are needed for the resident,

b) documented staff instructions or interventions that are resident specific,

c) weekly progress notes in the residents' record until the condition resolves.

3. The area needing correction will be evaluated:

a) daily to ensure that a short-term change of condition is documented on what action or intervention is needed for the resident.

b) daily to ensure that short-term changes of condition are documented with staff instructions or interventions are on resident specific needs.

c)weekly to ensure progress is noted until the condition resolves.    

4.

a) Memory Care Administrator, Wellness Director (RN), or designee will be responsible for corrections that are to be completed and maintained.

b) Memory Care Administrator, Wellness Director (RN), or designee will be responsible for ensuring a short-term change condition will be documented on what action or intervention is needed for the resident.

c) Memory Care Administrator, Wellness Director (RN) or designee will be responsible for ensuring a short-term change condition will be documented of staff instructions or interventions on resident specific needs.

d)Memory Care Administrator, Wellness Director (RN) or designee will be responsible for ensuring progress is  noted until the condition resolves.

RESIDENT 2-WEIGHLOSS

1. Action taken to correct the rule violation will include:

a) Resident 2 will have a comprehensive change of condition assessment specific to significant change of condition related to weightloss

b) Significant change of condition related to weightloss and interventions minimizing the continued risk of loss for resident 2 will be documented into the service plan.

c) Intervention of weightloss for resident 2 will be communicated in writing to staff on each shift.

d) Significant change of condition related to weightloss and interventions  for resident 2 will be documented weekly in progress notes until the condition resolves.

e) Significant change of condition related to weightloss for resident 2 will be on-going nursing monitoring until a new baseline can be established ore the resident 2 returns to historical baseline.

f) Staff will receive re-training specific to identify changes in the resident 2's physical, emotional and mental functioning for significant change of condition related to weightloss.

g) Staff will receive re-training specific to document on the resident's significant change condition related to weightloss.

h) Staff will receive re-training to report, 24-hour a day, seven days a week on the resident 2's significant change condition related to weightloss.

i) System of weekly weights and vitals for monitoring and nursing follow up as reflective to the service plan.

2. The system will be corrected, so this violation does not happen again by ensuring residents who have siginificant change of condition will have resident-specific instructions or interventions and will be documented and/or the conditions are monitored at least weekly through resolution.

a) 24-hour alert binder will be revised to include alert charting log/communications, Temporary Service Plan, significant change of condition log, and weekly weight/vitals/skin monitoring log.

b) Staff will follow alert charting/TSP/communication system for any resident identified to have a short term change of condition. When a change of condition is identified, staff will add the residents name to the alert log to ensure they monitor the resident and determine when to report concerns to Nursing or Physician.

c) Staff will be aware of what to report to the Wellness Director (RN)/Physician per TSP that has been put in place, and which are correlated with the resident's change of condition.

d) TSP has specific directions for staff, including what to look for, interventions, signs, and symptoms to report, and staff signature lines to sign once they have read and understood the TSP.

e) Staff should monitor the resident status until the Resident condition resolves and they are back at their baseline.

f) The 24-hour alert binder/process will be reviewed daily during clinical stand-up meeting as a means of identification of potential significant changes that need to be assessed by the Wellness Director (RN)

3. The area needing correction will be evaluated daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. Memory Care Administrator, Wellness Director (RN), and/or designee will be responsible for ensureing the corrections are completed and will be monitored.

RESIDENT 2-SKIN

1. Action taken to correct the rule violation will include:

a) Resident 2 will have a comprehensive change of condition assessment by Wellness Director (RN) specific to the skin breakdown on resident 2's perineal area.

c) Intervention of resident 2's skin break down on perineal area will be communicated in writing to staff on each shift.

d) Skin break down on perineal area and interventions for resident 2 will be documented weekly in progress notes until the condition resolves.

e) Resident 2's skin break down on perineal area will be on-going nursing monitored until a new baseline can be established or the resident 2 returns to historical baseline.

f) Staff will receive re-training specific to identify changes in the resident 2's physical, emotional and mental functioning for skin break down on perineum.

g) Staff will receive re-training specific to document on the resident's skin break down on perineal area.

h) Staff will recieve re-training to report, 24-hour a day, seven days a week on the resident 2's skin break down on perineal area.

2. The system will be corrected, so this violation does not happen again by ensuring residents who have short term change of condition will have resident-specific instructions or interventions and will be documented and/or the conditions are monitored at least weekly through resolution.

a) 24-hour alert binder will be revised to include alert charting log/communications, Temporary Service Plan, significant change of condition log, and weekly weight/vitals/skin monitoring log

b) Staff will follow alert charting/TSP/communication system for any resident identified to have a short term change of condition. When a change of condition is identified, staff will add the residents name to the alert log to ensure they monitor the resident and determine when to report concerns to Nursing or Physician.

c) Staff will be aware of what to report to the Wellness Director (RN)/Physician per TSP that has been put in place, which correlated with the resident's change of condition.

d) TSP has specific directions for staff, including what to look for, intervention to put in place, signs, and symptoms to report, and staff signature lines to sign once they have read and understood the TSP.

e) Staff should monitor the resident status until the Resident condition resolves and they are back at their baseline.

f) The 24-hour alert binder/process will be reviewed daily during clinical stand-up meeting as a means of identification of potential significant change that needs to be assessed by the Wellness Director (RN)

3. The area needing correction will be evaluated daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. Memory Care Administrator, Wellness Director (RN), and/or designee will be responsible for ensuring the corrections are completed and will be monitored.

RRESIDENT 2-FALL

1. Action taken to correct the rule violation will include:

a) Resident 2 will have a comprehensive change of condition assessment specific to the fall for resident 2 by Wellness Director (RN).

b) Fall notes, interventions, and monitor notes  for resident 2 will be documented in progress notes.

c) Staff will receive re-training specific to document on the resident's fall.

d) Staff will receive re-training to report, 24-hour a day, seven days a week on the resident 2's fall.

2. The system will be corrected, so this violation does not happen again by ensuring residents who have short term change of condition will have resident-specific instructions or interventions and will be documented and/or the conditions are monitored at least weekly through resolution.

a) 24-hour alert binder will be revised to include alert charting log/communications, Temporary Service Plan, significant change of condition log, and weekly weight/vitals/skin monitoring log.

b) Staff will follow alert charting/TSP/communication system for any resident identified to have a short term change of condition. When a change of condition is identified, staff will add the residents name to the alert log to ensure they monitor the resident and determine when to report concerns to Nursing or Physician.

c) Staff will be aware of what to report to the Wellness Director (RN)/Physician per TSP that has been put in place, which correlated with the resident's change of condition.

d) TSP has specific directions for staff, including what to look for, intervention to put in place, signs, and symptoms to report, and staff signature lines to sign once they have read and understood the TSP.

e) Staff should monitor the resident status until the Resident condition resolves and they are back at their baseline.

f) The 24-hour alert binder/process will be reviewed daily during clinical stand-up meeting as a means of identification of potential significant change that needs to be assessed by the Wellness Director (RN)

3. The area needing correction will be evaluated daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. Memory Care Administrator, Wellness Director (RN), and/or designee will be responsible for corrections that are to be completed and monitored.

RESIDENT 3: WEIGHTLOSS

1. Action taken to correct the rule violation will include:

a) Resident 3 will have a comprehensive change of condition assessment by Wellness Director (RN) specific to significant change of condition related to weightloss

b) Significant change of condition related to weightloss and interventions minimizing the continued risk of loss for resident 3 will be documented into the service plan.

c) Intervention of weightloss for resident 3 will be communicated in writing to staff on each shift.

d) Significant change of condition related to weightloss and interventions  for resident 3 will be documented weekly in progress notes until the condition resolves.

e) Significant change of condition related to weightloss for resident 3 will be on-going nursing monitored until a new baseline can be established or the resident 3 returns to historical baseline.

f) Staff will receive re-training specific to identify changes in the resident 3's physical, emotional and mental functioning for significant change of condition related to weightloss.

g) Staff will receive re-training specific to document on the resident 3 's significant change of condition related to weightloss.

h) Staff will receive re-training to report, 24-hours a day, seven days a week on the resident 3's significant change of condition related to weightloss.

i) System of weekly weights and vitals for monitoring and nursing follow up as reflective to the service plan.

2. The system will be corrected, so this violation does not happen again by ensuring residents who have a signigicant change of condition will have resident-specific instructions or interventions and will be documented and/or the conditions are monitored at least weekly through resolution.

a) 24-hoursalert binder will be revised to include alert charting log/communications, Temporary Service Plan, significant change of condition log, and weekly weight/vitals/skin monitoring log.

b) Staff will follow alert charting/TSP/communication system for any resident identified to have a short term change of condition. When a change of condition is identified, staff will add the residents name to the alert log to ensure they monitor the resident and determine when to report cocerns to Nursing or Physician.

c) Staff will be aware of what to report to the Wellness Director (RN)/Physician per TSP that has been put in place, which correlated with the resident's change of condition.

d) TSP has specific directions for staff, including what to look for, intervention to put in place, signs, and symptoms to report, and staff signature lines to sign once they have read and understood the TSP.

e) Staff should monitor the resident status until the Resident condition resolves and they are back at their baseline.

f) The 24-hour alert binder/process will be reviewed daily during clinical stand-up meeting as a means of identification of potential significant change that needs to be assessed by the Wellness Director (RN)

3. The area needing correction will be evaluated daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. Memory Care Administrator, Wellness Director (RN), and/or designee will be responsible for corrections that are to be completed and will be monitored.

2. Resident 4 was admitted to the MCC in 03/2024 with diagnoses including frontotemporal dementia.

The current service plan dated 06/16/24, "Short Term Observation" documents, and observation notes dated 06/06/24 through 08/30/24 were reviewed. Interviews with staff were completed between 09/09/24 and 09/11/24.

The facility failed to determine and document the action or intervention needed for the resident, communicate the resident-specific action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:

* 06/21/24 - Fall;

* 06/25/24 - Change in verbal communication, continence, reduced intake, tearfulness;

* 07/01/24 - Increase in memantine dosage for dementia;

* 07/07/24 - Resident attempted to hit another resident;

* 08/12/24 - Right shin injury;

* 08/15/24 - Increased confusion, weakness, instability, and hallucinations;

* 08/23/24 - Bruising to left side of forehead and scalp;

* 08/23/24 - Initiation of hospice services; and

* 08/23/24 - Medication changes.

The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, communicated the resident-specific interventions to staff on all shifts, and monitored the changes of condition, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24 at 5:05 pm. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure actions and interventions were determined, documented, and communicated to staff on each shift, residents were monitored consistent with their evaluated needs and service plan, and weekly progress was noted to resolution for short-term changes of condition for 2 of 2 residents (#s 4 and 5) whose records were reviewed. Resident 5 experienced repeated falls with injuries, including a right hip fracture, and a decline in ADL function resulting in a hospice admit. This is a repeat citation. Findings, include, but are not limited to:

1. Resident 5 was admitted to the facility in 08/2023 with diagnoses including Alzheimer's disease and was identified in the acuity interview as a high fall risk with recent falls, including a fall with left hip fracture on 05/04/24 and a fall with a right hip fracture on 07/24/24, and had received PT and OT services for fall prevention following the 05/04/24 fall.

The resident's 05/10/24 service plan, 08/09/24 change of condition evaluation, a facility incident report and investigation dated 07/10/24 and 07/11/24, and observation notes and short-term observations (STOs) dated 05/13/24 through 09/08/24 were reviewed. Interviews with staff were conducted.

a. Review of Resident 5's record indicated the following:

* The resident required one-person staff assistance for all transfers;

* The resident required one-person standby assistance for all ambulation while using his/her walker; and

* Staff were to ensure the resident used his/her walker for ambulation.

Review of the resident's progress notes indicated the resident experienced the following falls:

* 06/29/24 - Noninjury fall (progress notes did not indicate if the fall was witnessed or unwitnessed, and there was no investigation completed);

* 07/10/24 - Witnessed injury fall with "abrasion/bruise/swelling to forehead, skin tear/pain to right knee, right second digit discoloration and 'pins and needles' generalized pain" while resident was walking in the hallway alone; and

* 07/24/24 - Witnessed injury fall while resident was walking in the hallway alone without his/her walker. The resident was sent to the hospital and subsequently diagnosed with a right hip fracture. S/he required surgery and spent 16 days in the hospital before returning to the facility on 08/09/24.

There was no documented evidence the facility determined what resident-specific interventions were needed to mitigate fall risk following each of the above falls; therefore, there was no documented evidence resident-specific interventions were communicated to staff on each shift. Additionally, the facility failed to review previous fall interventions for effectiveness.

Upon return from the hospital on 08/09/24, progress notes indicated the resident had a decline in ADL ability and required full assistance with dressing, toileting, two-person transfers, and a decline in appetite, and was admitted to hospice on 09/10/24. During interviews with Staff 22 (Med Care Manager) and Staff 18 (Care Manager) on 09/10/24 it was reported the resident had not returned to baseline since s/he had returned from the hospital stay, had increased confusion, weakness, had been refusing meals, and had been mostly bedbound for approximately three weeks. The resident was admitted to hospice care on 09/10/24.

Observations made of the resident on 09/10/24 and 09/11/24 revealed the resident was confined to his/her wheelchair. S/he was not observed to self-propel. S/he was observed to sit with his/her head down and his/her eyes closed. S/he refused most food and liquid staff offered. Staff were observed to wheel the resident from his/her room to the dining room, and to wheel him/her back to his/her room after meals.

The facility failed to review previous fall interventions for effectiveness and to develop new interventions to reduce Resident 5's fall risk, and the resident continued to experience falls with injury, resulting in a right hip fracture, a hospital stay, a decline in ADL function, and was admitted to hospice.

b. The resident's 08/09/24 service plan and observation notes and short-term observations (STOs) dated 05/13/24 through 09/08/24 were reviewed. The following was identified:

There was no documented evidence the facility determined, documented, and communicated to staff on each shift any actions or interventions, and/or there was no documented evidence the facility monitored with weekly progress noted to resolution the following changes of condition:

* 06/08/24 - Skin tears on right and left shins;

* 09/01/24 - 7-pound weight loss from 07/2024 to 09/01/24; and

* 07/21/24 - Antibiotics started for infection.

The need to ensure resident-specific actions or interventions for changes of condition were determined, documented, and communicated to staff on each shift, were monitored, at least weekly, through resolution and fall interventions were reviewed for effectiveness was discussed with Staff 1 (Executive Director), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24 at 3:45 pm. They acknowledged the findings, and no further information was provided.

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

RESIDENT 5 and RESIDENT 4

1. Action taken to correct the rule violation will include:

Resident 5:

a) Incident report for the noninjury fall on 6/29/24 has been reviewed to include resident-specific interventions.

b) Incident report for the witnessed injury fall with "abration/bruise/swelling to forehead, skin tear/pain to right knee, right second digit discoloration and "pins and needles" generalized pain" on has been reviewed to include resident-specific interventions  to mitigate fall risk and STO also has been completed to communicate to staff.

c) Incident report for the witnessed injury fall with a right hip fracture has been reviewed to include resident-specifc interventions to mitigate fall risk and STO also has been completed to communicate staff.

d) RN comprehensive accessment and weekly progress notes have been documented to resolution for the following changes of condition:

o Skin tears on right and left shins on 6/8/24

o 7-pound weight loss from July 2024 to 9/1/2024

o Antibiotics started for infection on 7/21/2024

e) RN comprehensive accessment has been conducted to access resident's fall risk including the current/new interventions to reduce resident's fall risk

f) Current STO has been documented to communicate with staff on resident's current specific interventions and monitoring.

Resident 4:

a) RN comprehensive accessment and weekly progress notes have been documented to resolution for the following changes of condition:

o Fall 6/21/2024

o Change in verbal communication, continence, reducted intake, tearfulness 7/1/2024

o Increase in memantine dosage for dementia 7/1/2024

o Resident's behavior attempted to hit another resident 7/7/2024

o Right shin injury 8/12/2024

o Increased confusion, weakness, instablity, and hallucinations 8/15/2024

o Bruising to left side of forehead and scalp 8/23/2024

o Hospice services 8/23/2024

o Medication changes 8/23/2024

b) RN comprehensive accessment has been conducted to access resident's fall risk including the current/new interventions to reduce resident's fall risk

c) Current STO has been documented to communicate with staff on resident's current specific interventions and monitoring.

2. The system will be corrected so this violation does not happen again by ensuring:

o Immediate Review:

a) Review all high acuity care plans (8 residents) by 9/27/2024

b)Review all care plans (24 residents) by 9/30/2024

o System Modification to Prevent Recurrence:

a) The current EHR system (Alis) lacks the capability to generate individual STO alerts for each resident with multiple changes of condition, contributing to missteps in monitoring. We are actively working with Alis system representatives to implement software updates that will allow for individualized alerts for residents with multiple changes of condition. We do not have a specific time frame of completion yet, and we will provide evidence of system modifications to the state surveyor once implemented.

o Documentation and Communication of Changes of Condition:

a) Currently, caregivers do not have direct access to the EHR system, which limits their ability to see the alerts for changes of condition. A paper Temporary Service Plan (TSP) is used to notify staff of residents on alert. However, the current paper TSP does not meet state regulations, as it lacks documentation of the required actions or interventions for residents experiencing changes in condition. We will revise the paper TSP to include detailed documentation of actions and interventions needed and ensure it aligns with state regulations.

b) Caregivers will be trained on the revised paper TSP, and this document will be used to communicate alerts and required interventions to staff on all shifts. Training will be completed by [Oct  26, 2024] and documented with a record of staff attendance and the materials used in the training.

o Daily Clinical Review and Monitoring Process:

a) It was identified that even with the paper TSP in place, staff were missing important alerts from the EHR system, leading to failures in communicating and executing necessary interventions. To address this, we will implement a mandatory daily clinical meeting, effective immediately, where the clinical team will review all residents with changes of condition, cross-check EHR alerts, and ensure that the paper TSP is properly updated and distributed to all relevant staff. This daily meeting will involve nursing leadership and caregiving staff, ensuring continuity of care across shifts.

b) We will document attendance at these meetings and maintain a daily log of all residents on alert, including a review of interventions and actions taken.

oQuality Assurance Monitoring:

a) Monthly audits will be conducted by the clinical leadership team to ensure ongoing compliance with the use of the revised paper TSP and proper communication of resident alerts across all shifts. These audits will include random checks of residents' records and interviews with staff to verify understanding and proper implementation of the new process.

RN OVERSIGHT PLAN: Due to the facility going through changes in Nursing Oversight, the weekly progress notes in the residents' record until the condition resolves did not meet the rules.

o Corporate Clinical Support Specialist: Kenric Thompson, RN Full-Time

o Agency Clipboard Health RN 40 hours/week to provide nursing oversight

o Laurie Polneau, RN will start with Morning Star on 10/1 as Wellness Director

RN TRAINING PLAN:

Nursing Team and Administrator sign up @ Nurselearn.com for training on Medication Administration, Care Planning, and Change of Condition

o Nursing team will undergo mandatory Root Cause Analysis training with a completion deadline of October 15, 2024. Documentation of completed training will be submitted to the state surveyor no later than October 16, 2024.

o Chelsea Tudela, Memory Care Administrator, Kenric Thompson, RN and Tiana Jackson, Executive Director have enrolled in CBC Nurse Standard Program @Nurselearn

o Kenric Thompson, RN will attend the Role of the Nurse in CBC @OHCA 10/8-10/10 and is confirmed thru OHCA website.

o Laurie Polneau, RN is currently in CBC Nurse Enhanced Program Cohort @ Nurselearn

o Laurie Polneau, RN will attend the Role of the Nurse in CBC @OHCA on 12/9-12/12

3. The area needing correction will be evaluated:

o Daily Clinical Meetings for Continuous Oversight:

a) Daily Documentation Review: Daily clinical meetings will be conducted to ensure that both the EHR (Alis) system and the paper Task Sheet Protocol (TSP) clearly document the specific actions or interventions required for residents experiencing changes in condition. This review will focus on confirming that the necessary interventions are accurately recorded in both systems and communicated to staff.

b) Resident-Specific Interventions: During these daily clinical meetings, the interdisciplinary team will review resident-specific care needs to ensure that instructions for staff are clearly documented and align with the interventions required for each resident's condition. This ensures that all staff are fully informed of the actions they need to take to address residents' changing conditions.

c) Weekly RN Progress Notes: The daily meetings will also include a review of each resident's weekly Registered Nurse (RN) progress notes to ensure that ongoing monitoring and assessment of the resident's condition is documented until the issue is resolved. Any gaps in progress notes or missed updates will be promptly addressed to ensure continued compliance with regulatory standards.

o Accountability and Documentation:

a)The results of these daily clinical meetings will be documented, and a designated RN or clinical leader will be responsible for ensuring that all required actions, interventions, and staff instructions are updated in both the EHR and the paper TSP

b) A daily log of meeting outcomes will be maintained and reviewed by clinical leadership to ensure follow-through on all identified resident care needs and interventions   

4. Memory Care Administrator, RN, Executive Director, and/or designee will be responsible for corrections that are to be completed/maintained.

5. Facility Alleges Compliance: October 26, 2024 except for the following:

o  Nursing team will undergo mandatory Root Cause Analysis training with a completion deadline of October 15, 2024. Documentation of completed training will be submitted to the state surveyor no later than October 16, 2024.

o Chelsea Tudela, Memory Care Administrator, Kenric Thompson, RN and Tiana Jackson, Executive Director have enrolled in CBC Nurse Standard Program @Nurselearn

o Kenric Thompson, RN will attend the Role of the Nurse in CBC @OHCA 10/8-10/10

o Laurie Polneau, RN is currently in CBC Nurse Enhanced Program Cohort @ Nurselearn

o Laurie Polneau, RN will attend the Role of the Nurse in CBC @OHCA on 12/9-12/12     

Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 5 of 7 sampled residents (#s 1, 4, 7, 10, and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 03/2024 with diagnoses including frontotemporal dementia and claustrophobia.

Clinical records, including the current service plan and progress notes from 10/28/24 through 12/25/24 were reviewed, and interviews with facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 11/03/24: Resident-to-resident altercation;

* 11/10/24: Resident-to-resident interaction documented as "[Resident 7] lay on [Resident 4's] chest while [Resident 4] was in bed"; and

* 12/23/24: Resident-to-resident altercation.

The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN) and Staff 27 (Regional Vice President of Operations). They acknowledged the findings.

2. Resident 11 moved into the facility in 02/2024 with diagnoses including Alzheimer's dementia with paranoid delusions.

Clinical records, including the current service plan and progress notes from 10/29/24 through 12/28/24 were reviewed, and interviews with facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 11/12/24: Resident-to-resident altercation; and

* 12/02/24: Resident-to-resident incident involving kissing.

The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN) and Staff 27 (Regional Vice President of Operations). They acknowledged the findings.

3. Resident 10 moved into the facility in 02/2024 with diagnoses including dementia with senile behavioral disturbance.

Clinical records, including the current service plan and progress notes from 11/16/24 through 12/23/24 were reviewed, and interviews with facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

* 11/18/24: Unwitnessed fall;

* 11/19/24: Unwitnessed fall;

* 11/24/24: "...woke up confused asking where [his/her] daughter was, saying that [s/he] hears [his/her] calling [his/her] name."; and

* 12/23/24: "...resident was found on [his/her] knees in the bathroom floor".

The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN) and Staff 27 (Regional Vice President of Operations). They acknowledged the findings.

4. Resident 7 moved into the facility in 11/2024 with diagnoses including vascular dementia and dysphagia.

The resident's 11/29/24 service plan, incident reports and/or investigations, progress notes and Short Term Observations (STOs) dated 11/01/24 to 12/30/24 were reviewed, and interviews with staff were conducted.

The following short-term change of condition, documented in the progress notes, lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution:

* 11/07/24: Skin tear to eyelid;

* 11/10/24: Resident-to-resident interaction documented as "[Resident 7] lay on [Resident 4's] chest while [Resident 4] was in bed";

* 11/11/24: Choking episode and change in diet texture to mechanical soft;

* 11/12/24: Resident-to-resident altercation;

* 12/02/24: Resident-to-resident incident involving kissing;

* 12/08/24: Incorrect diet texture provided and difficulty swallowing;

* 12/11/24: Resident-to-resident altercation; and

* 12/19/24: Sexually inappropriate behavior in common area.  

The need to ensure all changes of condition had actions or interventions determined, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was reviewed on 01/02/25 at 1:30 pm with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN) and Staff 27 (Regional Vice President of Operations). They acknowledged the findings.

5. Resident 1 moved into the facility in 11/2023 with diagnoses including Alzheimer's disease and Parkinson's disease.

The resident's 11/18/24 service plan, and progress notes and Short Term Observations (STOs) dated 10/26/24 to 12/30/24 were reviewed, and interviews with staff were conducted.

The following short-term change of condition, documented in the progress notes, lacked actions or interventions communicated to staff on all shifts and/or were not monitored at least weekly to resolution:

* 12/22/24: Resident-to-resident altercation.

The need to ensure all changes of condition had actions or interventions determined, implemented, communicated to staff on all shifts, and were monitored at least weekly to resolution was reviewed on 01/02/25 at 1:30 pm with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN) and Staff 27 (Regional Vice President of Operations). They acknowledged the findings.

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

1.What actions will be taken to correct the rule violation for each example/resident?

Action taken to correct the rule violation will include:

RESIDENT 4:

a) Incident report for resident-to-resident altercation on 11/03/2024 has been reviewed. Resident-specific interventions to redirect the resident have been added to the service plan.

b) Incident report for resident-to-resident interaction documented as Resident #7 laying on Resident #4's chest while Resident #4 was in bed. Resident-specific interventions, such as locking the resident's door when they are sleeping in the room to prevent wandering, have been added to the service plan.

c) Incident on 12/23/2024 involving a resident-to-resident altercation. Resident-specific interventions to keep the resident away from Resident #1, due to their history of altercations, have been added to the service plan.

d) RN comprehensive assessment has been completed to reflect the above interventions for these three incidents.

e) The updated service plan has been provided for staff to review the new interventions.

RESIDENT 11:

a) The incident report for the resident-to-resident altercation on 11/12/2024 has been reviewed. The service plan has been updated to include resident-specific interventions for physical aggression.

b) The incident report for the resident-to-resident incident involving kissing on 12/02/2024 has been reviewed. The service plan has been updated to include resident-specific interventions for sexual behaviors.

c) An RN comprehensive assessment has been conducted to assess the resident's psychosocial needs.

d) The updated service plan has been provided to staff to review the new interventions.

RESIDENT 10:

a) Incident reports for unwitnessed falls on 11/18/24, 11/19/24, and 12/23/24 have been reviewed. The service plan has been updated to include resident-specific interventions to mitigate fall risk.

b) The incident on 11/24/24 has been reviewed. The service plan has been updated to reflect the resident's current mental status, including increased confusion and hallucinations.

c) The updated service plan has been provided to staff to review the resident's current mental status.

RESIDENT 7:

a) The skin tear to the eyelid from scratching on 11/07/24 has been resolved.

b) The resident-to-resident interaction on 11/10/24, where Resident #7 lay on Resident #4's chest while Resident #4 was in bed, has been reviewed. The service plan has been updated to reflect specific interventions.

c) The choking episode on 11/11/24 and the change in diet texture to mechanical soft have been reviewed. The service plan has been updated to reflect the current diet orders.

d) The resident-to-resident altercation on 11/12/24 has been reviewed. The service plan has been updated to reflect specific interventions.

e) The incident of resident-to-resident kissing on 12/02/24 has been reviewed. The service plan has been updated to reflect specific interventions.

f) The resident-to-resident altercation on 12/08/24 has been reviewed. The service plan has been updated to reflect specific interventions.

g) The resident-to-resident altercation on 12/11/24 has been reviewed. The service plan has been updated to reflect specific interventions.

h) The incident of sexually inappropriate behavior in the common area on 12/19/24 has been reviewed. The service plan has been updated.

RESIDENT 1:

a)Incident on resident to resident altercation on 12/22/24 has been reviewed and service plan has been updated to include interventions to redirect resident when agitated. No further altercations have occurred.

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

a) The facility will revise the short-term observation forms to include a section for resident-specific interventions for each condition.

b) The facility will retrain our staff on how to determine the appropriate resident-specific interventions for each condition.

c) The facility will retrain our staff on staff signatures as acknowledgment of communication regarding staff instructions for resident-specific interventions.

d) The facility will retrain our staff to ensure weekly progress documentation continues until the condition is resolved.

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

a) Daily Clinical Stand-Up: Review all short-term changes in condition to ensure that all resident-specific interventions are documented for each resident.

b) Daily Clinical Stand-Up and Shift Changes: Review staff signatures as acknowledgment of communication regarding staff instructions for resident-specific interventions.

c) Daily Clinical Stand-Up: Review weekly progress notes until the condition is resolved.

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

Memory Care Administrator, Wellness Director (RN), Wellness Nurse (RN) or designee will be responsible for the following:

a)Ensuring corrections that are to be completed and maintained.

b)Ensuring a short-term change condition will be documented on what action or intervention is needed for the resident.

c)Ensuring a short-term change condition will be documented of staff instructions or interventions on resident specific needs.

d)Ensuring progress is noted until the condition resolves.

5.Date facility alleges compliance.

a.Facility Alleges Compliance by February 1, 2025.

Based on observation, interview, and record review it was determined the facility to ensure short term changes had specific resident interventions determined and documented, and the condition monitored with weekly progress noted until resolved for 6 of 6 sampled residents (#s 2, 3, 4, 13, 14, and 15) who experienced short term changes. Resident 13 had recurring falls resulting in injuries. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 moved into the memory care facility in 11/2023 with diagnoses including late onset Alzheimer's disease.

Observations of the resident from 04/16/25 to 04/17/25 showed the resident ambulated around the facility without an assistive device with a steady gait.

a. The resident's 02/05/25 service plan indicated the resident was at high fall risk and

directed staff to "remind resident to use the call light" or "...the call light is within reach and working."

The incident reports and/or investigations, progress notes, and Short Term Observations (STOs), dated 02/01/25 to 04/16/25, were reviewed. The following was identified:

* 02/09/25: Injury fall, including an abrasion on the chin and a bleeding upper lip;

* 02/27/25: Injury fall, resulting in right wrist pain and bruising around the right eye;

* 03/18/25: Injury fall, causing a bump on the head;

* 03/21/25: Non-injury fall, fell from the couch in the resident's room;

* 03/22/25: Non-injury fall, falling off the couch in the room; and

* 03/24/25: Injury fall, causing an abrasion on the right knee.

There was no documented evidence the multiple falls were consistently evaluated, including developing actions or interventions to reduce the reoccurrence of future falls. Resident 13 continued to fall and sustained injuries consisting of bruising, lacerations, and pain.

b. The incident reports and/or investigations, progress notes, and STOs, dated 02/01/25 to 04/16/25, were reviewed. The following was identified:

* 02/03/25: Wound on both legs from scratching;

* 02/25/25: Experienced increased confusion;

* 03/12/25: An antibiotic use for a urinary tract infection;

* 03/18/25: Injury fall;

* 03/21/25: Non-injury fall;

* 03/22/25: Injury fall;

* 03/24/25: Emergency visit after fall, resulting purplish right eye bruising; and

* 04/03/25: Resident to resident altercation.

There was no documented evidence the facility monitored the resident's short-term changes of condition until resolution.

On 04/17/25 at 2:20 pm, the findings were discussed including the need to evaluate potential causes of the falls and to develop interventions to reduce further falls with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director, RN), Staff 28 (Wellness Nurse, LPN) and Staff 29 (Administrator). They acknowledged there were no interventions to reduce further falls.

2. Resident 4 moved into the memory care facility in 03/2024 with diagnoses including frontotemporal dementia.

The resident's progress notes, dated 04/01/25 through 04/15/25, and Short Term Observation (STO) documents were reviewed and noted the following:

* 04/03/25: Resident to resident altercation.

The facility initiated a STO using a pre-printed form, which included a generic intervention of "redirected both residents." However, there were no person-centered interventions implemented to prevent recurrence of resident to resident altercations.

The short-term change of condition lacked documented evidence that the facility determined what action or intervention was needed for Resident 4 and communicated the action or intervention to staff on each shift.

The need to ensure all changes of condition had documentation actions or interventions were determined and communicated to staff on all shifts was discussed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25 at 2:20 pm. No additional information was provided.

3. Resident 3 moved into the facility in 10/2023 with diagnoses including Alzheimer's disease.

The resident's progress notes, dated 04/03/25 through 04/16/25, and the clinical record was reviewed. Interviews with staff were conducted.

The following short-term change of condition, documented in the progress notes, lacked evidence that the facility determined and documented what action or intervention was needed for Resident 3 and communicated the action or intervention to staff on each shift:

* 04/03/25: Resident to resident altercation.

The need to ensure all changes of condition had documentation that actions or interventions were determined and communicated to staff on all shifts was discussed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25. No additional information was provided.

4. Resident 14 moved into the facility in 08/2023 with diagnoses including dementia.

The resident's progress notes, dated 03/06/25 through 04/15/25, and Short Term Observation documents were reviewed. Interviews with staff were conducted.

The following short-term change of condition lacked documented evidence the facility determined what action or intervention was needed for Resident 14 and communicated the action or intervention to staff on each shift:

* 03/06/25: Resident to resident altercation.

The need to ensure all changes of condition had documentation that actions or interventions were determined and communicated to staff on all shifts was discussed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25. No additional information was provided.

5. Resident 15 moved into the facility in 09/2023 with diagnoses including mild cognitive impairment.

The resident's progress notes, dated 02/01/25 through 04/15/25, Short Term Observation documents, and service plan, dated 02/24/25, were reviewed. Interviews with staff were conducted.

The following short-term changes of condition lacked documented evidence the facility determined what action or intervention was needed for Resident 15 and communicated the action or intervention to staff on each shift:

* 03/06/25: Resident to resident altercation;

* 04/09/25: Fall; and

* 04/10/25: Resident to resident altercation.

The need to ensure all changes of condition had documentation that actions or interventions were determined and communicated to staff on all shifts was discussed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25. No additional information was provided.

6. Resident 2 moved into the facility in 08/2023 with diagnoses including late onset Alzheimer's Dementia and type 2 diabetes.

The resident's clinical record, including progress notes, dated 02/01/25 through 04/16/25, and Short Term Observation documents were reviewed. Observations were made and staff interviews were conducted.

The resident's service plan included weight loss interventions that included four nutritional supplements a day and for staff to document the percentage of each meal consumed.

The following change of condition lacked documented evidence the facility monitored the resident consistent with his or her evaluated needs and actions or interventions were consistently implemented:

* Continuous weight loss.  

The need to ensure changes of condition and interventions for the change of condition were monitored consistent with the resident's evaluated needs was reviewed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25 at 4:01 pm. They acknowledged the findings.  

C270 - OAR 411-054-0040 (1-2): Change of Condition and Monitoring

1.What actions will be taken to correct the rule violation for each example/resident?

The facility acknowledges the cited deficiency for not ensuring short-term changes in condition were addressed with resident-specific interventions and ongoing weekly monitoring until resolved or stabilized. Immediate corrective actions taken include:

a. The Wellness Director has submitted their resignation, and we are actively recruiting a qualified RN to oversee change of condition monitoring.

b. A new Wellness Nurse was hired on April 7, 2025, and will be enrolled in the following training programs:

oNurse Learn course focused on identifying, assessing, and monitoring both short-term and significant changes of condition.

oThe Role of the RN course provided by OHCA.

_____________________________

Amended POC-C270 (1): How will the facility ensure all residents have been reviewed for change of condition and interventions implemented by the AOC date?

?The facility will conduct a comprehensive review of all residents by the AOC date to identify any recent or ongoing changes of condition.

?The Wellness Nurse or designee will be responsible for reviewing each resident's chart, including clinical notes, incident reports, and staff observations, to determine if a change of condition has occurred.

?For any resident identified as having experienced a change of condition, the service plan will be updated and appropriate interventions will be implemented and documented within 48 hours.

?The Wellness Nurse or designee is responsible for tracking and maintaining an audit log to ensure all residents have been reviewed, any updates or interventions are completed and signed off prior to the AOC deadline.

?This review process will be monitored daily by the Wellness or Administrator to ensure accountability and timely completion.

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

a. All residents identified with a significant change of condition will receive timely assessments and ongoing weekly monitoring until the condition resolves or a new baseline is established.

b. Short-term changes of condition (STOs) will be reviewed daily by the Wellness Nurse, Memory Care Administrator, or Manager on Duty to ensure:

oSTO documentation is in place

oResident-specific instructions and interventions are actively followed

c. Staff have received training on STOs, including the importance of timely documentation and follow-up, as evidenced by an in-service led by the Wellness Nurse by May 17, 2025.

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

oThis area will be reviewed during QAPI meetings monthly for three months, followed by quarterly reviews to ensure sustained compliance.

Amended POC-C270 (3): How frequent will this area need to be evaluated to ensure all proper documentation and implementation of the determined interventions when a resident experiences a change of condition.

To ensure accurate documentation and consistent implementation of appropriate interventions when a resident experiences a change of condition, the following processes will be followed:

?Short-Term Change of Condition

When a resident experiences a short-term change of condition, the situation will be evaluated during the daily clinical stand-up meeting. Required actions and interventions will be discussed and documented, drawing from staff observations, Staff-To-Observation (STO) reports, incident reports, and any identified concerns.

?Significant Change of Condition

If a resident experiences a significant change of condition, they will be monitored at least weekly by the Registered Nurse (RN). The RN will document progress notes weekly until the condition stabilizes or resolves. The resident's service plan will be reviewed and updated as needed to ensure it reflects their current care needs.

4.Who will be responsible to ensure the corrections are completed and monitored?

oThe Memory Care Administrator, Wellness Director, Wellness Nurse, Executive Director and/or designee will be responsible for ensuring corrections are implemented and monitored for effectiveness.

5.Date facility alleges compliance:

oThe facility alleges full compliance by May 17, 2025

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

Resident 2's current service plan and evaluation dated 11/28/23 noted the resident could eat independently, required cueing during meals, had no recent changes to his/her weight and had a regular diet.

Resident 2's weight records noted the following:

*12/06/23 182.4 pounds; and

*01/25/24 172.2 pounds.

Between 12/2023 and 01/2024 Resident 2 lost 10.2 pounds or 5.6 % of his/her body weight resulting in a significant weight loss requiring an RN assessment.

At the time of the survey, 03/05/24, Resident 2 weighed 169.9 pounds.  Resident 2 was observed to eat independently greater than 95% of his/her meal on 03/04/24 and 03/05/24.

Resident 2 experienced a significant change of condition related to weight loss.  There was no documented evidence the facility RN had completed an assessment to include findings, resident status, and interventions made as a result.

During an interview on 03/05/24 at 2:10 pm, Staff 1 (Senior Executive Director) stated the facility RN was new to the position and was not aware of the resident's significant weight loss.

Resident 2's weight loss and lack of RN assessment was discussed with Staff 1 and Staff 2(Administrator) on 03/06/24 at 11:30 am.  Staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment had been completed for 2 of 3 sampled residents (#s 2 and 3) who had a significant change of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2023 with diagnoses including Alzheimer's disease.

Staff were interviewed and the resident's record was reviewed, to include progress notes dated 01/03/24 through 03/03/24 and service plan dated 02/13/24.

Weights provided by the facility were as follows:

12/06/2023: 130.2 lbs.; and

02/22/2024: 119 lbs.

Between 12/22/23 and 02/22/24 Resident 3 lost 11.2 lbs or 8.6% of his her body weight resulting in a significant change of condition which required an RN assessment. There was no documented evidence an RN assessment including findings, resident status, and interventions made as a result of this assessment had been completed.

In an interview with Staff 3 (Wellness Director, LPN) on 03/06/24 at 10:54 am, she acknowledged a significant weight loss on 02/22/24. A focused resident assessment of the resident's weight loss was completed on 03/05/24.

The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (Senior Executive Director), Staff 2 (Administrator) and Staff 3 on 03/06/24. They acknowledged the findings.

Refer to C 270, example 2.

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

RESIDENT 3:

1. Action taken to correct the rule violation will include:

a) Resident 3 will have a comprehensive change of condition assessment specific to significant weightloss by Wellness Director (RN).

b) Weightloss findings, status, and interventions minimizing the continued risk of loss for resident 3 will be documented into the service plan by Wellness Director (RN).

c) Intervention of weightloss for resident 3 will be communicated in writing to staff on each shift by Wellness Director (RN).

d) Weightloss and interventions  for resident 3 will be documented weekly in progress notes by Wellness Director (RN) until the condition resolves.

e) Weightloss for resident 3 will be monitored by Wellness Director (RN)until a new baseline can be established or resident 3 returns to historical baseline.

2. The system will be corrected, so this violation does not happen again by ensuring residents who have a change of condition will have Wellness Director (RN) assessed. Wellness Director (RN) will document findings, resident status, and interventions made as a result of assessment. Wellness Director (RN) will be monitored and documented with resident-specific instructions or interventions and will be documented at least weekly through resolution.

a) 24-hour alert binder will be revised to include alert charting log/communications, Temporary Service Plan, significant change of condition log, and weekly weight/vitals/skin monitoring log.

b) Staff will follow alert charting/TSP/communication system for any resident identified to have a short term change of condition. When a change of condition is identified, staff will add the residents name to the alert log to ensure they monitor the resident and determine when to report concerns to Wellness Director (RN) or Physician.

c) Staff will be aware of what to report to the Wellness Director (RN)/Physician per TSP that have been put in place, which correlates with the resident's change of condition.

d) TSP has specific directions for staff, including what to look for, interventions to put in place, signs, and symptoms to report, and staff signature lines to sign once they have read and understood the TSP.

e) Wellness Director (RN) should monitor the resident's status until the resident's condition resolves and they are back at their baseline.

f) The 24-hour alert binder/process will be reviewed daily during clinical stand-up meeting as a means of identification of potential significant change that needs to be assessed by the Wellness Director (RN).

3. The area needing correction will be evaluated daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. Memory Care Administrator, Wellness Director (RN), and/or designee will be responsible for ensuring that corrections are completed and monitored.

RESIDENT 2

1. Action taken to correct the rule violation will include:

a) Resident 2 will have a comprehensive change of condition assessment specific to significant weightloss by Wellness Director (RN)

b) Weightloss findings, status, and interventions minimizing the continued risk of loss for resident 2 will be documented into the service plan by Wellness Director (RN).

c) Intervention of weightloss for resident 2 will be communicated in writing to staff on each shift by Wellness Director (RN).

d) Weightloss and interventions  for resident 2 will be documented weekly in progress notes by Wellness Director (RN) until the condition resolves.

e) Weightloss for resident 2 will be on-going nursing monitored by Wellness Director (RN)until a new baseline can be established or the resident 2 returns to historical baseline.

2. The system will be corrected, so this violation does not happen again by ensuring residents who have change of condition will be accessed by Wellness Director (RN). Wellness Director (RN) will document findings, resident status, and interventions make as a results of assessment. Wellness Director (RN) will monitor and document resident-specific instructions or interventions and will document results at least weekly through resolution.

a) 24-hour alert binder will be revised to include alert charting log/communications, Temporary Service Plan, significant change of condition log, and weekly weight/vitals/skin monitoring log.

b) Staff will follow alert charting/TSP/communication system for any resident identified to have a short term change of condition. When a change of condition is identified, staff will add the resident's name to the alert log to ensure they monitor the resident and determine when to report concerns to Wellness Director (RN) or Physician.

c) Staff will be aware of what to report to the Wellness Director (RN)/Physician per TSP, which correlates with the resident's change of condition.

d) TSP has specific directions for staff, including what to look for, intervention to put in place, signs, symptoms to report, and staff signature lines to sign once they have read and understood the TSP.

e) Wellness Director (RN) should monitor the resident status until the resident's condition resolves and they are back at their baseline.

f) The 24-hour alert binder/process will be reviewed daily during clinical stand-up meeting as a means of identification of potential significant changes that need to be assessed by the Wellness Director (RN).

3. The area needing correction will be evaluated daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. Memory Care Administrator, Wellness Director (RN), and/or designee will be responsible for corrections that are to be completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the RN completed a significant change of condition assessment for 2 of 2 sampled residents (#s 4 and 5) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the MCC in 03/2024 with diagnoses including frontotemporal dementia.

a. During the acuity interview on 09/09/24 at 10:35 am, Resident 4 was identified to have experienced weight loss. Resident 4's weight records were reviewed and revealed the following:

* 05/2024 - 121.4 pounds;

* 08/2024 - 114 pounds;

* 09/1/24 - 106.6 pounds; and

* 09/10/24 - 105.2 pounds (requested during survey).

From 08/2024 to 09/1/24, Resident 4 had a weight loss of 7.4 pounds or 6.49% of his/her body weight in one month. This severe weight loss indicated a significant change of condition and required an RN assessment.

On 09/10/24 at 1:30 pm, an RN assessment for the resident's severe weight loss was requested. Staff 12 (RN-Clinical Support Specialist) confirmed there was no documented evidence a facility RN completed an assessment of Resident 4's severe weight loss.

b. During the acuity interview on 09/09/24 at 10:35 am, Resident 4 was identified to have been admitted to hospice. The resident's observation notes dated 06/06/24 to 08/30/24 were reviewed.

According to an observation note dated 08/15/24, Resident 4 experienced a sudden decline in function which affected his/her cognition, strength, stability and included hallucinations. The resident was admitted to the hospital on 08/15/24, and s/he returned to the MCC on 08/23/24 on hospice services. The admit to hospice constituted a significant change of condition for which an RN assessment was required.

During an interview at 1:30 pm on 09/10/24, Staff 12 acknowledged there was no documented evidence the facility RN completed an assessment for Resident 4's new admission to hospice.

The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24 at 5:05 pm. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 08/2023 with diagnoses including Alzheimer's disease.

The resident's 09/08/24 change of condition evaluation and observation notes dated 05/13/24 through 09/08/24 were reviewed. Interviews with staff were conducted. The following was identified:

Observation notes indicated the resident sustained a fall with a right hip fracture on 07/24/24. The resident was hospitalized for surgery, and returned to the facility on 08/09/24. The resident's hip fracture and surgery constituted a significant change of condition for which an RN assessment including resident status, RN findings, and interventions made as a result of the assessment was required. There was no documented evidence an RN assessment had been completed.

At 1:33 pm on 09/10/24, Staff 12 (RN-Clinicial Support Specialist) confirmed no RN assessment had been completed for the hip fracture.

The need to ensure an RN assessment was completed when a resident experienced a significant change of condition was discussed with Staff 1 (Executive Director), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24 at 3:45 pm. They acknowledged the findings.

C280: OAR 411-054-0045 (1) (a-f)(A)(C-F) Resident Health Services

1. Actions taken to correct the rule violation include:

RESIDENT 4:

a) RN comprehensive assessment and significant change of condition for resident's weight loss and significant change of condition had been completed.

b) RN comprehensive assessment and significant change of condition admit to hospice had been completed.

RESIDENT 5:

a) RN assessment had been completed for hip fracture on 7/24/2024.

2. The system will be corrected, so this violation does not happen again by ensuring residents who have a significant change of condition have a comprehensive assessment done by RN. RN will document findings, resident status and interventions made as a result of assessment. RN will monitor and document with resident-specific instructions and interventions and will be documented through to resolution.

a) Staff will be aware of what to report to the RN and Physician per TSP that are put in place, which correlates with the resident's change of condition.

b) TSP has specific directions for staff, including what to look for, interventions to put in place, signs, and symptoms to report, and staff signature lines to sign once they have read and understood the TSP.

c) RN will monitor resident's status until the resident's condition resolves and they are back at their baseline.

d) The 24-hour alert monitoring binder/process will be reviewed daily during clinical stand-up meeting as a means of identification of potential significant change that needs to be assessed by the RN

3. The area needing correction will be evaluated daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. Memory Care Administrator, Wellness Director (RN), Executive Director and/or designee will be responsible for ensuring that corrections are to be completed and monitored

5.Facility Alleges Compliance: October 26, 2024     

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 2 sampled residents (#2) who received Home Health services. Findings include, but are not limited to:

Resident 2 moved into the facility in 08/2023 with diagnoses including dementia with paranoia and delusions and Type 2 diabetes.

During the acuity interview on 03/04/24, the resident was identified to receive outside provider services.

The resident's outside provider's visit notes dated 02/19/24, 02/21/24, and 03/04/24, service plan dated 11/28/23, temporary service plans dated 02/13/24 through 02/21/24, "Observation" notes dated 12/21/23 through 02/23/24, and an observation of a home health provider visit were reviewed and revealed the following recommendations made by Home Health providers:

* Resident to work on wheelchair mobility;

* "PT suggested that the care staff attempt to get resident to start moving themselves in their wheelchair;"

* Resident to use walker and staff to use gait belt to assist in ambulation to meals; and

* "Provide extra time for [resident] to process, give simple 1-step instructions with visual cues, and to ask yes or no questions."

There was no documented evidence these recommendations were communicated with staff and/or service plan adjusted if necessary.

The need to ensure on-going coordination of care was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/06/24. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc: On- and  Off-Site Health Service

RESIDENT 2:

1. Actions taken to correct rule violations include:

a) Memory Care Administrator, Wellness Director (RN), or designee to adjust resident 2's service plan, putting interventions in place reflecting the resident 2's outside home health provider recommendations.

b) Memory Care Administrator, Wellness Director (RN), or designee will inform staff of new interventions related to resident 2's outside home health provider recommendations.

2. The system will be corrected so this violation will not happen again by:

a)Memory Care Administrator, Wellness Director (RN), or designee will review daily resident's outside provider notes.

b) Memory Care Administrator, Wellness Director (RN), and designee will daily adjust resident's service plan to reflect the resident's outside health provider recommendations.

c) Memory Care Administrator, Wellness Director (RN), and designee will daily put new interventions in place and inform staff  of new interventions related to resident's outside health provider recommendations.

3. System will be evaluated daily and weekly to ensure: a) outside provider' notes are reviewed,

b) make changes to service plan as a result of the provision of on-site health services recommendations.

c) put new interventions in place,

d) and inform staff of new interventions

4. Memory Care Administrator, Wellness Director (RN) and/or designee will be responsible for corrections to be completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, and that the service plan was adjusted if necessary for 1 of 2 sampled residents (#5) who received outside services. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 08/2023 with diagnoses including Alzheimer's disease and was identified in the acuity interview as receiving outside services.

The resident's 08/09/24 service plan and outside provider notes, observation notes, and short-term observations (STOs) dated 05/13/24 through 09/08/24 were reviewed. The following recommendations from outside providers were identified:

* 05/23/24 - OT note stated "bed against wall for clear path to toilet ...Rest of area nice and open as well ...All lights on during day due to glaucoma/low vision ...Offer toileting schedule/assist as she allows";

* 05/28/24 - HH RN note stated "Please have facility nurse or staff change dressing every other day or if soiled/off. Please assess [left] shin periwound for resolution of redness-notify PCP if redness is not improved in 2 days. Clean wounds with wound cleaner or soap and water, pat dry, apply skin prep to periwound, xerofoam to wound bed, cover with adhesive foam dressing or island dressing";

* 05/29/24 - OT note: "encourage CG to keep lights on, at least bathroom. Could try fall mat by bed while sleeping, pulled up when not in bed. Really needs CG presence for any mobility attempts - keep up with frequent safety checks, sitter may be good idea if family agrees";

* 06/04/24 - HH RN note: "staff reporting patient appears weaker, sleeping in and sometimes missing meals - message left with son ...recommending that family bring in nutritional shakes for supplements";

* 6/12/24 - PT note: "needs [consistent] supervision [due to] fall risk [because] of cog[nitive] issues";

* 6/18/24 - HH RN note: "Please continue to provide supervision for safety and assistance with transfer and ambulation due to high risk of falls"; and

* 08/19/24 - HH RN note, "elevated irregular pulse of 118 ...please record daily [blood pressure] and pulse for review by HH [RN] and [primary care physician]. Please notify [primary care physician] if pulse [is greater than] 100, [systolic blood pressure is less than] 100 ...please record daily [bowel movements] ...patient continues to be at high risk for falls - please provide safety checks at least [hourly] or more."

There was no documented evidence the facility administrator or nurse was notified of the above outside provider services and recommendations, and/or the service plan was adjusted if necessary.

At 8:48 am on 09/11/24 Staff 2 (Reflections Coordinator) stated Med Care Managers were supposed to notify her of any recommendations from outside provider notes, and that she had not been notified of the above recommendations.

The need to ensure the facility management or licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, and that the service plan was adjusted if necessary was discussed with Staff 1 (Executive Director), Staff 2, and Staff 13 (Regional Vice President of Wellness) on 09/11/24. They acknowledged the findings.

C290: OAR 411-054-0045 (2) Res Hlth Srvc: On- and Off-Site Health Srvc

RESIDENT 5:

1. Actions taken to correct rule violations include:

a) Memory Care Administrator, RN, or designee had implemented outside prover services and recommendations for the following:

o 5/23/2024-Bed against wall; rest of area nice and open; all light on during day; and offer toileting schedule every 2 hours

o 5/28/2024-Change dressing every other day or if soiled; access left shin periwound for resolution of redness; Notify PCP if redness is not improved; Follow clean wound instructions

o 5/29/2024-Keep light on, at least bathroom; fall mat while sleeping; frequent safety check.

o 6/4/2024-family bring in nutritional shakes

o 6/12/2024- Consistent supervision due to fall risk.

o 6/18/2024-Supervision for safety and assistance with transfer and ambulation

o 8/19/2024- Record daily blood pressure and pulse. Notify PCP if pulse is greater than 100, systolic blood pressure is less than 100; record daily bowel movements; and safety check at least at hourly or more -Discontinued order for daily blood pressure and pulse. Currently tracking daily bowel movements

2. The system will be corrected so this violation will not happen again by:

a) Outside provider box has been installed outside Memory Care Administrator's office.

b) Memory Care Administrator, RN or designee will review daily resident's outside provider notes.

c) Memory Care Administrator, RN and designee will daily adjust resident's service plan to reflect the resident's outside health provider recommendations.

d) Memory Care Administrator, RN and designee will daily put new interventions in place and inform staff of new interventions related to resident's outside health provider recommendations.

3. System will be evaluated daily and weekly to ensure:

a) outside provider' notes are reviewed.

b) make changes to service plan as a result of the provision of on-site health services recommendations.

c) put new interventions in place.

d) and inform staff of new interventions

4. Memory Care Administrator, RN and/or designee will be responsible for corrections to be completed and monitored.

5. Facility Alleges Compliance: October 26, 2024

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed or written signed physician orders were documented in the resident's facility record for all medication and treatments the facility was responsible to administer for 2 of 3 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

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

Resident 2's MARs, dated 03/01/24 through 03/05/24 and physician orders dated 02/20/24 and 08/08/23 were reviewed and identified the following orders were not carried out as prescribed:

*Magnesium (supplement) was ordered to be administered once daily and was documented as administered twice a day; and

*Latanoprost (eye drops for glaucoma) was ordered to be administered one drop to each eye two times daily and was documented as administered one time daily.

The prescriber orders was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/06/24 at 11:30 am. Staff stated they would clarify the orders.

2.  Resident 1 was admitted to the facility in 11/2023 with diagnoses including Alzheimer's Disease.

Resident 1's MARs, dated 02/01/24 through 03/05/24 were reviewed and noted the following:

*Barrier cream applied to the resident twice daily, noted as on hold, without a current physician order in the record;

*Melatonin (sleep) documented as administered one time daily in the evening without a current physician order in the record; and

*Quetiapine (agitation) documented as administered twice daily without a current physician order.

The requirement to have physician orders for all medication and treatments the facility was responsible to administer was discussed with Staff 1 and Staff 2 on 03/05/24 at 2:45 pm. The staff faxed the physician to acquire signed orders on 03/05/24.

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

RESIDENT 2:

1. Actions taken to correct rule violations include:

a) Magnesium administered according to the latest physician orders.

b) Latanoprost administered according to the latest physician orders.

2. System will be corrected so that the violation will not occur again by:

a) daily, weekly and monthly review ofmedication and treatment orders to ensure medications are administered as prescribed.

b) daily, weekly, and monthly review of medication and treatment orders to ensure written, signed physician orders are documented in the resident's record

c) daily, weekly, and monthly review of medication and treatment orders to ensure resident's records are in alignment with signed physician's orders related to medication and treatments.

3. Corrections will be evaluated daily, weekly and monthly.

4. Memory Care Administrator, Wellness Director (RN) and/or designee will be responsible for corrections to be completed and monitored.

RESIDENT 1:

1. Actions taken to correct rule violations include:

a) Barrier cream administered according to the latest physician orders.

b) Melatonin administered according to the latest physician orders.

c) Quetiapine administered according to the latest physician orders.

2. System will be corrected so that the violation will not occur again by:

a) daily, weekly and monthly review of medication and treatment orders to ensure administeration and carry out as prescribed.

b) daily, weekly, and monthly review of medication and treatment orders to ensure written, signed physician orders are documented in the resident's record.

c) daily, weekly, and monthly review medication and treatment orders to ensure resident's records is align with signed physician's orders in related to medication and treatments.

3. Corrections will be evaluated daily, weekly and monthly.

4. Memory Care Administrator, Wellness Director (RN) and/or designee will be responsible for corrections are to be completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure treatment orders were carried out as prescribed for 1 of 1 sampled resident (#5) who had treatment orders related to falls. Resident 5 was not administered fall prevention treatment orders as prescribed and fell, sustaining a right hip fracture. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 08/2023 with diagnoses including Alzheimer's disease and was identified in the acuity interview as a high fall risk with recent falls.

The resident's 05/10/24 service plan, physician orders dated 07/12/24, an incident report dated 07/10/24, an investigation dated 07/11/24, and observation notes and short-term observations (STOs) dated 05/13/24 through 09/08/24 were reviewed. Interviews with staff were conducted. The following was identified:

The resident experienced an injury fall on 07/10/24 with "abrasion/bruise/swelling to forehead, skin tear/pain to right knee, right second digit discoloration and 'pins and needles' generalized pain."

A 07/12/24 signed physician order stated the following:

* "Make sure [Resident 5] is using [his/her] walker for any ambulation";

* "Provide cues that [his/her doctor] would like [him/her] to use the walker for [his/her] safety"; and

* "Make sure this is added to [his/her] care plan."

Review of the resident's record revealed no documented evidence the treatment orders were added to the service plan and carried out. The resident experienced a witnessed fall with a right hip fracture on 07/24/24, while walking without [his/her] walker.

At 3:45 pm on 09/11/24, Staff 2 (Reflections Coordinator) confirmed the orders had not been carried out as prescribed.

The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2, and Staff 13 (Regional Vice President of Wellness) on 09/11/24. They acknowledged the findings, and no further information was provided.

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

RESIDENT 5:

1. Actions taken to correct rule violations include:

a) Requested hospice for a discontinue order for walker

b) Updated resident's service plan on ambulation using only wheelchair

2. System will be corrected so that the violation will not occur again by:

o  Treatment Order and Administration Reviews:

a) Daily, Weekly, and Monthly Audits: The facility will implement a process for daily, weekly, and monthly reviews of treatment orders to ensure treatments are administered exactly as prescribed.

b) Verification of Physician Orders: A 3 check system for daily, weekly, and monthly reviews of treatment orders will be put in place to ensure that all written and signed physician orders are accurately documented in each resident's record. The facility will maintain up-to-date records of physician orders and perform regular audits to ensure compliance with this requirement.

o  Staff Training on Treatment Administration:

a) Med Tech Training via Relias: All Med Techs will undergo mandatory medication administration training via the Relias platform, with a completion deadline of October 15, 2024. Documentation of completed training will be submitted to the state surveyor no later than October 16, 2024.

3. Ongoing Evaluation and Monitoring:

a) Daily, Weekly, and Monthly Reviews: The effectiveness of these corrections will be evaluated through daily, weekly, and monthly audits conducted by the Memory Care Administrator, RN, and/or designee. These audits will focus on ensuring that treatments are being administered as prescribed and that all physician orders are documented and verified.

4. Accountability and Oversight:

a) Responsible Party: Memory Care Administrator, RN, and/or designated staff will be responsible for ensuring that all corrections are implemented and maintained. Ongoing monitoring will be documented, and any identified issues will be addressed promptly with corrective actions tracked.

5. Facility alleges compliance: October 26, 2024.  except for: Medication Administration training for Mech Techs through Relias by 10/15/2024 and will provide training documentation to SQ no later than 10/16/2024

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed or written signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 7, 8, and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 moved into the facility in 04/2024 with diagnoses including dementia with behavioral disturbance.

The resident's MARs, dated 10/26/24 through 12/30/24, and physician orders were reviewed. Staff were interviewed. The following was noted:

a. On 04/12/24, Resident 8's physician ordered 2.5 mgs of olanzapine (for combativeness, agitation, and aggression) with directions to staff to administer one "tablet once daily in the evening." The physician wrote a parameter instructing staff to increase the dose "after one week" to 5 mgs nightly if the resident had, "ongoing anxiety, agitation, combativeness, aggression."

The physician's order reflected the same instructions on 08/23/24.

On 12/13/24, the physician's order changed the time of administration from 2.5 mgs of olanzapine every evening to 2.5 mgs each morning.  

The facility administered 2.5 mgs of olanzapine in the morning and 2.5 mgs in the evening on the following months:

* 10/26/24 through 10/31/24: Six times;

* 11/01/24 through 11/30/24: Thirty times; and

* 12/01/24 through 12/30/24: Six times.

During an interview with Staff 23 (Wellness Director/RN) on 12/31/24 at approximately 1:00 pm, she explained that Resident 8 had been on olanzapine twice daily prior to admitting to the facility, but was not able to locate an order to administer the olanzapine twice a day after being admitted to the current facility.

b. Resident 8 was not administered 2.5 mgs of olanzapine each evening five times from 12/07/24 through 12/17/24, as the medication was "not available."

The need to ensure physician orders were followed as prescribed was discussed with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23, Staff 26 (Wellness Nurse/RN), and Staff 27 (Regional VP of Operations) on 01/02/25 at 12:40 pm. No additional information was provided.

2.  Resident 9 moved into the facility in 11/2024 with diagnoses including Alzheimer's Disease.

The resident's MARs, dated 11/19/24 through 12/30/24, and physician's orders were reviewed. Staff were interviewed and the following was noted:

The resident had a physician's order for citalopram (for agitation and agitated behavior associated with dementia), 20 mgs by mouth, every day.

Resident 9 did not receive the citalopram on 12/23/24, and from 12/26/24 through 12/30/24 as the medication was "not available" for staff to administer.

On 12/31/24 at 10:54 am, Staff 7 (Med Care Manager MC) verified the resident did not receive the medication on 12/24/24, even though it was documented as administered. Staff 7 reported, "I must have clicked the wrong button because [the medication] was not available."

The need to ensure physician orders were followed as prescribed was discussed with Staff 1 (Senior Executive Director), Staff 2 (Administrator), Staff 23 (Wellness Director/RN), Staff 26 (Wellness Nurse/RN), and Staff 27 (Regional VP of Operations) on 01/02/25 at 12:40 pm. No additional information was provided.

3. Resident 7 moved into the facility in 11/2024 with diagnoses including vascular dementia and dysphagia.

The resident's 12/01/24 through 12/30/24 MARs and physician's orders dated 11/01/24 to 12/30/24 were reviewed, and the following was identified:

a. The resident had a signed physician's order dated 11/07/24 which updated the resident's diet from puree to "regular diet." The order stated "Notify the [sp] hospice if any difficulties are noted." A progress note dated 11/10/24 stated "Resident was seen during lunchtime choking/having discomfort while eating his food." Staff 2 (Administrator) confirmed on 01/02/24 there was no documentation that hospice was notified.

b. The resident had a physician's order for losartan 50 mg (for hypertension) to be given once per day, with the order stating to hold the medication if the resident's systolic blood pressure was less than 110. On 12/07/24, the resident's blood pressure was recorded as 176/73. The MAR indicated that losartan was not administered to the resident on 12/07/24. Staff 23 (Wellness Director/RN) confirmed on 12/31/24 that there was no documentation of why the medication was held since the blood pressure was within parameters for the medication to be administered.  

c. On 12/05/24, a signed physician's order updated the resident's diet texture to puree. On 12/08/24, a progress note stated "Resident did not get puree for breakfast this morning and was having difficulties swallowing [his/her] food."

d. On 12/30/24, the resident was observed to be served the incorrect liquid texture with his/her lunch meal. The resident had a signed physician's order for regular texture liquid, and the resident was served nectar-thick liquid.

e. On 12/31/24, the resident was observed to be served the incorrect diet texture. The resident had a signed physician's order for puree diet texture, but was served oatmeal with large lumps.

The need to ensure physician's orders were carried out as prescribed was reviewed on 01/02/25 at 1:30 pm with Staff 1 (Senior Executive Director), Staff 2, Staff 23, Staff 26 (Wellness Nurse/RN) and Staff 27 (Regional Vice President of Operations). They acknowledged the findings.

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

1.What actions will be taken to correct the rule violation for each example/resident?

Actions taken to correct rule violations include:

RESIDENT 8:

a) Received current order to a discontinue routine and PRN olanzapine on 12/31/2024

RESIDENT 9:

a) Reviewed and confirmed the citalopram has been accurately administered since 1/2/2025 to present.

RESIDENT 7:

a) Confirmed the current diet order with hospice of puree soft texture diet and regular liquid.

b) Reviewed medication administering from 1/2/2025 to present to ensure staff is administered losartan according to physician's order to hold the medication if the resident's systolic blood pressure is less than 110.

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

System will be corrected so that the violation will not occur again by:

a) Daily, Weekly, and Monthly Audits: The facility will implement a process for daily, weekly, and monthly reviews of physician orders to ensure physician orders are followed as prescribed. The facility will implement a process for daily, weekly, and monthly reviews of medication orders to ensure medications are administered exactly as prescribed. These reviews will verify that the Medication Administration Record (MAR) is initialed by the administering staff member immediately after each administration. Any discrepancies in MAR documentation will be addressed in real-time, with corrective actions taken as necessary.

b) Verification of Physician Orders: A 3 check system for daily, weekly, and monthly reviews of physician orders will be put in place to ensure that all written and signed physician orders are accurately documented in each resident's record. The facility will maintain up-to-date records of physician orders and perform regular audits to ensure compliance with this requirement.

c) Medication Not Available: Staff will follow the established protocol when medication is unavailable. The resident must be closely monitored until the medication is received. Staff should contact the pharmacy to request the medication and continue following up until it is delivered. The primary care physician must also be notified.

o  Staff Training on Medication Administration:

a)Med Tech Training via Relias: All Med Techs will undergo mandatory medication administration training via the Relias platform.

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

Ongoing Evaluation and Monitoring:

a) Daily, Weekly, and Monthly Reviews: The effectiveness of these corrections will be evaluated through daily, weekly, and monthly audits conducted by the Memory Care Administrator, Wellness Director (RN), Wellness Nurse (RN) and/or designee. These audits will focus on ensuring that physician orders are being administered as prescribed and that all physician orders are documented and verified.

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

Accountability and Oversight:

a) Responsible Party: Memory Care Administrator, Wellness Director (RN), Wellness Nurse (RN) and/or designated staff will be responsible for ensuring that all corrections are implemented and maintained. Ongoing monitoring will be documented, and any identified issues will be addressed promptly with corrective actions tracked.

5.Date facility alleges compliance.

a.Facility Alleges Compliance by February 1, 2025.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed or written signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 2 of 3 sampled residents (#s 2 and 15) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 15 moved into the facility in 09/2023 with diagnoses including mild cognitive impairment and generalized anxiety.

The resident's MARs, dated 03/01/25 through 04/16/25 and the resident's facility record was reviewed. Staff were interviewed and the following was noted:

There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders in Resident 15's facility record for all medications and treatments the facility was responsible to administer.

The need to ensure the facility had written, signed physician or other legally recognized practitioner orders in residents' facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25. No additional information was provided.

2. Resident 2 moved into the facility in 08/2023 with diagnoses including late onset Alzheimer's Dementia, weight loss, dysphagia, and type 2 diabetes.

The resident's record was reviewed including the MARs, dated 03/01/25 through 04/16/25, April Care Tracking Sheet, and current physician orders. Staff were interviewed and the following was identified:

The following physician orders were not carried out as prescribed:

* Glucerna chocolate carton, four times daily (for nutritional supplement) - on 33 occasions;

* Meal tracking, three times daily (for weight loss) - on 10 occasions;

* Weekly weight (for weight loss) - on four occasions.

On 04/17/25 at 10:31 am, Staff 28 (Wellness Nurse/LPN) confirmed there was no additional documentation relating to the orders for Glucerna chocolate carton, meal tracking, or weekly weights.

The need to ensure physicians' orders were carried out as prescribed was reviewed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25 at 4:01 pm. They acknowledged the findings.  

C303 - OAR 411-054-0055 (1)(f-h): Systems - Treatment Orders

1.What actions will be taken to correct the rule violation for each example/resident?

The facility acknowledges the cited deficiency of not ensuring physician orders were consistently carried out as prescribed or ensuring written orders were present in the resident's chart. Immediate corrective actions taken include:

a. Implementation of a double-check system for 90-day physician orders:

oAll 90-day orders will be reviewed by two separate staff members prior to being sent to the physician for signature.

b. Implementation of a triple-check system for all physician orders outside of 90-day cycles:

oThe Medication Manager will check in new orders and enter them into the MAR.

oA second staff member will review the entry to ensure accuracy and completeness.

oA Wellness Nurse will complete the final verification and sign off to confirm the order is correctly entered into the MAR.

_________________________

Amended C303 (1): How will the facility ensure all residents have signed physician orders by the AOC date?

?The facility will complete a full audit of each resident's chart to verify the presence of current, signed physician orders.

?Any missing or outdated physician orders will be identified and addressed immediately.

?Administrative consultants will complete an audit of all resident charts and communicate the findings to the Wellness nurse, Administrator, or designee with required follow up action.

?The Wellness Nurse, Administrator or designee will coordinate with the primary care providers to obtain required signatures. If signatures are not received on the day of the initial request, daily follow-up will be conducted via phone call and/or re-fax until the signatures are obtained. Follow-up attempts will be documented each day, including the date, time, method of contact, and the individual contacted.

?This audit will be completed by the AOC date to ensure full compliance.

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

a. PharMerica will conduct quarterly audits of the medication carts to identify and resolve discrepancies.

b. All missed medications will be reviewed daily during clinical stand-up meetings. A report of all missed doses from the previous day will be printed and discussed.

c. The admission Physician Plan Of Care form has been amended to require the Wellness Nurse or designee to:

oReview all initial admission orders for validity

oConfirm presence of physician signature on any attached medication lists

oObtain missing signatures prior to the resident's move-in.

_______________________

Amended C303 (2): How will the facility ensure all resident charts are audited with signed orders for medications that include doctor appointments, hospitalizations, emergency room visits, hospice admissions, etc., that will not encompass the 90-day orders?

The facility will ensure that all resident charts include signed physician orders for medications related to doctor appointments, hospitalizations, emergency room visits, hospice admissions, and other significant medical events-excluding the standard 90-day orders. To achieve this:

?Administrative Consultant will complete a comprehensive audit of each resident's chart by the AOC date. This audit will verify the presence and accuracy of signed physician orders related to these specific events.

?Any missing documentation will be immediately addressed, with follow-up conducted by the Wellness Nurse, Administrator, or designee to obtain the necessary physician signatures and ensure compliance.

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

oThis area will be reviewed at QAPI meetings monthly for three months, and quarterly thereafter.

____________________

Amended C303 (3): How frequent will this area need to be evaluated to ensure all residents are being administered current, signed physician orders and have current signed physician orders in their charts?

oThis area will be evaluated daily during clinical stand-up meetings to ensure that all new medications and treatments are being administered in accordance with current and signed physician orders documented in each resident's chart.

oThe Wellness Nurse, Administrator, or designee will be responsible for verifying that each new order is properly documented and signed by the prescribing physician.

oAny discrepancies or missing signatures will be promptly identified and addressed. Follow-up will continue daily until each issue is fully resolved and all required documentation is complete.

oIn addition to the daily review, the Wellness Nurse, Administrator, or designee will be responsible for conducting monthly audits of all resident charts to confirm ongoing compliance and to ensure that all standing physician orders remain current and properly signed.

4.Who will be responsible to ensure the corrections are completed and monitored?

oThe Memory Care Administrator, Wellness Director, Wellness Nurse, Executive Director and/or designee.

5.Date facility alleges compliance:

oThe facility alleges full compliance by May 17, 2025.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order for 1 of 2 sampled residents (# 1) who was reviewed with medication and treatment refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2023 with diagnoses including Alzheimer's disease.

Resident 1's MARs from 01/01/24 through 02/16/24 were reviewed. The MAR directed staff to administer barrier cream twice a day to the resident's buttocks.

Resident 1 refused application of the barrier cream 16 times and there was no documented evidence the facility notified the prescriber of the resident's treatment refusals.

During an interview on 03/04/24 at 2:42 pm, Staff 14 (MT) stated the physician would be notified if the resident refused a medication and wasn't sure if the physician would be notified related to treatment refusals.

The facility's failure to notify the physician when Resident 1 refused an ordered treatment to ensure a system was in place for subsequent treatment refusals, as requested by the prescriber, was reviewed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/05/24. No additional information was provided.

OAR 411-054-0055 (1) (j-k) System: Resident Right to Refuse

1. Action taken to correct the rule violation includes:

a) Notified resident 1's physican of resident's treatment refusal of barrier cream

2. The system will be corrected so that the violation will not occur again by re-training Med Tech staff to notify the physician when a resident refuses consent for an order related to medications and treatments.

3. Corrections will be evaluated daily, weekly, monthly to ensure physician(s) are notified when a resident refuses consent to an order.

4. Memory Care Administrator, Wellness Director (RN) and/or designee will be responsible for corrections that are to be completed and monitored.

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

Resident 2's 03/01 through 03/05/24 MAR was reviewed and noted the following medications lacked reasons for use:

*Atorvastatin;

*Divalproex;

*Furosemide;

*Lantanoprost;

*Lisinopril;

*Magnesium;

*Memantine;

*Metformin;

*Multi-vitamins;

*Potassium;

*Ramelteon;

*Vitamin B12;

*Vitamin D3; and

*Acetaminophen.

Accuracy of MARs including reasons for use of medications was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/06/24 at 11:30 am.  No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure that MARs/TARs contained reasons for use of multiple medications for 2 of 2 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1.  Resident 3's 02/01/24 through 02/29/24 MARs were reviewed.

Resident 3's MAR revealed the following seven medications lacking specific reasons for use:

* Cephalexin;

* Escitalopram;

* Menmantine;

* Metoprolol;

* Probiotic Formula;

* Rivastigmine; and

* Hyoscyamine sulfate.

In an interview with Staff 2 (Administrator) at 12:41 pm on 03/05/24, she acknowledged the lack of reasons for use.

The need to ensure MARs included reasons for use was reviewed with Staff 1 (Senior Executive Director), Staff 2 and Staff 3 (Wellness Director, LPN) on 03/06/24. They acknowledged the MARs were not accurate.

OAR 411-054-0055 (2) Systems: Medication Administration

RESIDENT 3:

1. Action taken to correct the rule violation includes:

a) specific reasons for use medication for resident 3 have been entered in MAR.

2. The system will be corrected so that the violation will not occur again by daily, weekly, and monthly review to ensure all residents' medications have reason for use for each resident's medication record.

3. Corrections will be evaluated daily, weekly, and monthly review to ensure all residents' medications have a reason for use for each resident's medication record.

4. Memory Care Administrator, Wellnes Director (RN) and/or designee will be responsible for corrections that are to be completed and monitored.

RESIDENT 2:

1. Action taken to correct the rule violation includes:

a) specific reasons for medication usage for resident 2 has been entered in MAR

2. The system will be corrected so that the violation will not occur again by daily, weekly, and monthly review  ensuring all residents' medications have a reason for use for each resident's medication record.

3. Corrections will be evaluated daily, weekly, and monthly review to ensure all residents' medications have reason for use for each resident's medication record.

4. Memory Care Administrator, Wellnes Director (RN) and/or designee will be responsible for corrections that are to be completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure MARs had resident-specific parameters for PRN medications for 1 of 1 sampled resident (# 15) who had multiple PRN medications prescribed for the same diagnosis. Findings include, but are not limited to:

Resident 15 moved into the facility in 09/2023 with diagnoses including mild cognitive impairment.

The resident's MARs dated from 03/01/25 through 04/16/25 and the resident's clinical record was reviewed.

a. There was no documented evidence of parameters to direct unlicensed staff on which PRN bowel medication to administer in what order for the following medications:

* Bisacodyl suppository;

* Bisacodyl tablet;

* Enema; and

* Milk of magnesia.

b. There was no documented evidence of parameters to direct unlicensed staff on which PRN pain medication to administer in what order for the following medications:

* Acetaminophen; and

* Ibuprofen.

The need to ensure MARs included parameters to direct unlicensed staff on the sequential order of medications prescribed for the same diagnosis was reviewed with Staff 1 (Senior Executive Director), Staff 23 (Wellness Director/RN), Staff 28 (Wellness Nurse/LPN), and Staff 29 (Administrator) on 04/17/25. No additional information was provided.

C310 - OAR 411-054-0055 (2): Systems - Medication Administration

1.What actions will be taken to correct the rule violation for each example/resident?

The facility acknowledges the cited deficiency of not ensuring that MARs (Medication Administration Records) include resident-specific parameters for PRN (as-needed) medications. Immediate corrective actions include:

a. PharMerica will conduct an in-service training with facility medication managers, focusing on proper documentation of PRN parameters and best practices in medication administration.

b. Administrative Consultant with RN credentials will conduct a three-way audit-comparing the MAR, medication cart, and physician orders-to identify and correct any discrepancies, including missing or unclear PRN parameters.

____________________

Amended C310 (1): What was done for the resident used the example and how will the facility ensure all residents have identified parameters for administration by the AOC date?

?Resident #15: A full chart audit has been conducted to ensure the MAR includes clear and sequential instructions for PRN medication administration. The instructions have been updated to reflect the following parameters:

1) PRN Bowel Medications:

oFirst: Administer Milk of Magnesia

oSecond: If ineffective, administer Bisacodyl tablet

oThird: If no result, administer Bisacodyl suppository

oLastly: Use enema if prior interventions fail

2) PRN Pain Medications:

oFirst: Administer Acetaminophen as the initial intervention for pain.

oSecond: If ineffective, Ibuprofen may be administered within 2 hours of the given Acetaminophen dose.

o

?Facility-Wide Plan:

To ensure all residents have clearly identified PRN parameters by the AOC date, a comprehensive audit of all current resident charts will be completed by administrative consultants. This audit will focus specifically on PRN medications to ensure each has:

oA clearly defined sequence of use

oSpecific time intervals between options

oClear documentation on the MAR that guides caregivers on when and how to administer each PRN medication

Any missing or unclear parameters in PRN (as-needed) medication orders will be promptly identified and corrected. Updated and complete documentation will be obtained and signed by the prescribing physician.

Staff Re-Education and Documentation: Medication Technicians (Med Techs) will be re-educated on the following, with training documented in their personnel files:

oThe revised PRN medication protocols to ensure full understanding and compliance.

oThe daily triple-check system, which must be strictly followed:

oFirst Check: Conducted by the Med Tech upon receipt of new medication orders.

oSecond Check: Conducted by another Med Tech, Administrator, Lead Med Tech, or designee to ensure redundancy and accuracy.

oFinal Check: Conducted by the Licensed Nurse (LN) for final verification and sign-off.

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

a. A double-check system will be implemented for all 90-day physician orders. Each order will be reviewed by two different staff members prior to being submitted for physician signature, ensuring PRN instructions and parameters are clearly defined and documented.

______________________

Amended C310 (2): How will the facility ensure all residents' MARs and physician orders are audited to ensure accuracy of administering medications?

?Administrative Consultant will complete a full audit of all current residents' Medication Administration Records (MARs) and physician orders to verify accuracy in medication administration by the AOC date.

?The facility will ensure continued accuracy by auditing each resident's MARs and physician orders during the routine 90-day physician order review and the daily triple check system as well.

?Any discrepancies identified during these audits will be addressed immediately, with corrections documented and appropriate follow-up conducted, including staff re-education if necessary.

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

oThis area will be reviewed during QAPI meetings monthly for three months, and then quarterly thereafter.

_____________________

Amended C310 (3): How frequent will this are need to be evaluated to ensure all residents have parameters identified on their MAR after medication changes?

?All new medication and treatment orders will be reviewed daily during clinical stand-up meetings to ensure that each includes clearly defined parameters and directions appropriate for unlicensed staff.

?Any missing or unclear instructions will be addressed immediately through coordination with the prescribing provider.

?Monthly audits of Medication Administration Records (MARs) will also be conducted by Wellness Nurse, Administrator or designee to ensure continued compliance and accuracy in documentation of medication parameters.

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

oThe Memory Care Administrator, Wellness Director, Wellness Nurse, Executive Director and/or designee will be responsible for oversight and compliance.

5.Date facility alleges compliance:

oThe facility alleges full compliance by May 17, 2025     

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

There was no documented evidence the facility was accurately using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.

A review of the ABST being used by the facility and an interview with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/06/24 revealed the following:

* During a review of sampled resident's service plans, it was determined the ABST failed to accurately include activities of daily living and other tasks related to care due to service plans lacking updated and accurate information on resident care needs; and

* The required care elements for each resident were not visible as a time allotment for each ADL area.

The requirements of the ABST were discussed with Staff 1, Staff 2 and Staff 3 (Wellness Director, LPN) on 03/06/24. They acknowledged the current acuity tool in use by the facility did not include all the required information and did not generate an accurate staffing plan.

OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool

1. Actions will be taken to correct rule violations include:

a) Service plan will be updated for each resident reflecting their needs,

b) Siginificant change of condition evaluations will be updated for residents who experience significant change of condition to reflect their needs.

c) Update acuity-based staffing tool to convert residents' needs into staffing hours to generate a staffing plan

2. System will be corrected so this violation will not happen again by:

a) Service plan will be updated for each resident reflecting their needs,

b) Siginificant change of condition evaluations will be updated for residents who experience significant change of condition to reflect their needs.

c) Update acuity-based staffing tool to convert residents' needs into staffing hours to generate a staffing plan

d) facility met with Katie Gaffney, ABST Policy Analyst for Safely, Oversight and Quality Unit to learn ABST requirements. Facility is working with our ABST system (Alis) to pull reports of 22 ADLs corresponding with hours needed for each resident to generate a staffing plan.

3. The area needing correction will be evaluated to address a resident's needs:

a) before a resident move in,

b) within the first 30 days of resident move in,

c) whenever there is a significant change of condition, and/or

d) quarterly of update resident's service plan

4. Memory Care Administrator, Wellness Director (RN), Executive Director, and/or designee will be responsible for ensuring corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 9, 11, and 13) had documented demonstration of competency of first aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 03/06/24 at 10:30 am revealed the following:

There was no documented evidence Staff 9 (CG), hired 10/20/23, Staff 11 (MT), hired 07/30/23, and Staff 13 (MT), hired 12/01/23, had demonstrated competency in first aid and abdominal thrust within 30 days of hire.

The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Senior Executive Director), Staff 2 (Administrator) and Staff 3 (Wellness Director, LPN) on 03/06/24. They acknowledged the findings.

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

1. Actions taken to correct the rule violation includes:

a) Current direct care staff will be trained in the use of the abdominal thrust and First Aid.

b) Newly hired direct care staff will be trained in use of the abdominal thrust and First Aid within 30 days of hire.

2. The system will be corrected so that the violation will not occur again by weekly review of staff training either through Relias system or manual tracking spreadsheet for newly hired staff to ensure staff to be trained on abdominal thrust and First Aid within 30 days of hire.

3. Corrections will be evaluated weekly and as needed to ensure staff to be trained on abdominal thrust and First Aid within 30 days of hire.

4. Memory Care Administrator, Business Office Administrator, and/or designee will be responsible for corrections that are to be completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (#16) had documented demonstration of competency in abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Review of the facility's training records on 09/10/24 at 3:50 pm revealed the following:

There was no documented evidence Staff 16 (Med Care Manager), hired 05/31/24, had demonstrated competency in abdominal thrust within 30 days of hire.

The need to document demonstrated competency of job duties within 30 days of hire was discussed with Staff 1 (Executive Director), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24. They acknowledged the findings.

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

1. Action taken to correct the rule violation includes:

a) Newly hired direct care staff #16 training record has been updated to reflect demonstration of competency in abdominal thrust training.

2. The system will be corrected so that the violation will not occur again by reviewing all staff training records to meet all training requirements including pre-service, 30 days competencies, and annual training.

3. Corrections will be evaluated weekly and as needed to ensure staff to be trained on abdominal thrust within 30 days of hire.

4. Memory Care Administrator, Business Office Manager, and/or designee will be responsible for corrections that are to be completed and monitored.

5. Facility alleges compliance: October 26, 2024.

Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of fire drill and fire and life safety records from August 2023 through February 2024 identified the following required elements were not documented:

* Location of simulated fire origin;

* Escape route used; and

* Problems encountered, comments relating to residents who resisted or failed to participate in the drill.

The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 1 (Senior Executive Director), Staff 2 (Administrator) and Staff 4 (Maintenance Director) on 03/04/24. They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety:

1. Action taken to correct the rule violation includes:

a) Fire drill form will be updated to include the elements; location of simulated fire origin, escape route used, and problems encountered, comments relating to residents who resisted or failed to participate in the drill.

2. To ensure that the system will be corrected and that the violation will not occur again, the fire drill form will be updated to include the elements location of simulated fire origin, escape route used, and problems encountered, comments relating to residents who resisted or failed to participate in the drill will be included.

3. Corrections will be evaluated monthly or as needed to ensure the fire drill form is completed with the elements of location of simulated fire origin, escape route used, and problems encountered, and having comments relating to resident who resisted or failed to participate in the drill.

4. Memory Care Administrator, Maintenance Director and or designee will be responsible for corrections that are to be completed and monitored.    

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

Refer to C 260, C 270, C 280, C 290, C 303, C 372, Z 155, and Z 163.

C 455: OAR 411-054-0150 (2-4) Inspections and Investigation: Insp Interval

Please refer to C 260, C 270, C 280, C 290, C 303, C 372, Z155, and Z 163

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

Refer to C231, C270, and C303.

C 455: OAR 411-054-0150 (2-4) Inspections and Investigation: Insp Interval

Please refer to C231, C270, and C303.

Facility Alleges Compliance by February 1, 2025.

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

Refer to C 231, C 270, and C 303.

C455 - OAR 411-054-0105 (2-4): Inspections and Investigations - Inspection Interval

Corrective Action:

Please refer to the following previously submitted plans of correction, which address the violations associated with inspection interval compliance:

oC231 - Reporting & Investigating Abuse

oC270 - Change of Condition and Monitoring

oC303 - Systems: Treatment Orders

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

On 03/04/24 during a tour of the facility, there was an electric fireplace insert identified inserted in the partial wall facing the communal living room.

On 03/04/24 at approximately 3:20 pm, the electric fireplace insert was observed on and was hot to touch. Temperatures were taken by this surveyor of the metal material bordering the electric fireplace insert. Temperatures ranged between 132 and 182 degrees Fahrenheit. Survey immediately informed Staff 1 (Senior Executive Director) of the excess temperatures. Staff 1 stated the electric fireplace insert would be turned off promptly and the functional remote would be removed to ensure resident safety.

The need to ensure the surfaces around the electric fireplace insert did not exceed 120 degrees Fahrenheit was discussed with Staff 1 and Staff 4 (Maintenance Director) on 03/05/24 at 10:48 am. They acknowledged the findings.

On 03/06/24, Staff 1 informed the survey team that the electric fireplace insert settings had been adjusted and would no longer produce heat. This surveyor observed the digital fireplace to be on and was cool to touch.

OAR 411-054-0200 (8) Heating and Ventilation

1. Action taken to correct the rule violation includes:

a) electric fireplace heating element has been disconnected to ensure the electric fire place insert did not exceed 120 degress Fahrenheit

2. The system will be corrected so that the violation will not occur again by disconnecting the heat element for the electric fire place.

3. Correction will be evaluated daily.

4. Memory Care Administrator, Maintenance Director, and/or designee will be responsible for corrections that are to be completed and monitored.

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 361, C 372, C 420, and C 540.

OAR 411-057--140(2) Administration Compliance

Refere to C 361, C372, C 420, and C 540

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

Refer to C 150, C 231 and C 372.

OAR 411-057-0140 (2) Administration Compliance

Please refer to  C 150, C 231 and  C372.

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

Refer to C231.

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

Please refer to C231

Facility Alleges Compliance by February 1, 2025.

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

Refer to C 231.

OAR 411-057-0140 (2): Administration - Compliance

Corrective Action:

Please refer to:

oC231 - Reporting & Investigating Abuse

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 4, 9, 11, and 13) had completed all required orientation, pre-service training prior to beginning their job duties and/or had documented evidence of competency demonstrated within 30-days of hire. Findings include, but are not limited to:

Review of training records for newly hired Staff 4 (Maintenance Director) hired 12/23/23, Staff 9 (CG) hired 10/20/23, Staff 11 (MT) hired 07/30/23, and Staff 13 (MT) hired 12/01/23 identified the following:

*Staff 4, 9, 11, and 13 failed to have documented evidence of completing all orientation and pre-service training's prior to beginning their job duties; and

*Staff 9, 11, and 13 failed to have documented all required competencies demonstrated within 30-days of hire.

On 03/06/24, the need to ensure all orientation and pre-service training was completed prior to starting job duties and all 30-day competencies were demonstrated and documented was discussed with Staff 1 (Senior Executive Director), Staff 2 (Administrator), and Staff 3 (Wellness Director, RN). They acknowledged the findings. Staff 1 stated Staff 9, 11, and 13 would remain off the schedule until they complete med-pass and first aid/abdominal thrust.

OAR 411-057-0155 (1-6) Staff Training Requirements

1. Action taken to correct the rule violation includes:

a) Current staff will complete all required orientation, pre-service training prior to beginning their job duties.

b) Newly hired staff will complete all required orientation, pre-service training prior to begining their job duties.

c) Current staff will have the completed records of all required competencies demonstrated within 30-days of hire.

d) Newly hired staff will have the completed records of all required competencies demonstrated within 30-days of hire.

2. The system will be corrected so that the violation will not occur again by:

a) track and document staff training records when they are hired to ensure all required orientation, pre-service training prior beginning their job duties.

b) track and document staff training records to ensure all required competencies are demostrated within 30 days of hire.

3. Corrections will be evaluated:

a) upon staff hire and as needed to ensure staff are trained on orientation, pre-service training prior to  beginning their job duties.

b) daily, weekly, monthly to ensure all required competencies demonstrated within 30 days of hire.

4. Memory Care Administrator, Business Office Administrator, and/or designee will be responsible for corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (#16) had documented evidence of satisfactory performance in any assigned job duty within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were requested at 2:24 pm on 09/09/24. Review of the facility's training records on 09/10/24 at 1:30 pm revealed the following:

There was no documented evidence Staff 16 (Med Care Manager), hired 05/31/24, had demonstrated competency in assigned job duties within 30 days of hire. During an interview at 3:50 pm on 09/14/24, Staff 1 (Executive Director) stated Staff 16 completed and signed competencies, including medication pass training, on 09/09/24, after it was discovered she did not have them. Documentation of the completed competencies was received at the time of the interview.

The need to ensure satisfactory performance in assigned job duties was demonstrated and documented within 30 days of hire was discussed with Staff 1, Staff 2 (Reflections Coordination), and Staff 13 (Regional Vice President of Wellness) on 09/11/24 at 3:45 pm. They acknowledged the findings.

Z 155: OAR 411-057-0155(1-6) Staff Training Requirements

1. Action taken to correct the rule violation includes:

a) Newly hired direct care staff #16 training record has been updated to reflect demonstration of competency as Med Tech.

2. The system will be corrected so that the violation will not occur again by reviewing all staff training records to meet all training rule requirements including pre-service, 30-day competencies, and annual training.

3. Corrections will be evaluated weekly and as needed to ensure staff training records meeting all training rule requirements including pre-service, 30-day competencies and annual training.

4. Memory Care Administrator, Business Office Manager, and/or designee will be responsible for corrections that are to be completed and monitored.

5.Facility alleges compliance: October 26, 2024.      

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 252, C 260, C 270, C 280, C 290, C 303, C 305, and C 310.

OAR 411-057--160(2b) Compliance with Rules Health Care

Please refer to C 252, C 260, C 270, C280, C290, C303, C305, and C 310

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

Refer to C 260, C 270, C 280, C 290, and C 303.

OAR 411-057-0160 (2b) Compliance with Rules Health Care

Please refer to C 260, C 270, C 280, C 290 and C 303.

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C270 and C303.

Z 162: OAR 411-057-0160(2b) Compliance with Rules Health Care

Please refer to C270 and C303

Facility Alleges Compliance by February 1, 2025.

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 260, C 270, C 303 and C 310.

OAR 411-057-0160 (2)(b): Compliance with Rules - Health Care

Corrective Action:

Please refer to the following plans, which collectively address the cited healthcare compliance issues:

oC260 - Service Plan: General

oC270 - Change of Condition and Monitoring

oC303 - Systems: Treatment Orders

oC310 - Medication Administration

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 2 of 3 sampled residents (#s 2 and 3) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to:

Service plans for Residents 2 and 3 were reviewed during survey. Both service plans lacked individualized nutrition and hydration information and staff instructions related to resident specific nutrition and hydration needs.

The need to ensure that individualized nutrition and hydration plans in resident service plans was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/06/24. They acknowledged the findings.

OAR 411-057-0160(2)©(A)(B) Nutrition and Hydration

RESIDENT 2 and RESIDENT 3

1. Actions taken to correct rule violations includes:

a) individualized nutrition and hydration information and staff instructions related to resident 2 and resident 3 will be added into their service plan.

b) All staff will be receive in-service plan training specific to offer nutrition and hydration specific to resident 2 and resident 3.

2. All residents' service plans will be adjusted to reflect individualized nutrition and hydration information and staff instructions related to offer nutrition and hydration.

3. System will be evaluated weekly to ensure individualized nutrition and hydration information  is reflected on each resident's service plan.

4. Memory Care Administrator, Wellness Director (RN) and/or designee will be responsible for ensuring corrections are completed and monitored.  

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 plan for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 4 and 5's current service plans, dated 06/16/24 and 08/09/24, respectively, were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.  

The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED), Staff 2 (Reflections Coordinator), and Staff 13 (Regional Vice President of Wellness) on 09/11/24 at 5:05 pm. They acknowledged the findings.

Z 163: OAR 411-057-0160(2)(A)(B) Nutrition and Hydration

RESIDENT 4 and RESIDENT 5

1. Actions taken to correct rule violations includes:

a) Resident's service plans have been updated to reflect individualized a daily meal program based on resident's preferences and needs.

2. All residents' service plans will be adjusted to reflect individualized nutrition and hydration information and staff instructions related to offer nutrition and hydration.

3. System will be evaluated weekly to ensure individualized nutrition and hydration information is reflected on each resident's service plan.

4. Memory Care Administrator, RN and/or designee will be responsible for ensuring corrections are completed and monitored

5.Facility alleges compliance: October 26, 2024.  

Based on observation, interview, and record review, it was determined the facility failed to ensure the activity evaluation addressed all required components and an individualized activity plan was developed based on the activity evaluation for 3 of 3 sampled residents (#s 1, 2, and 3) whose activity plans were reviewed. Findings include, but are not limited to:

During the survey, many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, which several residents attended. Some residents did not attend the activities and, instead, stayed in their rooms or walked around the facility.

The activity section of Resident 1, 2 and 3's current service plans were reviewed. Though there was some information about each resident's past or current interests, the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations needed 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 residents with more individualized activities. There were no instructions for providing activities for residents who did not participate in group activities. Individualized activity plans were not included on the resident's activity service or care plan.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Senior Executive Director) and Staff 2 (Administrator) on 03/05/24. They acknowledged the findings.

OAR 411-057-0160(2d) Activities

RESIDENT1, RESIDENT 2, RESIDENT 3

1. Actions taken to correct rule violations includes:

a) Individualized activity plan separate from service plan for resident 1, resident 2, and resident 3 will be developed base on the activity evaluation to include the elements of:

*Resident's past interests

*Resident's current interests

*Current abilities and skills;

*Physical abilities and limitations;

*Adapations needed to participate; and

*Identification of activities for behvioral interventions.

b) Individualized activity plan seperated from service plans for resident 1, resident 2, and resident 3 will be developed to include the elements of:

*when, how, and how often staff should offer and assist residents based on their individualized activities.

*staff instructions for providing activities for these 3 residents who do not participate in group activities.

2. System will be corrected so this violation will not happen again by

a)developing an individualized activity plan to include all the above elements for each resident going forward.

b) Staff will receive in-service training specific to how to provide activities based on an individualized activity plan for each resident.

3. The area needing correction will be evaluated weekly, monthly, quarterly and as needed.

4. Memory Care Administrator, Life Enrichment Coordinator, and/or designee will be responsible for ensuring corrections are implemented, completed, maintained and monitored.

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design and maintained to prevent resident injury or aid in elopement. Findings include, but are not limited to:

On 03/04/24 at 10:00 am during a tour of the facility's outdoor recreation area, the following was identified:

* Multiple chairs and several tables that were lightweight;

* Four chairs and one table were located directly next to the perimeter fencing, increasing the potential of elopement; and

* An unsampled resident was observed shifting and lifting two different chairs, up to approximately four inches at a time.

On 03/05/24 at 10:48 am, a tour of the outdoor recreation area was completed with Staff 1 (Senior Executive Director) and Staff 4 (Maintenance Director). They acknowledged the findings.

OAR 411-057--170 (6) Secure Outdoor Recreation Area

1.Outdoor furniture will be adjusted to ensure:

a) sufficient weight to prevent resident injury or aid in elopement.

b) the location of furniture not next the to perimeter fencing to prevent the potential of an elopement

2. System will be corrected so this violation will not happen again by adjusting outdoor furniture:

a) to have sufficient weight to prevent resident injury or aid in elopement.

b)Furniture will not be located next to the perimeter fencing to prevent the potential of an elopement.

3. Corrections will be evaluated daily as as needed.

4. Memory Care Administrator, Maintenance Director and/or designee will be responsible for corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their room. Findings include, but are not limited to:

Observations of the memory care from 03/04/24 through 03/06/24 determined 15 of 23 occupied resident rooms (#s 201, 203, 207, 208, 210, 211, 213, 215, 217, 219, 220, 222, 224, 225, and 232) lacked individual identification of the room for the resident. Each identified resident had resided in the facility for more than five weeks.

The need to ensure each resident room was individually identified was reviewed with Staff 1 (Senior Executive Director) and Staff 4 (Maintenance Director) on 03/05/24 at 10:48 am. They acknowledged the findings.

OAR 411-057-0179(9) Resident Rooms

1. Actions taken to correct the rule violation includes:

a) Individualize each resident's memory box, located outside resident's door to assist residents in recognizing their room.

2. System will be corrected so this violation will not happen again by assisting residents/families to individualize each resident's memory box within their first 30 days of move in.

3. The area needing correction will be evaluated monthly.

4. Memory Care Administrator, Life Enrichment Coordinator and/or designee will be responsible for corrections are completed and monitored.