The findings of the relicensure survey, conducted 03/28/22 through 03/29/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/29/22, conducted 06/28/22 through 06/29/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.

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 revisit to the re-licensure survey of 03/29/22, conducted 01/09/23 are documented in this report.  It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

2.  Resident 3 was admitted to the facility in 2018 with diagnoses including dementia.

Observations of the resident from 03/28/22 to 03/29/22 revealed the resident required staff assistance with transfers and incontinent care.

Progress notes reviewed from 10/31/21 through 03/28/22 noted the following:

On 11/30/21, Staff documented Resident 3 had "large bruise on left buttock ..."

There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the injury of unknown cause was not the result of abuse or neglect of care.

On 03/29/22 at 1:07 pm, Staff 2 (RN/Health Service Director) confirmed the physical injury had not been investigated nor reported to the local APS.

The failure to investigate unknown physical injury and to report to local APS when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (ED) and Staff 2 on 03/29/22. The incident was reported to the local SPD office per request of the surveyor. Confirmation the incident had been reported was received on 03/29/22.

Based on observation, interview and record review, it was determined the facility failed to investigate incidents to rule out suspected abuse or neglect for 2 of 2 sampled residents (#s 1 and 3), who were identified to have sustained injuries of unknown cause. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia. Progress notes dated 02/11/22 through 03/25/22, the 03/01/22 through 03/28/22 MAR, and Hospice notes dated 03/14/22 through 03/28/22 were reviewed.

On 03/14/22, the Hospice RN identified a "pressure injury" to both left and right dorsal great toes. Facility progress notes, dated 03/24/22, provided instruction to staff to "leave shoes off" when the resident was in his/her room and informed staff that the Hospice RN brought a "foot tent" for the resident to use while in bed to minimize "discomfort at night." On 03/25/22, the MAR was updated directing staff to, "continue to monitor site to left big toe" and reported the area was "scabbed over."

On 03/29/22, Staff 2 (RN/Health Services Director) confirmed the facility had not investigated how Resident 1 obtained the bi-lateral pressure injuries on his/her toes.    

The need to ensure injuries of unknown cause were immediately and thoroughly investigated to rule out abuse and neglect or reported to the local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Memory Care Coordinator) on 03/29/22. They acknowledged the findings. As requested, the injuries of unknown cause were reported to the local SPD office before the survey concluded.

i.Abuse Reporting and Training, monthly training, refreshed and presented during all-staff, built upon the "Abuse Reporting and Investigation Guide for Providers" created by ODHS. Which, includes training to care staff to fill out an incident report any time he or she identifies a skin issue

ii.Med Tech, RSC, and RN to provide first, second, and third check for every outside provider note, to identify, among other items, any skin issue that does not have a facility generated incident report and investigation. Med tech will review all orders when first received and implement any medication changes as per provider orders. RSC will review all orders after med tech review and make any needed changes to care plan. RN will have the final review of all orders.

iii.  All skin issues/concerns will be reported to health services management team and reviewed daily during health services jump.  RN will review all incidents with injury that are reported during daily health services jump.

iv.  Health Service responsible to ensure corrections are made as outlined above.  

Resident 1- Incident report was completed for unexplained injuries and report completed to APS. Care plan has been updated to reflect skin interity concerns that were identified and reported. Skin concerns that have been identified as pressure injuries previously have not required completiong of incident reports however moving forward, will now include pressure injuries in incident reports to rule out abuse.

Resident 2- Incident report was completed for unexplained bruising and report completed to APS. Skin concern has since resolved.    

Based on observation, interview and record review, it was determined the facility failed to thoroughly investigate allegations of suspected abuse involving a resident-to-resident altercation and failed to report the incident to the local Seniors and People with Disabilities (SPD) office for 2 of 2 sampled residents (#s 3 and 4) who experienced a resident to resident altercation. This is a repeat citation. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 2018 with diagnoses including dementia and was observed during the survey to utilize a walker independently for mobility.

During the acuity interview on 06/28/22, Resident 3 was identified to be involved in a resident to resident altercation.

Interviews with staff and review of the resident's clinical records from 05/28/22 through 06/28/22 showed the following:

* 06/07/22 incident report indicated Resident 3 pushed his/her walker into the other resident's leg;

* 06/17/22 incident report indicated a caregiving staff found Resident 3 who was agitated and his/her clothes were wet with a dark liquid; and

* In an interview on 06/28/22, Staff 10 (Lead Med Tech) stated Resident 3 was involved in a resident to resident altercation on 06/17/22.  Staff stated Resident 3 threw coffee at a non-sampled resident which resulted in a non-sampled resident fall and the non-sampled resident threw a coffee cup at Resident 3.

There were no documented evidence the incidents had been thoroughly investigated to rule out the possibility of abuse and there was no documented evidence the incidents were reported to the local SPD.

On 06/29/22, the surveyor requested Staff 2 (Health Services Director /RN) and Staff 9 (ALF Administrator) report the incident to SPD. Subsequently, the surveyor received verification the incident had been reported.

2. Resident 4 was admitted to the facility in 12/2018 with diagnoses including dementia.

A review of Resident 4's record revealed the following:

An incident report dated 06/27/22 identified Resident 4 was experiencing a known behavior of packing up belongings in his/her laundry basket and had brought them down to the living room. "[His/her] body language read aggressive. The caregiver tried to ask [him/her] to sit down and reached for the resident's hand. The resident pulled [his/her] hand/arm away from the caregiver whacking [striking] another resident in the back of the head." The caregiver tried another approach and was able to redirect the resident away from other residents.

Resident 4 was placed on alert charting; however, there was no documented evidence the incident had been reported to the SPD office.  

During an interview on 06/28/22 with Staff 2 (Health Services Director/RN) and Staff 9 (ALF Administrator), Staff 9 stated she had not reported the incident to the SPD office. The surveyor requested the incident be reported to the local SPD office.

The surveyor received confirmation of the report to the SPD office on 06/29/22.

The need to ensure resident-to-resident physical altercations were investigated and reported to the local SPD office as appropriate was discussed with Staff 1 (ED), Staff 2 (Health Services Director/RN)  and Staff 9 (ALF Administrator) on 06/29/22. They acknowledged the findings.

i.Abuse Reporting and Training, monthly training, refreshed and presented during all-staff, built upon the "Abuse Reporting and Investigation Guide for Providers" created by ODHS. Which, includes training to care staff to fill out an incident report any time he or she identifies a skin issue

ii.Med Tech, RSC, and RN to provide first, second, and third check for every outside provider note, to identify, among other items, any skin issue that does not have a facility generated incident report and investigation

Resident 1- Incident report was completed for unexplained injuries and report completed to APS. Care plan has been updated to reflect skin interity concerns that were identified and reported. Skin concerns that have been identified as pressure injuries previously have not required completiong of incident reports however moving forward, will now include pressure injuries in incident reports to rule out abuse.

Resident 2- Incident report was completed for unexplained bruising and report completed to APS. Skin concern has since resolved.    

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

The kitchen was toured on 03/28/22 at 10:25 am. The following areas were identified as needing cleaning or repair:

* By the ware-washer, there was a build-up of mold on the wall above the seam and above the metal panel;

* The lids and sides of dry storage bins had caked on food debris and dust;

* Whipped topping stored in plastic bags were not labeled. Whipped cream topping was dripping from the bag onto the floor of the refrigerator;

* Ice cream in a small freezer was not covered. There was melted ice cream along the edges of the inside freezer and there was build-up of ice in the freezer;

* There was build-up of food debris and dust on metal storage shelves where clean serving bowls and plates were stored;

* On the commercial oven and stove, there was a heavy build-up of dark brown and black grease on the metal burners and inside the oven. The doors and sides of the oven had a build-up of grease and food debris particles;

* The floor in front of, behind, and along sides, of the commercial oven had a had a heavy build-up of dark brown and black grease, sticky matter;

* A steamer was not clean and in good repair. It was not being used due to being broken. The handles and shelves inside had a sticky build-up of grease;

* Multiple drains on the floor in the kitchen had a heavy build-up of dirt and debris;

* Below the handwashing sink and across from the dry storage room, there was a build-up of dirt and debris on the floor and on the pipes;

* The meat slicer had a build-up of dried food debris;

* A waffle iron had a build-up of grease and sticky matter on the handle and top cover; and

* Two walk-in freezers both had a build-up of food debris on the floor.

2. The MCC kitchenette was toured on 03/28/22 at 11:15 am. The following areas were identified as needing cleaning or repair:

* Cupboard doors were broken and had areas with exposed, cracked wood;

* There was a build-up of food debris and dust in storage drawers including a drawer that contained clean knives;

* There was a mop and dirty rags stored on the floor in the food serving area;

* The floor below the steam table had a build-up of food debris and dust;

* A drain on the floor had a build-up of dirt;

* A fan in use had a build-up of dust; and

* A soup warmer had a buildup of white matter.

The need to ensure the kitchen was clean and maintained in accordance with Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED) on 03/28/22 at 1:45 pm. She acknowledged the findings.

C 240

#2 Both MC Kitchen and Main Kitchen were thoughly cleaned.  New cabinets and equipment has been ordered. #3 & #4-Kitchen cleaning task list has been updated and will be monitored and audited by Executive Chef weekly/monthly.

#1

*  By the ware-washer, the caulking was replaced before survey team left.

* The lids and sides of dry storage bins have been cleaned.

* Whipped topping was cleaned and labeled before survey team left.

*Ice cream in a small freezer was defrosted and cleaned before survey team left

* metal storage shelves where clean serving bowls and plates are stored were cleaned before survey team left;

*On the commercial oven and stove, have been cleaned but cannot be restored to new finish due to years of use.  New equipment has been ordered.

*The floor in front of, behind, and along sides, of the commercial oven has been cleaned;

*A steamer was not clean and in good repair. It was not being used due to being broken. It has been removed and new equipment has been ordered.; C 240

*Multiple drains on the floor in the kitchen were cleaned before survey team left.

*Floor below the handwashing sink and across from the dry storage room has been cleaned.

*The meat slicer and waffle iron have been cleaned.

*Two walk-in freezers floor has been cleaned.

2. The MCC kitchenette was toured on 03/28/22 at 11:15 am. The following areas were identified as needing cleaning or repair:

*Cupboard doors were removed and new have been ordered.

* Drawers including a drawer that contained clean knives have been cleaned.

* Mop and dirty rags storage has been moved.

* The floor below the steam table has been cleaned

* Floor drain has been cleaned.

* Fan has been cleaned

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

1. Resident 3 was admitted to the facility in 2018 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan updated 03/28/22 and 10/31/21 thru 03/28/22 progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas:

* Upper arm weight bearing status;

* Direction of managing glasses;

* Dentures and oral care status;

* Transfer status;

* Dressing, grooming, hygiene and toileting assistance required;

* Ambulation and mobility;

* Use of compression stockings; and

* Edema on lower extremities status.

The need to ensure resident service plans were reflective and provided clear directions to staff was discussed with Staff  1 (ED), Staff 2 (RN/Health Service Director) and Staff 3 (Memory Care Coordinator) on 03/29/22. Staff acknowledged the findings.

2. Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia. The resident's service plan and facility record was reviewed and staff were interviewed. The service plan was not reflective or lacked clear direction to staff in the following areas:

* Preferred activity or interests;

* Staff assistance related to cleaning glasses;

* Prosthetic use;

* Skin monitoring; and

* Dining and nutritional needs.

The need to ensure the resident's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (RN/Health Service Director) and Staff 3 (Memory Care Coordinator) on 03/29/22. They acknowledged the findings.

RSC to illicit feedback from care staff at the time of the quarterly and to utilize the 24 hour report and progress notes, to gain feedback from care staff on changes to the resident's care needs.

Resident 3- Care plan has been updated to ensure all directions are added to tasks in POC more clearly for the caregivers to see when providing care. Retraining to be completed on 4/22/22 on POC and how to access the information that is present for detailed care of all residents.

Resident 1- Care plan has been updated to reflect activity interests and most up to date care needs and monitoring.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status for 1 of 2 sampled residents (# 3) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 2018 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan updated 06/28/22 and 05/28/22 thru 06/28/22 progress notes, showed the plan was not reflective of the resident's status in the following areas:

* Dentures and oral care status;

* Incontinent status and scheduled toileting assistance status;

* Use of compression stockings; and

* Edema on lower extremities.  

The need to ensure resident service plans were reflective and provided clear directions to staff was discussed with Staff 1 (ED), Staff 2 (RN/Health Service Director) and Staff 9 (ALF Administrator) on 06/29/22. Staff acknowledged the findings.

RSC to illicit feedback from care staff at the time of the quarterly and to utilize the 24 hour report and progress notes, to gain feedback from care staff on changes to the resident's care needs.

Resident 3- Care plan has been updated to ensure all directions are added to tasks in POC more clearly for the caregivers to see when providing care. Retraining to be completed on 4/22/22 on POC and how to access the information that is present for detailed care of all residents.

Resident 1- Care plan has been updated to reflect activity interests and most up to date care needs and monitoring.  

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes were evaluated and actions or interventions were identified and implemented for 1 of 2 sampled residents (# 3) who experienced short term changes of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 2018 with diagnoses including dementia.

Observations of the resident from 03/28/22 to 03/29/22 showed the resident required staff assistance with transfers and bowel and bladder management.

Progress notes and incident reports dated 10/31/21 through 03/28/22 indicated the following:

* On 02/04/22 staff documented on a facility incident report "Resident was found on the floor ... it was noted that [his/her] pants were wet ..." Staff continued documenting the resident was sent out to the emergency department for further evaluation and had returned to the facility on the same day with a diagnosis of a closed displaced fracture to the right humerus [long bone of the upper limbs];

* On 02/05/22 staff documented on a facility progress note "Resident was found on the floor ...[Resident] stated s/he was trying to get up from the chair to use the bathroom;"

* On 02/05/22 staff documented on a facility incident report "Resident was found on the floor ...[Resident] stated s/he was trying to get up from the chair to use the bathroom ..." staff further documented "feet of the recliner were up and s/he was unable to put them down his/herself as his/her right shoulder is fractured;" and

* 05/13/21 Service Plan stated "assist hands on with care, toileting per scheduled ..."

There was no documented evidence the facility thoroughly reviewed the incidents to determine the circumstances of the falls or if service planned interventions were followed in the area of bladder and bowel management and evaluated for effectiveness.

On 03/29/22, Resident 3's progress notes and incident reports were reviewed with Staff 1 (ED) and Staff 2 (RN/Health Service Director), including evaluation and monitoring the effectiveness of the current service-planned interventions. Staff acknowledged the findings.

i.Staff training provided on POC (point of care). POC is the software system we use to track changes to resident's care that is outside of what is currently service planned. RSC to provide initial POC training of all new hires. RSC to perform monthly training on POC during mandatory monthly all staff training.

ii.Caregivers have the option to document point-of-care services that populate on the RSC's dashboard, in order to capture changes of condition, both short term and long term. RSC to review dashboard daily and will report at daily health services meeting of any changes.

iii.Short term changes of condition to be monitored via alert charting, and service plan updated as needed. RSC will review alert charting daily and implement any short term changes of conditions needed.

iv.Significant changes of condition to be monitored via PCC software, prompting the RN to monitor interventions for effectiveness and recommending changes to the service plan as needed. Significant changes of condition to be reviewed daily by RN at health services meeting.

Resident 3- Retraining to staff to include the following when completing incident reports:

- Incident that occurred

-When resident was last checked/toileted

-Condition resident was found in

-Investigation to include if past interventions have been effective related to incident

2. Resident 3 was admitted to the facility in 2018 with diagnoses including dementia.

Resident 3 was observed during the survey to utilize a walker independently for mobility.

The service plan indicated the resident had identified behaviors that had a negative impact on the resident and others. The facility had identified interventions to reduce behaviors in the current service plan.

Resident 3's clinical record from 05/28/22 through 06/29/22 revealed the resident was involved in a resident to resident altercation on 06/07/22 and 06/17/22.

There was no documented evidence the service planned interventions were implemented, the incident was not evaluated and interventions were not monitored to determine if the they were effective.

The need to monitor behavior interventions for Resident 3 was reviewed with Staff 1 (ED), Staff 2 (Health Services Director/RN) and Staff 9 (ALF Administrator) on 06/29/22. They acknowledged the findings.

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

1. Resident 4 was admitted to the facility in 12/2018 with diagnosis of dementia.

A review of progress notes dated 05/31/22 through 06/27/22, service plan dated 05/25/22 and Bedside Individual Service Plan report dated 06/28/22, service plan updates, and incidents reports were reviewed during the survey.

The service plan indicated the resident had identified behaviors that had a negative impact on the resident and others. The facility had identified interventions to reduce behaviors in the current service plan.

Resident 4's clinical record revealed the following:

On 06/20/22 the resident experienced a change in behavior described as "difficult to care for or responds aggressively towards staff, refused to cooperate. Staff continue to monitor."

There was no documented evidence the service planned interventions were implemented, the incident was not monitored weekly through resolution and the incident was not evaluated with interventions monitored to determine if the interventions were effective.

The need to monitor behavior interventions experienced by Resident 4 was reviewed with Staff 1 (ED), Staff 2 (Health Services Director/RN) and Staff 9 (ALF Administrator) on 06/29/22. They acknowledged the findings.

Staff training provided on POC (point of care). POC is the software system we use to track changes to resident's care that is outside of what is currently service planned.

ii.Caregivers have the option to document point-of-care services that populate on the RSC's dashboard, in order to capture changes of condition, both short term and long term

iii.Short term changes of condition to be monitored via alert charting, and service plan updated as needed

iv.Significant changes of condition to be monitored via PCC software, prompting the RN to monitor interventions for effectiveness and recommending changes to the service plan as needed

Resident 3- Retraining to staff to include the following when completing incident reports:

- Incident that occurred

-When resident was last checked/toileted

-Condition resident was found in

-Investigation to include if past interventions have been effective related to incident

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (# 3) whose orders were reviewed. Findings include, but are not limited to:

a. Resident 3 had a physician's order, dated 03/15/22, to check CBG (blood sugar level) before meals and at HS (before bed).

Resident 3's 03/01/22 through 03/28/22 MAR revealed there was no documented evidence that the facility checked the resident's CBGs at HS.

b. Resident 3 had a physician's order, dated 03/15/22, to contact to physician when CBGs were greater than 350.

Resident 3's 03/01/22 through 03/28/22 MAR revealed there were five occasions CBGs were greater than 350, however there was no documented evidence the facility notified the physician as prescribed.

On 03/29/22, the physician orders and the MARs were reviewed with Staff 1 (ED) and Staff 2 (RN/Resident Care Director). They acknowledged the findings.

i.Orders to follow, at least, a triple check system. First check, med tech. Second check, med tech and/or RSC. Third check, RN. To ensure each order is keyed correctly on the MAR. Orders will be reviewed daily.

ii.RN to use the supplementary documentation

feature to prompt the med techs to notify the physician (or RN, depending on what is ordered) when a vital sign is out of parameter. Quarterly review of vitals by RN to be conducted unless noted otherwise by PCP.

iii Daily review and quarterly review.

iV.  Heaalth services team responsible as outlined above

Resident 3- On day of survey, ordered add to MAR to include CBG checks at HS. PCP notified of increase in CBG readings and parameters around current reporting order. PCP ordered increase dose in long acting insulin and increased reporting of CBGs to anything >450.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications, including resident specific instructions and parameters for 1 of 2 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses which included dementia. The resident's 03/01/22 through 03/28/22 MAR was reviewed.

There were specific directions to staff for "bowel monitoring three times daily" and to "notify RN for no [bowel movement] in two days." Documentation revealed Resident 1 did not have a bowel movement during the following dates:

* 03/12/22 through 03/16/22, for four days;

* 03/18/22 through 03/23/22, for five days; and

* 03/26/22 through 03/28/22, for two days.

There was no documented evidence staff had informed the RN when the resident had no bowel movement for two days as directed on the MAR.  

In an interview with Staff 2 (RN/Health Services Director) on 03/29/22, she confirmed staff had not notified her that the resident had not had a bowel movement in two or more days.

The need to ensure MARs were accurate and staff followed the resident specific parameters was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Memory Care Coordinator) on 03/29/22. No further information was provided.

Resident 1- Bowel monitoring protocol has been updated to reflect current policy within TSL. Further training to be completed on 4/22/22 with medication techs to run bowel monitoring report in PCC at the beginning of every shift to review bowel concerns and initiate protocol. Retraining med techs to ensure RN is notified via the 24 hour report if starting bowel protocol.

i. Med techs to run bowel monitoring report at the beginning of each shift and implement facility bowel protocol if needed.

ii. RN to be notified if PRN Milk of Magnesia and PRN bisacodyl suppository are not effective via 24 hr log.

iii.  RSC to review bowel monitoring weekly to ensure process is being followed.

iv.Health Services team are responsible as outlined above to ensure issue is corrected.  

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code. Findings include, but are not limited to:

On 03/28/22 at 2:00 pm, facility fire drill and fire and life safety records, from 10/21/21 through 01/11/22 were reviewed. The documentation of the fire drills conducted lacked the following required components:  

* Location of simulated fire origin;

* Escape route used;

* Evacuation time-period needed;

* Number of occupants evacuated; and

* Problems encountered and comments related to residents who resisted or failed to participate in the drills.

The requirements for fire drills were discussed with Staff 1 (ED) on 03/28/22 at 3:00 pm. She acknowledged the findings.

Documentation of Fire Drills

#1 &#2 Fire Drill Documents have been updated to include:

*Location of simulated fire origin;

* Escape route used;

*Evacuation time-period needed;

*Number of occupants evacuated; and

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

#3 & #4 Plant Operations Manager, Safety Committee and Administrator will review all Fire Drills monthly.

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

Refer to C 231, C 260 and C 270.

refer to POC for C231, C260 and C 270

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 C231, C240 and C420.

Please refer to C231, C240 and C420 Plan of Corrections as outlined within this document.

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 231.

Please refer to C231 Plan of Corrections as outlined within this document.

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 C260, C270, C303 and C310.

Please refer to C260, C270, C303 and C310 Plan of Corrections as outlined in this document.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 260 and C 270.

please refer to C260, C270,Plan of Corrections as outlined in this document.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 3's current service plans were reviewed during the survey. Each service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED), Staff 2 (RN/Health Service Director) and Staff 3 (Memory Care coordinator) on 03/29/22. No additional information was received.  

On admission, quartlery and with any change in condition, resident's preference and needs are reviewed for individualization of nutrition and hydration. Individualized preferences of meal times, beverages, foods as well as special instructions such as level of assistance resident may need through-out meal times or adaptive utensil use have been added to care plan. This also includes any history of dehydration, food allergies and current diet orders.  This information is available to staff via point of care (POC). Staff have the ability to document if there is a change in residents ability, refusals of meals and meal consumption which appears on MCC dashboard for review daily. MCC reviews dashboard and 24 hr log daily for changes in resident ability, condition or preference.  Updates are then made to resident care plans quarterly or as changes occur to ensure that the most up to date information is shared with the team. These changes appear in point of care as they are made.

All plates and bowls used in Footsteps provide visual contrast between plates, eating utensils and table to maximize resident independence.

Resident 1 & 3 careplans have been updated to reflect more individualized preferences as listed above.

Based on observation, interview and record review, it was determined the facility failed to develop an individualized activity plan for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 1 and 3) and failed to provide a social and recreational activity program based upon individual and group interests. Findings include, but are not limited to:

1. Resident 1 and 3 resided in a Memory Care Community and were observed during the survey to require assistance from staff to initiate, attend or participate in activities.

Resident 1 and 3's service plans were reviewed during the survey. Each of the service plans lacked an individualized activity plan that included the following:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities.

2. During the survey, 03/28/22 through 03/29/22, the following observations were made:

* Great Room Music, scheduled for 03/28/22 at 1:00 pm did not take place;

* Exercise as Supported by Caregivers, scheduled for 03/29/22 at 9:00 am did not take place;

* Great Room Movie Matinee, scheduled for 03/29/22 at 1:00 pm, did not take place;

* There were no scheduled activities after 1:00 pm on any day of the month except for BINGO at 3:00 pm on 03/31/22;

* Residents sat out in the common area for long periods of time sleeping, wandered the halls, or remained in their rooms; and

* Staff provided very few individualized activities to residents including a puzzle with one or two residents.

On 03/29/22, the need to ensure each resident was evaluated and an individualized activity plan was developed and the failure to provide an activity program based on individual and group interests was reviewed with Staff 1 (ED), Staff 2 (RN/Health Service Director) and Staff 3 (Memory Care Coordinator). Staff acknowledged the findings.

Upon admission, quarterly and with any change of condition, activities assessments are completed to indicate assistance level for participation and activity preferences and adaptations needed to aid in participation of the resident. MCC reviews dashboard and 24 hr log daily for changes in resident ability, condition or preference.  Updates are then made to resident care plans quarterly or as changes occur to ensure that the most up to date information is shared with the team. These changes appear in point of care as they are made.

For Residents 1 & 3- care plan updated with more personalized resident interests, tasks, hobbies, favorite activities and level of assistance needed with activities. Care plan also reflects resident ability to communicate,  understand verbal content and behavioral triggers with gatherings including activities that could be used as interventions for applicable residents. Information that is updated is available to staff via point of care for reference .

With additional staffing in Memory Care planned  activities are being held as posted.