The findings of the re-licensure survey, conducted 08/13/24 through 08/15/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 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. Tag numbers beginning with the letter H refer to the 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 first re-visit to the re-licensure survey of 08/15/24, conducted 09/24/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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

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 second revisit to the re-licensure survey of 08/15/24, conducted on 12/10/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure residents' rights to receive services in a manner that protected privacy and dignity for residents who had a shared bathrooms and living space. Findings include, but are not limited to:

The facility had 10 resident rooms with shared bathrooms. All bathrooms in resident rooms were not lockable.

The facility had six rooms where residents shared living and sleeping space. The rooms were observed and noted to be without a privacy curtain or screen of any kind to provide privacy.

The lack of privacy for residents residing in shared apartments was reviewed with Staff 1 (Director), Staff 2 (RN), Staff 3 (Assistant Director), and Staff 4 (RCC). They acknowledged the findings.

C-200 ORA 411-054-0027

Privacy/Dignity-

The following actions have been taken to correct the violations noted, per examples listed:

1.Facility has installed a locking system in each of the eight shared bathroom rooms in the memory care unit at Prairie House MCU. Two out of the ten rooms utilize restrooms that will always remain private/ not shared and will not have a need for locks.

2.The six rooms in Memory Care that have a shared sleeping space have been provided with a privacy curtain that is attached to the ceiling of each room and may be closed during resident care, or whenever a resident may choose to close it.

3.This system is being corrected by the Maintenance and the Campus Administrator: Bathroom locks were installed, and privacy curtains hung in all shared spaces.

4.Maintenance and Administrator will check daily (during the working week) while doing the morning walk through the building to ensure all locks and curtains are in good repair.

Based on interview and record review, it was determined the facility failed to ensure resident physical altercations were reported to the local SPD office for 1 of 1 sampled resident (#1) who was involved in a physical altercation. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 01/2023 with diagnoses including Parkinson's.

A facility Charting Note dated 03/21/24 indicated: "Resident is being placed on alert due to having an altercation with another resident. [S/he] was sitting at the table after dinner with table mates and one of [his/her] mates didn't like that [s/he] was making a grunting sound, due to [Resident 1's] Parkinson's [s/he] was unable to stop making the sound which agitated [his/her] table mate and [room number] went up to [Resident 1] and [room number] and grabbed [him/her] by the collar of [his/her] shirt and proceeded to punch [him/her] with a full fist in the face, and punched [him/her] multiple times in the head. [Resident 1] had two scratches on both sides of [his/her] neck where the other resident had grabbed [him/her], and has was [sic] looked like a start of a bruise on the left side of [his/her] face due to being punched in the face..."

There was no documented evidence the incident had been reported to the local unit.

The need to ensure physical altercations were immediately reported to the local SPD was reviewed with Staff 1 (Director) on 08/14/24. The  staff acknowledged the findings.

The facility was asked to report the physical altercation. Confirmation of the report was provided prior to survey exit.

C231 OAR 411-054-0028

Reporting & Investigation Abuse: Other Action-

1.The following actions have been taken to correct this violation:

A. Retraining of staff/Medication Technicians has taken place on the Memory Care unit at Prairie House by teaching staff how to first locate and then utilize the correct forms for abuse reporting and how to follow the correct policy and procedure for reporting abuse to administration and the state correctly.

B. As well as correctly identifying abuse.

C. A shelf has been cleared in Memory Care and a desk organizer/mail basket with slots has been placed on this shelf containing the correct forms for abuse reporting. Also, instructions have been posted on the front of this basket so that there will be no room in the future for misinterpretation.

D. During morning stand up/morning management meeting, this component will be added to the daily check list.

2.This system is being corrected by: The facility Administrator, MCU Administrator, and the Resident Care Coordinator/RCC.

3.The facility Administrator, MCU Administrator, and RCC will be responsible for correction and overseeing ongoing compliance.

Based on observation, interview, and record review, it was determined the facility failed to immediately investigate an un-witnessed fall, document the fall was not the result of abuse or neglect, and report the incident to the local SPD office if abuse could not be ruled out, for 1 of 1 sampled resident (#4). This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 04/2024 with diagnoses including dementia.

During the survey, Resident 4 was observed to ambulate with the use of a walker and stand by assistance from staff.

Facility Charting Notes from 09/04/24 through 09/20/24 were reviewed and staff were interviewed. Staff reported Resident 4 required assistance with care and at times required two staff for transfers.

On 09/17/24 facility Progress Notes indicated "...was found on floor with head under dresser..." at 2:40 pm.

A facility incident investigation dated 09/17/24 noted "Resident found on floor in [his/her] room. [His/her] head was under the dresser on the co-residents (sic) side of the room. [S/he] was showing signs of being disoriented, and confused, [s/he] is having some signs of redness and rug burn on the left side of [his/her] head. Resident unable to give description."

The investigation of the un-witnessed fall did not rule out abuse or neglect. There was no evidence the incident had been reported to the local SPD.

In an interview with Staff 1 (Director) on 09/24/24, she acknowledged the incident investigation had not ruled out abuse or neglect and it had not been reported.

The need to immediately investigate un-witnessed falls to rule out abuse or neglect, and report the incidents to the local SPD office if abuse could not be ruled out, was reviewed with Staff 1 (Director), Staff 3 (Assistant Director), and Staff 4 (RCC) on 09/24/24. They acknowledged the findings.

The above incident was reported to the local SPD on 09/24/24.

C231 OAR 411-054-0028 Reporting/ Investigating Abuse-Other Action

The following actions have been taken to correct the violation noted, per examples listed below.

1.)Policy and procedure have been reviewed by RN with all med techs. Forms for reporting abuse to the local APD/APS office have been place in the medication room with clear instructions posted with them. RN is also teaching class to all Prairie House medication tech on how to tell the whole story taking credit for work done during the investigation by documenting correctly. While documenting/investigating ensuring abuse and neglect are ruled out or reported immediately to APD/APS.

2.)This system is being corrected by Nursing. RN will check incident reports before they are completed each day in the electronic system in place/Point Click Care, and review with both Directors on a daily basis either at morning stand up or at end of day.

3.)The system will be maintained by Nursing/RN and reviewed daily by MCU and Campus Directors.

Based on interview and record review, it was determined the facility failed to ensure MARs included resident-specific parameters for PRN medications and medication-specific instruction to direct non-licensed staff for 2 of 2 sampled residents (#s 1 and 2) whose medications were reviewed. Findings include, but are not limited to:

Resident 1 and 2's 08/01/24 through 8/16/24 MARs and current medication orders were reviewed.

1. Resident 1 was admitted to the facility in 01/2023 with diagnoses including Parkinson's and anxiety.

Resident 1 had the following PRN orders for pain:

* Arnicare gel three times daily as needed for pain;

* Acetaminophen 325 mg two tablets every six hours as needed for pain;

* Cyclobenzaprine 10 mg nightly if painful; and

* Tramadol 50 mg every six ours as needed for pain.

Resident 1 had the following PRN orders for skin treatment:

* Dermacerin cream to affected areas as needed for rash;

* Hydrocortisone 0.5% cream to affected areas twice daily for rash; and

* Nystatin 100,000 gram powder to affected area twice daily as needed for rash.

The MAR lacked parameters and clear instructions to guide unlicensed staff which medication to attempt first.

The need to provide clear parameters and instructions to guide non-licensed staff in the administration of PRN medications was reviewed with Staff 1 (Director) and Staff 2 (RN). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2024 with diagnoses including dementia.

Resident 2 had the following PRN orders for bowel care:

* Bisacodyl 10 mg suppository as needed for bowel care; and

* Polyethylene glycol powder as needed for bowel care.

Resident 2 had the following PRN orders for pain:

* Acetaminophen 325 mg two tablets as needed for pain; and

* Morphine 15 mg as needed for pain.

The MAR lacked parameters and clear instructions to guide unlicensed staff which medication to attempt first.

The need to provide clear parameters and instructions to guide non-licensed staff in the administration of PRN medications was reviewed with Staff 1 (Director) and Staff 2 (RN). They acknowledged the findings.

C310 OAR  411-054-0055

Medication Administration  

The following action has been taken to correct this violation:

1.The facility RN has worked in coordination with each resident's PCP and the correct pharmacy to ensure that resident-specific orders are in place in Point Click Care EMAR system with appropriate parameters also being in place to ensure that non-licensed staff have instruction on when and how to administer PRN/As Needed medications.

2.This system was corrected by the facility RN.

3.The facility RN will be responsible for correction and overseeing ongoing compliance. RN will check parameters when confirming a new medication in Point Click Care.

Based on interview and record review, it was determined the facility failed to ensure MARs included resident-specific parameters for PRN medications and medication-specific instruction to direct non-licensed staff for 2 of 2 sampled residents (#s 3 and 4) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 3 and 4's 09/01/24 through 9/24/24 MARs were reviewed.

1. Resident 3 was admitted to the facility in 11/2022 with diagnoses including dementia and was receiving hospice services.

Resident 3 had the following PRN orders for pain:

* Acetaminophen 500 mg two tablets every four hours as needed for pain;

* Oxycodone 5 mg one tablet every two hours as needed for pain; and

* Morphine Sulf IR 15 mg tablet every four hours as needed for pain.

The Oxycodone was given five times in 09/2024.

The MAR lacked parameters and clear instructions to guide unlicensed staff which medication to attempt first.

On 09/24/24, the need to provide clear parameters and instructions to guide non-licensed staff in the administration of PRN medications was reviewed with Staff 1 (Director), Staff 3 (Assistant Director), and Staff 4 (RCC). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 04/2024 with diagnoses including dementia and was receiving hospice services.

Resident 4 had the following PRN orders for pain:

* Acetaminophen 325 mg two tablets every four hours as needed for pain; and

* Morphine 15 mg one tablet every hour as needed for pain.

Both medications had been administered in 09/2024.

The MAR lacked parameters and clear instructions to guide unlicensed staff which medication to attempt first.

Resident 4 had the following PRN orders for anxiety and agitation:

* Haloperidol 1 mg one tablet every hour as needed for agitation; and

* Lorazepam 0.5 mg every three hours as needed for anxiety.

The Lorazepam was administered twice in 09/2024.

The MAR lacked parameters and clear instructions to guide unlicensed staff how the resident would express anxiety or agitation.

On 09/24/24, the need to provide clear parameters and instructions to guide non-licensed staff in the administration of PRN medications was reviewed with Staff 1 (Director), Staff 3 (Assistant Director), and Staff 4 (RCC). They acknowledged the findings.

C 310 OAR 411-054-0055 Systems Medication Administration

1.)The following actions have been taken to correct the violation noted.

ED for campus has reached out to all 3rd party hospice agencies and requested that they send orders moving forward that clearly state PRN medications parameters spell out when they are to be given and what order. The facility RN will continue to work with all PCP Primary Care Physicians on doing the same. This standard will pertain to all PRN medications whether it be bowel care or pain narcotics.

2.)This system is being corrected by Nursing on a daily basis while checking and confirming orders from outside agencies such as hospices or any PCPs sending new orders for any resident to Prairie House in the EMAR system/Point Click Care.

3.)The Administrator will follow up with the RN daily to ensure the system is being followed and orders are being corrected as legally as possible through the cooperation of all outside agencies such as hospice and/or all doctors involved in the care of our residents at Prairie House.

Based on interview and record review, it was determined the facility failed to develop a staffing plan to meet the scheduled and unscheduled needs of the residents based on care minutes calculated by their ABST tool. Findings include, but are not limited to:

The facility's ABST tool calculations, resident ABST data entries, and the facility's staffing plan were reviewed on 08/13/24 and 08/14/24.

Review of resident ABST entries showed multiple ADL areas which reflected excessive minutes for care. Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (Director). Staff 1 acknowledged the staffing plan was not accurate.

The facility had a census of 14 residents at the time of the survey.

Review of the staffing plan generated by the ABST indicated a need for 18 staff at times.

The need to ensure ABST resident entries were accurate and staffing calculations were used to develop and implement a staffing plan to meet resident needs was discussed with Staff 1 on 08/13/24. She acknowledged the findings.

C361 OAR 411-054-0037

Acuity Based Staffing Tool

The following actions have been taken to correct this violation:

1.The Administrator of the facility has arranged for ABST training with Katie Gaffney with DHS and Kim Hector DHS (policy and procedure analyst) and attended said training with the MCU Administrator and the Resident Care Coordinator/ RCC.

2.All Memory Care Unit resident individual Acuity Based Staffing Tool profiles have been reviewed and corrected in the state ABST by the Administrator of the facility.

3.The system itself is being corrected by:

A. Campus Administrator, MCU Administrator, and RCC attending retraining.

B. Campus Administrator initially reviewing and correcting all MCU resident profiles in the State ABST.

C. The Campus Administrator, Memory Care Administrator, and Resident Care Coordinator/ RCC will be responsible for correction and overseeing ongoing compliance with the ABST. RCC will update as each Service Plan is created/updated and will notify the Campus Administrator and Memory Care Administrator of any changes.

Based on observation, interview, and record review, it was determined the facility failed to ensure the re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 231, C 310, and H 1518.

C 455 OAR 411-054-0105 Administrative Compliance

The following actions are being taken to correct this violation.

1.)The Director for the campus will review daily with RN any changes that need to occur to continue to help the facility stay in compliance with all re-licensure plan of corrections put in place and approved.

2.)This system will be corrected by the RN and both the MCU Director and Director of the campus.

3.)The Campus Director, MCU Director, and RN will work together daily to ensure corrective measures put in place on the plan of correction are continuing to be implemented and followed by all staff each day by daily monitoring of each system reviewed.

Based on observation and interview, it was determined the facility failed to ensure residents' rights of privacy and dignity. Findings include, but are not limited to:

Refer to C 200.

H1510 OAR411-004-0020 (1) (c)

See C200

Based on observation and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units. Findings include, but are not limited to:

Resident 1 was observed with a key on a lanyard around his/her neck.

In an interview with Staff 4 (CNA/MA) on 08/13/24, she stated three of the 14 residents living in the MCC were provided keys to their rooms.

The need to ensure all residents were provided keys to their units was discussed with Staff 1 (Director), Staff 3 (Assistant Director), and Staff 4 (RCC) on 08/13/24 and 08/14/24. They acknowledged the findings.

H1518 OAR411-004-0020

1.This action has been taken to correct this violation per examples listed:

*Facility has provided a key to every resident in memory care for their specific room.

*If they are unable to use their key it will be kept hanging in their room by their door in a spot that is ergonomically easy to reach/access.

*If the resident prefers a lanyard with their key on it has been provided so that they may wear it only during waking hours, or at all times.

2.This system is being corrected by providing all residents in Memory Care with a key for their door.

3.The facility Administrator and MCU Administrator will check to ensure keys are still in place with each resident either in their room or on their person and replacing lost/ misplaced keys on workday (Monday-Friday) morning walk through.

Based on observation and interview, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their unit. This is a repeat citation. Findings include, but are not limited to:

In an interview with Staff 6 (MA/CG) on 09/24/24, she stated all of the 12 residents living in the facility were provided keys to their homes. She explained residents who did not use the key had them hung on a lanyard inside their rooms.

Resident 3's room was noted to have a key on a lanyard hung inside the unit by the door. When attempting to use the key, it did not operate the lock to Resident 3's room.

Several other un-sampled residents rooms were observed with keys hanging inside the unit by the door. The keys did not operate the locks to the units, and when compared with each other,it was noted they were all the same key.

The need to ensure all residents were provided keys, keyed specifically to their units, was discussed with Staff 1 (Director), Staff 3 (Assistant Director), and Staff 4 (RCC) on 09/24/24. Staff 1 stated they were not aware the keys did not work or that they were not keyed to the specific resident units. They acknowledged the findings.

H1518 OAR411-004-0020

The following action has been taken to correct this violation noted.

1.)The facility has had new keys cut for each of the apartments in the MCU unit this time they will be color coded. Example 132's keys are red, 133's keys are blue this way staff will not be confused as to which keys belong to which room when residents take them out into the memory care unit and lay them down, thus ensuring the right key is returned to the right room by staff when they are found out in the memory care community.

2.)This system is being corrected by Maintenance who will ensure all room are color coded and staff has a master of the color codes for each room in memory care.

3.)Keys will be checked daily by the head of Maintenance and both Directors on the daily walk-throughs. In the future when an ordered engraver arrives room numbers may also be added to the color-coded keys.

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 200, C 231, and C 361.

Z142  OAR 411-057-0140 (2)

See C200, C231, and C361

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 231.

Z 142 OAR 411-057-0140 Administration Compliance

1.)See corrective action for C231 OAR 411-054-0028 Reporting/ Investigating Abuse-Other Action

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 310.

Z162 OAR 411-57-0160 (2b)

See 310

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 310.

Z 162 OAR 411-057-0160

1.)See corrective action for C 310 OAR 411-054-0055 Systems Medication Administration

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 1 of 2 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2024 with diagnoses including dementia.

Residents 2's records were reviewed during the survey. There was no documented evidence an activity evaluation which addressed the following elements was completed, nor that an individualized activity plan had been developed from the evaluation:

* Residents' past and current interests;

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate in activities; and

* Identified activities for behavior interventions.

There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist Resident 1 with individualized activities.

On 08/14/24 and 08/15/24, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (Director), Staff 3 (Assistant Director), and Staff 4 (RCC). They acknowledged the findings.

Z164 OAR 411-057-0160 (2d)

242   411-057-0610

Activities

1.The following actions have been taken to correct this violation, per example listed:

The facility is doing a thorough activity evaluation review on resident #2. An updated Activity evaluation containing her past and current interests, current abilities and skills, emotional/social needs/ patterns, her physical limitations, adaptations necessary for her to participate in activities, and identified activities for behavioral interventions.

2.This system is being corrected as follows:

A.The Campus Administrator will initiate the activity evaluation at the time of admission with the resident and family and complete the second half with the life enrichment coordinator.

B.Activity evaluation will be updated with any change of Condition/ CoC.

C.Activity evaluation will be updated with each service plan update.

3.This system will be elevated as follows:

A.The facility/ Campus Administrator, MCU director, RCC, and Life Enrichment Coordinator will update every service plan at every service plan meeting or with Change of Condition.