Print Inspection: 3CCF

The findings of the re-licensure survey, conducted 04/29/24 through 05/01/24, 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 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter 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. 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 first revisit to the re-licensure survey of 05/01/24, conducted 10/02/24 through 10/04/24, 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 for Home and Community Based Services Regulations.

Tag numbers beginning with the letter 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. 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

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

Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas:

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

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

OAR 411-057-0155 (1-6) Staff Training Requirements

The facility put immediate plans of correction in place during the survey.

The findings of the second re-visit to the re-licensure survey of 05/01/24, conducted 02/03/25 through 02/05/25, are documented in this report. It was determined the facility was in 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.

Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of operations which included supervision and training of staff. The facilities failure to ensure quality of services provided to residents and lack of supervision and oversight to staff performing job duties for 1 of 2 sampled residents (#8) put the residents safety at risk. Resident 8 experienced an avoidable skin issue. Findings include, but are not limited to:

1. During the first revisit survey, conducted 10/02/24 through 10/04/24, administrative oversight to ensure adequate resident care and services rendered in the facility were found to be ineffective based on the scope, severity and number of citations.

Situations were identified which posed a risk to residents' health and safety and constituted immediate plans of correction in the following areas:

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

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

OAR 411-057-0155 (1-6) Staff Training Requirements

The facility put immediate plans of correction in place during the survey.

Refer to deficiencies in the report.

2. Resident 8 was admitted to the facility in 07/2020 with diagnoses including dementia.

Observations of the resident from 10/02/24 to 10/04/24 showed the resident required staff assistance with transfers, incontinent care and needed supervision while in the geriatric chair (a large padded wheeled chair designed to help people with limited mobility) due to his/her leaning forward movement.

Observations of the resident, interviews with staff, and review of the resident's clinical record, including incident reports/investigations, observation notes dated 06/30/24 through 10/02/24, the service plan dated 06/23/24, and temporary service plans dated 06/27/24 through 07/30/24 indicated the following:

* A 07/30/24 observation note showed the care staff reported the resident had "2 scrapes" on the left knee area;

* A 07/30/24 incident report concluded the "scrapes" were a result of the resident's left knee bumping the footrest of the geriatric chair, and a temporary service plan dated the same day instructed staff to "apply pillow at sides of geriatric chair and under legs to prevent legs from falling";

* Observations made on 10/02/24 and 10/03/24 revealed multiple staff working on the unit did not ensure Resident 8 had pillows placed on the sides of his/her geriatric chair, and the resident's leg was observed hanging off the chair, rubbing against the chair, and/or becoming wedged between the armrest and the footrest; and

* On 10/02/24 at 1:35 pm, a red mark was observed on the resident's outer left leg, approximately 10 cm in length and 1 cm in width, which was reported to Staff 29 (CG) at 2:50 pm.

The licensee's failure to ensure adequate administrative oversight of the facility's operation and supervision led to the resident's avoidable skin issue, and the findings were discussed with Staff 22 (Wellness Nurse, RN) on 10/03/24 at 12:56 pm. The staff acknowledged the findings.

On 10/04/24 at 10:33 am, the failure of the licensee to ensure adequate administrative oversight of the facility operations and supervision was discussed with Staff 22, Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer). They acknowledged the findings.

OAR 411-054-0025 (1) Facility Administration: Operation

1. Action to correct the rule violation is as follows: Resident #8 was placed on weekly RN skin monitoring, along with daily checks provided by med techs.

2. System will be corrected so this violation will not happen again by; re-education was provided by the RN, with supporting documentaion, competencies have been completed and STO was reviewed and signed as acknowledgment to care that is to be provided. Instruction reporting skin conditions to RN has been relayed and instructed to med/care staff. 10/29 - added to MAR: Med techs to check Resident #8 correct placement of pillows on geri-chair.

3. Area needing correction will be evaluated on a daily and weekly basis until skin issue has been deemed resolved by RN Emily.

4. Staff responsible to see that corrections are completed/monitored are; administrator, RN Emily, med tech or designee in charge.

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. Findings include, but are not limited to:

The facility was toured on 04/29/24 at 11:10 am. The following items were not posted as required:

* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility;

* A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable; and

* The Ombudsman Notification Poster.

The need to ensure all required items were posted was reviewed with Staff 1 (Administrator) on 05/01/24. Staff 1 acknowledged the items were not posted as required.

OAR 411-054-0025 (5) Facility Administration: Required Postings

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

a. Required postings have been posted on each floor of Memory Care, MOD, re-licensure survery, and Ombudsman poster.

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

a. ALL postings will be updated routinely as necessary and ensure that each posting is accurate and UTD.

3. Each area needing correction will be evaluated quarterly and PRN.

4. The Memory Care Administrator or designee will be responsible to see that corrections are completed and or monitored.

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records for 3 of 4 sampled residents (#s 2, 3, and 4) and two unsampled residents. Findings include, but are not limited to:

a. Records for Residents 2, 3, and 4 were reviewed during survey and found to be incomplete and/or inaccurate in the following areas:

* Resident 3 was admitted to the hospital for a fall with a left hip fracture from 01/21/24 to 01/31/24. Review of the discharge paperwork indicated the resident had a "left hip pinning with dynamic hip screw" surgery on 01/22/24. The paperwork further included instructions for managing the surgical wound.

Interviews with staff indicated hospice was managing the surgical wound, and staff were following hip precautions at the time of discharge.

Review of the resident's clinical record including hospice provider notes from 02/08/24 to 04/16/24, progress notes and short term observation forms (STOs) dated 01/16/24 through 04/29/24, and the service plan dated 02/09/24 revealed no mention of the surgical wound.

The change of condition evaluation completed 02/09/24 for the left hip fracture, return from hospital, and hospice admit indicated "no" for skin conditions.

There was no documentation in the resident's record of what the hip precautions were, or that they were communicated to all staff.

* Interviews with care staff and review of the electronic charting system indicated while some resident service plan information was available on their tablets, staff had to access the full service plan located in residents' hard charts. Resident 2, 3, and 4's hard charts were reviewed and lacked their current service plans.

* Interviews with care staff indicated they were informed of resident short term changes of condition via the facility's STO forms. There were no STOs for Resident 3's hip precautions, surgical wound, redness on groin and abdomen, and multiple behavior episodes. There were no STOs for Resident 4's resident-to-resident altercation, return from hospital, hospice admit, or injury fall.

* Interviews with care staff indicated they were to call hospice when Resident 3 refused to consent to a medication or treatment order. There was no documentation in the resident's record that hospice was notified of the refusals.

* Interviews with care staff indicated they were to attempt non-pharmacological interventions prior to administering PRN psychotropics for Residents 1, 3, and 4. There was no documentation in the residents' records that the interventions were attempted.

b. Two unsampled residents' medication orders and STOs were found in Resident 3's hard chart.

The need to ensure resident records were complete and accurate was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings, and no further information was provided.

Refer to C260, C270, C305, and C330.

OAR 411-054-0025 (8) Facility Administration: Records

Reference C260, C270, C305, C330.

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

During the survey, conducted 10/02/24 through 10/04/24, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be infective.

On 10/04/24 at 1:03 pm, Staff 37 (Chief Wellness Officer) was interviewed about the facility's quality improvement program. She reported the facility was supposed to have monthly Quality Assurance and Performance Improvement (QAPI) meetings. However, she reported the facility had "probably not" implemented it.

Refer to the deficiencies in the report.

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

1. Actions taken to correct rule violations as follows: QAPI meetings for Memory Care have been scheduled for the last Monday of each month.

2. Implementation of set meeting has been scheduled with all management staff utilizing QAPI meeting minutes form, including all required elements for QAPI program, records to be kept in administrative office for review at ALL times.

3. Area needing correction will be evaluated on a monthly basis. Any areas identified during QAPI will develop an action plan and will be reviewed at next scheduled meeting- ALL LEADERSHIP.

4. MC Administrator, Exectuive Director, RN or designee in charge will be responsible for ensuring corrections are completed and/or monitore.

Based on observation, interview, and record review, it was determined the facility failed to investigate incidents, document all required areas of an investigation, and report to the local SPD office if abuse or neglect could not be ruled out for 2 of 2 sampled residents (#s 1 and 4) who experienced resident-to-resident altercations. Findings include, but are not limited to:

1. Resident 1 moved to the facility in 03/2024 with diagnoses including agitation associated with dementia.

Observations of the resident, interviews with staff, and review of the resident's 04/12/24 service plan, progress notes dated 03/15/24 through 04/27/24, and incident reports were completed and revealed the following:

An incident report dated 04/19/24 stated Resident 1 "pushed resident" which caused "resident to fall to the ground". Resident 1 stated that the other resident was "trying to get in [his/her] room" at the time of the incident.

In an interview on 04/30/24 at 3:15 pm, Staff 1 (Administrator) stated the occurrence had not been reported to the local SPD office. This surveyor requested Staff 1 report the above incident to the local SPD office, and confirmation was received on 04/30/24 at 3:30 pm.

The need to ensure incidents of abuse or neglect were immediately reported to the local SPD office was discussed with Staff 1 on 05/01/24 at 12:35 pm. He acknowledged the findings.

2. Resident 4 was admitted to the facility 11/2021 with diagnoses that included Alzheimer's disease and mood disorder.

Progress notes dated 03/04/24 through 04/06/24 and incident reports were reviewed. The following information was documented:

* Progress note dated 03/03/24 - "... often acts out and can be aggressive when attempting to do personal care. Resident has a prn Quetipine, which I instructed staff to go give if [resident] becomes aggressive and other means of distraction, comfort measures etc. are not working. Staff will continue to notify [Wellness Director] if behaviors are existing."

* Progress note on 03/12/24 - "Spoke to [Resident 4's spouse] today. [S/he] was in the room when this incident occurred. Together we discussed [Resident 4's] recent behavior and [spouse] agreed to me discussing this with [Resident 4's] physician and the possibility of [his/her] medications changing to help avoid aggressive behavior. We discussed efforts to prevent the outbursts such as diversion of offering a dessert or fruit while [s/he] is dressing to encourage cooperation, talking softly while attempting cares and moving passively."

* Progress note on 03/15/24 - LATE ENTRY  "RN was able to talk to [Resident 4's spouse] about the current behaviors [Resident 4] is exhibiting. We discussed interventions such as offering a snack when resident is agitated to diffuse the situation, remove resident of which anger is directed toward, calm resident by allowing private time in [his/her] room. We also discussed as this was not the first time that we would have to notify Dr. as [his/her] safety and other resident's safety is our highest concern. [Resident 4's spouse] is interested in the Physician looking at [his/her] current medication to assess whether or not a medication adjustment is needed. This RN contacted [physician's] office to explain the recent behaviors [Resident 4] is exhibiting, awaiting a return phone call."

There was no additional documentation regarding an incident that involved a resident to resident altercation.

In an interview on 04/30/24 at 12:15 pm Staff 1 (Administrator) stated there had been a resident to resident altercation where Resident 4 tossed a magazine and Jenga blocks onto another resident's chest. An incident report, dated 03/14/24, was provided. The incident report did not specify how the facility ruled out abuse and neglect and did not state it was reported to the local SPD office.

The surveyor requested the incident be reported to the local SPD office. Verification the facility reported the resident to resident altercation was received on 05/01/24 at 12:24 pm.

The need to ensure resident to resident altercations were immediately reported to the local SPD office was discussed with Staff 1 on 04/30/24. He acknowledged the findings.

OAR 411-054-0028 (1-3)

Reporting and Investigating Abuse- Other Action

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

Resident #1 and #4 resident to resident altercation was reported to the local SPD office on 4/30/24 (#1) and 5/1/24 (#4)

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

a. All staff will be provided training on the following topics: Incident reporting, investigating IR's, how to appropriately rule out abuse and neglect, implementing interventions on STO's, ensuring previous interventions and service planning were being followed to rule out abuse and neglect, as evidenced by when to report and when to report and when to notify local APS.

b. The system will be corrected so the violation does not occur again ensuring all incidents are reviewed timely. If absue and neglect cannot be ruled out or for injuries of unknown cause, community will follow abuse reporting to APS. IR's to be reviewed with daily stand up meetings. The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan.

3. The area will be reviewed on a daily-weekly basis with incident review in stand-up and quarterly basis.

4. The facility Administrator or designee will be responsible for ensuring the system is corrected and monitored.

2. Resident 8 was admitted to the facility in 07/2020 with diagnoses including dementia.

Observations of the resident from 10/02/24 to 10/04/24 revealed the resident required staff assistance with transfers, incontinent care and needed supervision while in the geriatric chair (a large padded wheeled chair designed to help people with limited mobility) due to his/her leaning forward movement.

Observations of the resident, interviews with staff, and review of the resident's clinical record, including incident reports/investigations, observations notes dated 06/30/24 through 10/02/24, 06/23/24 service plan and temporary service plans dated 06/27/24 to 07/30/24 indicated the following:

* A 06/23/24 service plan showed the resident was a high fall risk and staff were to provide safety checks, ensure the bed was at the lowest height, the fall mat was in place, and to scoot the resident to the middle of the bed and place a pillow under the fitted sheet;

* On 07/27/24, an observation note showed the resident was on alert charting for an unwitnessed fall; and

* A 07/27/24 incident report indicated the resident had redness on the right shoulder area which resulted from the fall.

There was no documented evidence the facility's investigation included all required components and ruled out abuse and neglect. Also, the investigation failed to review whether all fall interventions were in place at the time of the incident. There was no documented evidence the occurrence was reported to the local SPD office if abuse and/or neglect could not be ruled out.

The need to investigate incidents of suspected abuse and neglect of care and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 22 (Wellness Nurse, RN) and Staff 37 (Chief Wellness Officer) on 10/03/24 and 10/04/24. Staff 22 confirmed she had not reported the above incidents to the local SPD, at which time the surveyor requested Staff 22 to immediately report the incidents. Confirmation that the incidents were reported was received prior to the survey team exiting the facility.

Based on interview and record review, it was determined the facility failed to investigate incidents or injuries of unknown cause to rule out abuse, document all required areas of an investigation and report to the local SPD office, if abuse or neglect could not be ruled out, for 3 of 3 sampled residents (#s 6, 7 and 8) with incidents or injuries of unknown cause. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia.

Interviews with staff were conducted, and the resident's record was reviewed including the current service plan, temporary service plans, 06/30/24 through 10/01/24 progress notes, incident reports and investigations. The following was identified:

* 09/03/24 - Injury of unknown cause, bilateral elbows;

* 09/04/24 - Injury of unknown cause, bruising on upper back; and

* 09/04/24 - Injury of unknown cause, right elbow skin tear.

There was no documented evidence the facility's investigation included all required components and ruled out abuse and neglect. There was no documented evidence that the occurrences were reported to the local SPD office if abuse and/or neglect could not be ruled out.

In an interview on 10/02/24 with Staff 37 (Chief Wellness Officer), the facility's investigation process was reviewed, and it was acknowledged that the facility had not been ruling out abuse and neglect, including neglect of cares, during their investigations.

At the request of the survey team, all incidents above were reported to SPD prior to survey exit.

The need to ensure injuries of unknown cause were immediately investigated, contained all required areas of documentation, including if abuse and neglect could be ruled out, and if not, the injuries were reported to the local SPD office, was reviewed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

3. Resident 7 was admitted into the facility in 01/2020 with diagnoses including dementia.

The resident's 06/30/24 to 10/02/24 progress notes, short term observations, and temporary care plans, and investigations were reviewed. The following was identified:

The resident's progress notes indicated the resident experienced the following injuries of unknown cause:

* 09/01/24 - "[T]wo small skin abrasions"; and

* 09/05/24 - "[S]kin laceration to [left] elbow."

The above injuries were of unknown cause and required an immediate investigation to rule out abuse and/or neglect. At 10:15 am on 10/03/24 Staff 36 (ALF Administrator) stated no investigation had been completed for either injury. Survey requested the above injuries of unknown cause be reported to the local SPD office, and confirmation was received at 11:23 am on 10/03/24.

The need to ensure immediate investigations were completed for injuries of unknown cause and/or reported to the local SPD if abuse or neglect could not be ruled out was discussed with Staff 27 (ED), Staff 36, and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

OAR 411-054-0028 (1-3)

Reporting and Investigating Abuse- Other Action

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

Resident #6 'Injury of Unknown Cause' was reported to the local SPD office. Resident #8 'Fall' was reported to the local SPD office. Resident #7 'Skin Tear - Unknown Cause' was reported to SPD office 10/3/2024.

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

a. All staff will be provided training on the following topics: Incident reporting, investigating IR's, how to appropriately rule out abuse and neglect, implementing interventions on STO's, ensuring previous interventions and service planning were being followed to rule out abuse and neglect, as evidenced by when to report and when to report and when to notify local APS.

b. The system will be corrected so the violation does not occur again ensuring all incidents are reviewed timely. If absue and neglect cannot be ruled out or for injuries of unknown cause, community will follow abuse reporting to APS. IR's to be reviewed with daily at stand up meetings. The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan.

3. The area will be reviewed on a daily-weekly basis with incident review in stand-up and quarterly basis.

4. The facility Administrator and/or designee will be responsible for ensuring the system is corrected and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs as identified in the evaluation, provided clear direction regarding the delivery of services, were readily available to staff, and were implemented for 3 of 4 sampled residents (#s 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2022 with diagnoses including Alzheimer's disease.

The resident's service plan dated 03/15/24 was reviewed, observations of the resident were made, and interviews were conducted. The following was identified:

a. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Use of hearing aids;

* Home health services;

* History of venous stasis wounds;

* Time and date of shower to coincide with outside provider;

* Assistance with laxative;

* Bowel incontinence; and

* Assistance required for transfers.

b. The current service plan available to the staff in the resident's hard chart was dated 12/15/23. An updated service plan dated 03/15/24 was provided by Staff 1 (Administrator) on 04/29/24 at 3:04 pm.

The need to ensure service plans were reflective of residents' current needs and were readily available to staff was discussed with Staff 1 on 05/01/24. He acknowledged the findings.

3. Resident 4 was admitted to the MCC in 11/2021 with diagnoses which included dementia.

Interviews with care staff and observations of Resident 4 during the survey revealed s/he was non-ambulatory, incontinent, dependent on staff for ADL care, and had hospice services.

a. Resident 4's service plan and quarterly evaluation, dated 04/03/24, revealed they were not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Hospice;

* Ambulation;

* Pain;

* Activities;

* Transfers;

* Bathing; and

* Significant change of condition.

b. The most recent service plan was not available to staff in the Resident's binder.

The need to ensure the service plan was current, reflective of Resident 4's current care needs as identified in the evaluation and provided clear direction to staff was discussed with Staff 1 (Administrator) during an interview on 04/30/24 at 12:15 pm. He reviewed the service plan and acknowledged it needed to be updated. No further information was provided.

2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.

The resident's service plan dated 02/09/24 and short term observation forms (STOs) dated 01/16/24 to 04/29/24 were reviewed, observations of the resident were made, and interviews were conducted. The following was identified:

a. The resident's current service plan was not reflective of his/her needs and preferences and/or was not implemented in the following areas:

* Behaviors;

* Hearing/vision status and assistive devices;

* Sleeping schedule;

* Diet texture;

* Hospital bed;

* Nail care;

* Skin;

* Activities;

* Meal routine; and

* Use of gait belt for transfers.

b. Interviews with care staff indicated they had access to some resident ADL tasks via work-issued tablets; however they accessed the full service plan in residents' hard charts. Resident 3's current service plan was not available to staff in his/her hard chart.

The need to ensure service plans were reflective and available to staff and services were implemented was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings, and no further information was provided.

OAR 411-054-0036 (1-4)

Service Plan: General

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

a. Resident #2 SP has been updated to be reflective of resident's needs and preferences, and clear instructions to staff in the following areas:

*Use of hearing aides

*Incontinence Cares

*Assistance with laxatives

*Showers to coincide with outside providers

b. Resident #3 SP has been updated to be reflective of resident specific direction for staff to follow in the below stated areas:

*Behaviors

*Hearing/vision status and assistive devices

*Sleeping schedule

*Diet texture

* Hospital bed

*Nail care

*Skin *Activities

*Meal routine; and

*Use of gait belt for transfers.

c. Resident #4 SP has been updated to be reflective of resident specific direction or needs for staff to follow in the below stated areas:

* Hospice

* Ambulation

* Pain

* Activities

* Transfers

* Bathing; and

* Significant change of condition.

ALL resident current SP's are in a binder for each floor available to staff and will ensure that it is available in the residents binder moving forward.

2. The system will be corrected so that this violation does not happen again by ensuring that the SP is created to reflect the residents current status prior to m/i, w/i 30-days, Q90D thereafter or with any significant COC per company policy and OR state rule. ALL updates to SP will be initiated and dated, leadership to provide observations to ensure SP's are being followed. ALL SP's should be reviewed and updated to reflect change via Temporary Service Plan, clinical, care staff and administration will participate in this. The updates will be placed in the 24 hour book.

3. The area needing correction will be evaluated quarterly and PRN. Changes to SP will be reviewed daily in stand-up meeting to ensure accuracy and appropriateness.

4. Facility administrator, or nursing will be responsible for completion and correct monitoring.

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 was implemented for 3 of 3 sampled residents (#s 6, 7 and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 07/2020 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the 06/23/24 service plan and temporary service plan, dated 06/27/24 through 07/30/24, revealed Resident 8's service plan was not reflective of the resident's status and did not provide clear directions regarding the delivery of services including what, when, how and how often the service should be provided, and were not implemented in the following:

* Use of pillows on the side of legs while on the geriatric-chair;

* Grooming status; and

* Personal hygiene, including washing face and brushing teeth.

On 10/04/24 at 10:33 am, the service plan was discussed with Staff 22 (Wellness Nurse, RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer). They acknowledged the service plans were not reflective of the resident's status, lacked clear directions, and were not implemented.

2. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia.

The resident's clinical record was reviewed, including service plan dated 07/01/24 and progress notes and temporary service plans dated 06/30/24 through 10/01/24, the resident was observed, and interviews with staff were conducted.

The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not being implemented in the following areas:

* Assistance required for dressing, ambulation and toileting;

* Use of hearing aides;

* Fall prevention interventions;

* Presence of the large stuffed dog in apartment;

* Moving/hoarding items from other resident's rooms;

* Frequency of snacks; and

* Location of pain.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were being implemented, was reviewed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

3. Resident 7 was admitted into the facility in 01/2020 with diagnoses including dementia.

The resident's 09/01/24 service plan and temporary care plans dated 06/30/24 to 10/02/24 were reviewed. Observations of the resident were made, and interviews with staff were conducted. The service plan was not implemented in the following areas:

* Use of bilateral heel protectors;

* Use of gait belt for transfers; and

* Use of barrier cream for redness to the buttocks.

The need to ensure services were implemented for residents was discussed with Staff 27 (ED), Staff 36 (ALF Administrator), and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings, and no further information was provided.

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

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

a. Resident #8 SP has been updated to reflect the following:

* Use of pillows on the side of legs while

on the geriatric-chair;

* Grooming status; and

* Personal hygiene, including washing

face and brushing teeth

b. Resident #6 SP has been updated to reflect the following:

* Assistance required for dressing,

ambulation and toileting;

* Use of hearing aides;

* Fall prevention interventions;

* Presence of the large stuffed dog in

apartment;

* Moving/hoarding items from other

resident's rooms;

* Frequency of snacks; and

* Location of pain

c. Resident #7's SP has been updated to reflect the following:

* Use of bilateral heel protectors;

* Use of gait belt for transfers; and

* Use of barrier cream for redness to the

buttocks

ALL resident current SP's are in a binder for each floor available to staff and will ensure that it is available in the residents binder moving forward.

2. The system will be corrected so that this violation does not happen again by ensuring that the SP is created to reflect the residents current status prior to m/i, w/i 30-days, Q90D thereafter or with any significant COC per company policy and OR state rule. ALL updates to SP will be initiated and dated, leadership to provide observations to ensure SP's are being followed. ALL SP's should be reviewed and updated to reflect change via Temporary Service Plan, clinical, care staff and administration will participate in this. The updates will be placed in the 24 hour book.

3. The area needing correction will be evaluated quarterly and PRN. Changes to SP will be reviewed daily in stand-up meeting to ensure accuracy and appropriateness.

4. Facility administrator, or nursing will be responsible for completion and correct monitoring.

4. Resident 1 was admitted to the facility in 03/2024 with diagnoses including agitation associated with dementia.

Resident 1's clinical record including progress notes dated 03/15/24 to 04/27/24, and current service plan were reviewed. The following was identified:

The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:

* 03/13/24 - moved-in to the facility;

* 03/15/24 - attempted elopement; and

* 03/27/24 - medication dosage change.

Although alert monitoring was initiated for the changes, there was no documented monitoring of resident's conditions until resolution.

The need to ensure short-term changes of condition are monitored at least weekly through resolution was discussed with Staff 1 (Administrator) on 05/01/24 at 12:35 pm. He acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease.

Resident 2's progress notes dated 01/16/24 to 04/29/24, current service plan, and home health provider notes dated 03/06/24 to 04/24/24 were reviewed. The following was identified:

a. There was no documented evidence the facility determined actions or interventions, provided written communication of the change of condition and any actions or interventions to staff on all shifts, and monitored at least weekly to resolution the following short term changes of condition:

* 02/29/24 - started a course of antibiotics.

b. There was no documented evidence the facility provided written communication of changes of condition and any actions or interventions to staff on each shift, and monitored at least weekly to resolution the following short term changes of condition:

* 02/24/24 - venous stasis ulcers to right lower extremity; and

* 03/26/24 - skin tear to left lower shin.

The need to ensure the facility determined and documented actions or interventions for short term changes of condition, provided written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensured documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings, and no additional information was provided.

3. Resident 4 was admitted to the facility in 11/2021 with diagnoses which included dementia.

Resident 4's clinical record and charting notes, reviewed from 03/04/24 through 04/26/24, revealed the following:

The resident experienced multiple short-term changes without weekly progress noted until resolution in the following areas:

* 03/14/24 - a resident to resident altercation;

* 03/24/24 - fall with injury;

* 04/24/24 - redness to perineal area; and

* 04/24/24 - prescription change.

Although alert monitoring was initiated for some of the changes, the facility failed to determine if service-planned interventions were implemented, were effective or if new interventions were needed, and failed to communicate determined actions/interventions to staff on each shift. There was no documented monitoring of resident's conditions until resolution.

Additional information was requested from Staff 1 (Administrator) on 04/30/24 at 12:15 pm.

On 04/30/24 at 12:15 pm, Staff 1 (Administrator) reported he reviewed the resident's record and concluded the short-term changes in condition had no documented resolution.

The need to ensure the facility determined and documented what action or intervention was needed for the resident's short term changes of condition and monitored the resident until the condition was resolved was discussed with Staff 1 (Administrator) and Staff 3 (RN/Wellness Director) on 04/30/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to determine and document actions or interventions for short term changes of condition, provide written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensure documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved for 4 of 4 sampled residents (#s 1, 2, 3, 4) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.

Resident 3's progress notes dated 01/16/24 to 04/29/24, current service plan and short term observations, hospital discharge notes dated 01/31/24, MAR dated 04/01/24 to 04/29/24, and hospice provider notes dated 02/05/24 to 04/16/24 were reviewed. The following was identified:

a. There was no documented evidence the facility determined actions or interventions, provided written communication of the change of condition and any actions or interventions to staff on all shifts, and monitored at least weekly to resolution the following short term changes of condition:

* 01/21/24 - left hip surgery with surgical wound;

* Undated incident - Resident 3 "threw soup at [his/her] neighbor";

* 03/29/24 - redness on left side of groin and abdomen;

* 04/07/24 - agitation;

* 04/10/24 - agitation; and

* 04/20/24 - hospice discharge.

b. There was no documented evidence the facility provided written communication of changes of condition and any actions or interventions to staff on each shift, and monitored at least weekly to resolution the following short term changes of condition:

* 04/15/24 - loose stool;

* 04/15/24 - agitation and combativeness; and

* 04/23/24 - agitation.

The need to ensure the facility determined and documented actions or interventions for short term changes of condition, provided written communication of a resident's change of condition and any required interventions to staff on all shifts, and ensured documentation of staff instructions or interventions were made part of the resident record with weekly progress noted until the condition resolved was discussed with Staff 1 on 05/01/24. He acknowledged the findings, and no additional information was provided.

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

1. Actions taken to correct this rule violation area as follows:

a. Resident #1, #2, #3, and #4; service planning interventions and effective new interventions will be documented and communicated to each shift moving forward. Documentation will be conducted and followed through until resolution documentation is recorded.

2. To ensure that the system will be corrected so this violation will not happen again, a 24-hour system will be in place to include:

1. SHIFT TO SHIFT COMMUNICATION LOG

2. ALERT CHARTING LOG

3. Sig. COC log

4. Weekly RN Monitoring

a. Med staff will start the short-term monitoring/communication for any residnet identified to have an acute change of condition such as skin events, confusion, return to community, or falls.

b. Staff to be made aware on what to report to RN/MD per the TSP that has been put into place, which will cooralte with the residents COC. The TSP has specific directions for staff and what to look for/monitor.

c. Staff should document and monitor until resident condition resolves or they are back at their baseline.

d. 24-hour book/process will be reviewed on an every other day basis or during stand-up for indentification of possible COC that need assessed by an RN.

3. System will be review daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. The facility administrator and RN will be responsible for ensuring the system has been corrected and monitored.

Based on observation, interview, and record review, it was determined the facility failed to have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who could determine if a change in the resident's condition required further action, and to ensure changes of condition were evaluated and referred to the RN when needed, interventions were determined, documented, communicated to staff, and implemented, and interventions were monitored for effectiveness for 2 of 3 sampled residents (#s 6 and 7) who experienced changes of condition. Resident 6 had repeated falls with injury without interventions or monitoring, which put him/her at risk and constituted an immediate threat to the residents' health and safety. This is a repeat citation. Findings include, but are not limited to:  

1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia.

The resident's current service plan, updated 07/01/24, progress notes dated 06/30/24 through 10/1/24, temporary service plans (TSPs) and incident reports were reviewed, and staff were interviewed.

a. During the acuity interview on 10/02/24, Resident 6 was identified by Staff 22 (Wellness Nurse, RN) and Staff 36 (ALF Administrator) as someone who experienced frequent falls.

Documentation in the resident record revealed the resident experienced the following:

* 07/11/24 at 6:15 pm - Unwitnessed fall with injuries including two thoracic vertebrae compression fractures (T11 and T12), three fractured ribs, head abrasion and left arm hematoma. The resident was found laying on the bathroom floor near his/her sink, and was subsequently sent to the hospital. The resident returned to the facility on 07/12/24, and a TSP was placed on 07/12/24 instructing staff to provide "1 person ambulation assistance for safety purposes", ensure "room safety check[s] are done every 2 hours while res[ident] is in [his/her] Apt" and "ensure res[ident] is using walker to ambulate."

* 09/03/24 at 10:00 am - Unwitnessed fall with injury including bilateral elbow redness. Resident was found lying on the bathroom floor in front of his/her sink. A TSP was placed 09/03/24 which did not include any new fall prevention interventions.  

* 09/04/24 at 7:25 pm - Unwitnessed fall with injury including skin tear to right elbow. Resident was found in the doorway of his/her room. There was no documentation the resident was evaluated. A TSP was placed 09/04/24 which did not include any new fall prevention interventions.

* 09/06/24 - Resident returned from emergency room after a near-fall outside of the medication room on 09/05/24. Progress notes and the incident report described the resident as appearing to be lightheaded, showing signs of dizziness, being unable to bear weight and trembling. The resident was diagnosed in the emergency room with a seizure. A TSP was placed on 09/06/24 which did not include any new fall prevention interventions or resident-specific instructions to staff.

* 09/21/24 at 12:30 pm - Unwitnessed fall. Resident was found on the floor in the doorway to his/her room. A TSP was placed on 09/23/24 which did not include any new fall prevention interventions.

* 9/28/24 at 8:10 pm - Unwitnessed fall with injuries including head injury, right eye laceration and facial bruising. Resident was found sitting on the floor in front of his/her room. A TSP was placed on 09/29/24 which did not include any new fall prevention interventions.

Resident 6 experienced an unwitnessed fall on 07/11/24 which resulted in fractured vertebrae and fractured ribs. The resident continued to experience unwitnessed falls with injuries on 09/03/24, 09/04/24 and 09/28/24, in addition to a near-fall requiring a visit to the emergency room on 09/05/24 and an unwitnessed non-injury fall on 09/21/24. There was no evidence the facility evaluated the resident, determined and documented new interventions to reduce the resident's risk of falling, and communicated these to staff on all shifts, with monitoring of the resident and the interventions at least weekly until resolution. This created a serious risk of harm and immediate threat to the health and safety of the resident.

During the survey, 10/02/24 through 10/03/24, the resident was observed to be ambulating unassisted throughout the facility. During an interview with Staff 16 (CG), she showed the "task sheet" on the facility's documentation system where care tasks/needs were shown and documented by the caregiver for each resident. Resident 6's task sheet, including frequency of safety checks and ambulation assistance, had not been updated since 07/01/24, prior to the fall with fracture on 07/11/24 and subsequent falls.

The facility's failure to evaluate the resident's fall risk, determine actions or interventions, communicate these to all staff on all shift and monitor interventions for effectiveness created a serious risk of harm to the resident and immediate threat the residents' health and safety.

An immediate plan of correction was requested at 2:31 pm on 10/03/24. The facility provided an acceptable plan of correction on 10/03/24 at 6:22 pm, prior to survey exit. The immediate risk was addressed, however, the facility will need to evaluate the overall system failure associated with the licensing violation.

The need to ensure residents were evaluated, actions or interventions were determined, documented, communicated to staff on all shifts, and implemented, and ensure interventions were monitored for effectiveness was reviewed with Staff 22, Staff 27 (ED), Staff 36 and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

b. The resident's record identified that the following short term changes of condition were not evaluated, actions or interventions determined and communicated to staff on all shifts, and/or monitored through resolution:

* 07/11/24 - Post-fall injuries including vertebral and rib fractures, left arm hematoma and head abrasion;

* 07/12/24 - New medication, losartan (for high blood pressure);

* 07/31/24 - Return from urgent care for high blood pressure;

* 08/04/24 - Medication discontinued, ibuprofen (for pain);

* 08/16/24 - New behavior including hitting staff;

* 08/29/24 - Resident to resident altercation;

* 09/03/24 - Bilateral elbow redness post-fall;

* 09/04/24 - Bruise on upper back;

* 09/04/24 - Skin tear to right elbow;

* 09/09/24 - New behavior plan; and

* 09/15/24 - Loose stools.

The need to determine actions or interventions for changes of condition, and monitor at least weekly through resolution was discussed with Staff 22 (Wellness Nurse), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

c. A fax to the resident's doctor on 07/30/24 stated the resident's blood pressure had been taken on 07/30/24 with the following readings:

* 205/101 mmhg;

* 201/96 mmhg; and

* 198/98 mmhg.

The resident's MAR stated that the resident's blood pressure should be recorded daily and a nurse should be notified if the systolic blood pressure was greater than 160 mmhg.

A progress note dated 07/30/24 at 3:07 pm stated "called Emily [Wellness Nurse, RN] to notify but did not answer." There was no documentation that a designated staff member was accessible to identify whether the change of condition required further action.

The need to have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who could determine if a change in the resident's condition required further action was reviewed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

2. Resident 7 was admitted into the facility in 01/2020 with diagnoses including dementia.

The resident's 06/30/24 to 10/02/24 progress notes, short term observations, and temporary care plans were reviewed. The following was identified:

There was no documented evidence the facility identified actions/interventions, communicated them to staff on each shift, and/or monitored with weekly progress noted to resolution the following short-term changes of condition:

07/11/24 - Noninjury fall;

08/27/24 - Redness to buttocks; and

09/05/24 - Skin laceration on left elbow.

The need to ensure actions/interventions were determined, documented, and communicated to staff on each shift and weekly progress was noted to resolution for short-term changes of condition was discussed with Staff 27 (ED), Staff 36 (ALF Administrator), and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings, and no further information was provided.

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

1. Actions taken to correct this rule violation area as follows:

a. Resident #6 and #7; service planning interventions and effective new interventions will be documented and communicated to each shift moving forward- in person and through staff MEMO via ALL MEMORY CARE group text message. Documentation will be conducted and followed through until resolution documentation is recorded.

2. To ensure that the system will be corrected so this violation will not happen again, 24-hour system will be in place and followed-up on daily as follows:

1. SHIFT TO SHIFT COMMUNICATION LOG

2. ALERT CHARTING LOG

3. Sig. COC log

4. Weekly RN Monitoring

a. Med staff will start the short-term monitoring/communication for any residnet identified to have an acute change of condition such as skin events, confusion, return to community, or falls.

b. Staff to be made aware on what to report to RN/MD per the TSP that has been put into place, which will cooralte with the residents COC. The TSP has specific directions for staff and what to look for/monitor.

c. Staff should document and monitor until resident condition resolves or they are back at their baseline.

d. 24-hour book/process will be reviewed on an every other day basis or during stand-up for indentification of possible COC that need assessed by an RN.

3. System will be review daily, weekly, monthly and quarterly to ensure compliance is maintained.

4. The facility administrator and RN will be responsible for ensuring the system has been corrected and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed and included documented findings, resident status and interventions made as a result of the assessment, and the licensed nurse reviewed the service plan with date and signature within 48 hours for 2 of 2 sampled residents (#s 3 and 4) who experienced significant changes of condition related to a fall with injury and admission to hospice. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease.

Progress notes dated 03/04/24 through 04/24/24, and the current service plan, dated 04/03/24 were reviewed and revealed the following:

Resident 4 experienced a fall with a head injury on 03/24/24, was hospitalized and admitted to hospice effective 04/01/24. The facility failed to ensure an RN assessment was completed for the fall or hospice admission which documented findings, resident status, and interventions made as a result of the assessment. Resident 4's service plan was updated 04/03/24 but was not reflective of the significant changes of condition.

The need to ensure an RN conducted an assessment of all residents with significant changes of condition and participated in updating the resident's service plan with the changes was discussed with Staff 1 (Administrator) and Staff 3 (RN/Wellness Director) on 04/30/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.

Progress notes dated 01/16/24 to 04/29/24, hospital discharge paperwork dated 01/31/24, and a change of condition evaluation dated 02/09/24 were reviewed and the following was identified:

Resident 3 experienced a fall with a left hip fracture and was hospitalized for surgery from 01/21/24 to 01/31/24. The resident was admitted to hospice 02/05/24. The hip fracture, surgery, and hospice admit constituted a significant change of condition for which an RN assessment was required. During an interview at 10:00 am on 05/01/24, Staff 3 (RN) stated there was no RN assessment completed which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (Administrator) on 05/02/24. He acknowledged the findings.

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

1. Action(s) taken to correct this violation;

a. Resident #3 will have a comprehensive COC assessment specific to fall with left hip fracture and will include residents current status and interventions. Resident will have on-going f/u related to change until new baseline is formed.

b. Resident #4 will have a comprehensive COC assessment specific to admit to hospice, fall with injury and interventions/goals related to admit and fall. Resident will have on-going follow-up related to changes as time goes on or if a baseline begins to form.

2. To ensure that the system will be corrected so this violation will not happen again includes but is not limited to:

The community will follow 24hr communication system. The 24hr binder has been set up to include:

1) shift to shift comm. log

2) alert charting log

3) sig COC and weekly skin monitoring -- Nursing will handle.

a. Staff will follow short-term monitoring and communication systems for any resident indentified to have acute med changes, COC, missed med, return to facility, etc.

b. Staff will be aware on what to report to the nurse/MD per the STO that has been put in place, which coorelates with the residents COC.  The STO will have specific guidelines/information on what to watch for or report to the appropriate parties.

c. Staff should monitor residents status until residents condition resolves or they return back to their baseline.

d. 24 hour book process will be reviewed during manager meeting and identifications necessary will be made.

3. System will be reviewed daily, weekly, monthly and quarterly to ensure that we are in compliance.

4. The facility administrator and RN/WD will be responsible for ensuring the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment and interventions were developed based on the condition of the resident for 1 of 2 sampled residents (#6) who experienced a significant change of condition. Resident 6 continued to experience unwitnessed falls with injury which put him/her at risk and constituted an immediate threat to the residents' health and safety. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia.

The resident's current service plan, updated 07/01/24, progress notes dated 06/30/24 through 10/1/24, temporary service plans and incident reports were reviewed, and staff were interviewed.

The most recent evaluation, dated 07/01/24 indicated the resident was independent while ambulating and was not evaluated as having pain or notable confusion.

The resident experienced an unwitnessed fall on 07/11/24, with injuries including two thoracic vertebrae compression fractures (T11 and T12), three fractured ribs, a head abrasion and a left arm hematoma.

A progress note dated 07/12/24 stated the resident was "needing assistance ambulating due to weakness from [his/her] injury", was "confused", and "showed discomfort."

The resident's 07/11/24 fall, change in ambulation status, and increased confusion constituted a significant change of condition, which required a timely RN assessment that included resident status, RN findings, and interventions made as a result of the assessment. An RN progress note dated 07/23/24, 12 days after the significant change of condition occurred, did not address the resident's status, and no new interventions were identified.

The failure to complete a timely RN assessment following the significant change of condition, including resident findings and interventions made as a result of the assessment created a serious risk of harm to the resident and posed an immediate threat to the resident's health and safety.

An immediate plan of correction was requested at 2:31 pm on 10/03/24. The facility provided an acceptable plan of correction on 10/03/24 at 6:22 pm, prior to survey exit. The immediate risk was addressed, however, the facility will need to evaluate the overall system failure associated with the licensing violation.

The need for an RN to complete and document a timely assessment following a significant change of condition, including interventions made as a result of the assessment, was discussed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

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

1. Action(s) taken to correct this violation;

a. Resident #6 will have a comprehensive COC assessment specific to reocurring falls which will include residents current status and interventions. Resident will have on-going f/u related to change until new baseline is formed. POC: 1:1 Private CG has been initiated DAILY, EACH shift.

2. To ensure that the system will be corrected so this violation will not happen again includes but is not limited to:

The community will follow 24hr communication system. The 24hr binder is set up to include:

1) shift to shift comm. log

2) alert charting log

3) sig COC and weekly skin monitoring - Nursing will handle and review daily on scheduled days (Monday-Friday).

a. Staff will follow short-term monitoring and communication systems for any resident indentified to have acute med changes, COC, missed med, return to facility, etc.

b. Staff will be aware on what to report to the nurse/MD per the STO that has been put in place, which coorelates with the residents COC.  The STO will have specific guidelines/information on what to watch for or report to the appropriate parties.

c. Staff should monitor residents status until residents condition resolves or they return back to their baseline.

d. 24 hour book process will be reviewed during manager meeting and identifications necessary will be made.

3. System will be reviewed daily, weekly, monthly and quarterly to ensure that we are in compliance.

4. The facility administrator and RN/WD will be responsible for ensuring the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (# 5) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to:

Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client.

During the acuity interview on 04/29/24, Resident 5 was identified to be administered an insulin injection once daily by a facility UAP.

Resident 5's MARs from 04/01/24 through 04/29/24 revealed insulin injections had been given by Staff 7 (Medication Care Manager), Staff 14 (Medication Care Manager), and Staff 15 (Medication Care Manager).

There was no documented evidence upon review of the delegation binder that the initial nursing delegation was completed for Staff 14. The initial nursing delegation for Staff 7 was dated 04/19/24 and for Staff 15 was dated 04/20/24, respectively.

During the interview on 04/30/24, Staff 3 (RN/Wellness Director) confirmed Staff 14 was not delegated to prepare and administer insulin injections for Resident 5. On 04/30/24 at 1:30 pm,  Staff 3 stated she planned to conduct initial nursing delegation for Staff  7 on 04/30/24 during the scheduled evening shift. Staff 3 verbalized Staff 7 would not administer insulin until delegation was completed.

Additionally, the initial delegation reviews for Staff  7 and Staff 15 lacked the following documentation:

* The client did not require assessment during the procedure;

* The procedure did not require interpretation or independent decision making;

* The procedure was not life-threatening, and delegation posed minimal risk to the client;

* The client's environment supported safe performance of the procedure;

* Availability of RN to provide ongoing assessment of the client at frequency deemed necessary to determine ongoing stability and predictability;

* Availability of RN to provide ongoing competency validation of Unregulated Assistive Person's performance; and

* Documented recommendations on how the client would continue to receive the procedure if the RN was no longer a member of the health care team and the procedure remained ordered for the client.

The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (Administrator) and Staff 3 on 05/01/24. They acknowledged the findings. No further information was provided.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

1. Action taken to correct this rule is as follows:

a. Staff #14 has now had their initial nursing delegation for resident #5 completed by the RN/WD.

b. ALL medication staff will have delegations UTD per OR rules and regulation.

2. To correct the system the violation does not happen again, the delegation log has been updated and a copy will be kept in the medication room for all med techs to share accountability with scheule and plan to re-delegate. A comprhensive delegation audit will be completed to ensure delegation and supervision of special tasks of nursing care are being done consistently in accordance with OBSN Administration rules.

3. The area needing correction will be evaluated on a monthly basis, utilizing delegation audit tool and updating the delegation log PRN.

4. The RN will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#3) whose ADL care was observed, and for multiple unsampled residents who received meal service and assistance. Findings include, but are not limited to:

1. Observations of meal service were completed on 04/29/24 and 04/30/24 revealed the following:

a. Multiple care staff served food and provided direct feeding assistance to residents without donning a protective barrier over potentially contaminated clothing.

b. During an interview at 9:18 am on 04/30/24, Staff 14 (MT) stated CGs and MTs were responsible for taking meal trays to residents who preferred to eat in their rooms. At 9:20 am, Staff 13 (MT) was observed taking a plate of food and two beverages to Resident 3's room. The was no protective covering on the food or beverages to prevent contamination during transport.

2. Staff 13 was observed providing incontinence care to Resident 3 at 8:38 am on 04/30/24. She did not perform hand hygiene prior to providing hands on assistance to the resident. She changed the soiled briefs and pants, then performed perineal care and donned cleaned briefs and pants without removing soiled gloves and performing hand hygiene in between. After incontinence care she touched multiple surfaces and resident personal items in the room with the soiled gloves still on.

The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

OAR 411-054-0050 (1-5) Infection Prevention and Control

1. Action taken to correct the rule or violation as follows:

Care staff serving food will have aprons (cloth or disposable) moving forward during all service of foods to prevent possible contamination from clothing.

b. Meal trays to have coverings up until delivery to residents apartment as well as beverages covered with plastic wrap and then removed once delivered.

c. Infection Control and Handwashing has been assigned to ALL care related staff as hand hygiene was not preformed while doing cares on Resident #3. The importance has also been passed on and discussed to all staff. The need to establish and maintain infection control and prevention protocols to provide safe and sanitary envrionment.

2. The system will be corrected so this violation will not happen again by supplying the appropriate neccesities and tools to ensure compliance.

3. The area needing correction will be re-evaluated on a daily to weekly basis.

4. The Memory Care administrator will be responsible for the corrections stated aboved and will ensure they are being followed and completed.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 2 of 2 sampled residents (#s 7 and 8) whose ADL care was observed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted into the facility in 01/2020 with diagnoses including dementia, and was identified in the acuity interview as dependent on staff for incontinent care.

a. Staff 16 (CG) and Staff 30 (CG) were observed providing incontinence care for Resident 7 at 11:22 am on 10/02/24. They did not perform hand hygiene prior to donning single-task gloves. The staff changed the resident's soiled brief, then performed perineal care and donned cleaned briefs and pants without removing soiled gloves and performing hand hygiene in between. Staff 30 placed the soiled incontinence trash on the floor of Resident 7's room. After incontinence care was provided, both staff touched multiple surfaces and the resident's personal items such as the handles of the resident's geriatric chair with the soiled gloves still on. Both staff exited the resident's room and touched multiple surfaces and unsampled residents' wheelchairs and other personal items with the soiled incontinence care gloves.

b. Staff 16 and agency staff were observed providing incontinence care for Resident 7 at 1:45 pm on 10/03/24. They did not perform hand hygiene prior to donning single-task gloves. The staff changed the resident's soiled brief, then performed perineal care and donned clean briefs and pants without removing soiled gloves and performing hand hygiene in between. After incontinence care both staff touched multiple surfaces and personal items in the resident's room with the soiled gloves. Both staff removed the soiled gloves in the resident's room, but did not perform hand hygiene before exiting the room.

The above observations were discussed with Staff Staff 27 (ED), Staff 36 (ALF Administrator), and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged infection prevention protocols had not been implemented.

2. Resident 8 was admitted to the facility in 07/2020 with diagnoses including dementia. Observation of the resident during the survey showed the resident required staff assistance with incontinent care.

The surveyor observed on 10/03/24 at 10:46 am, Staff 11 (CG) and Staff 18 (CG) provide incontinence care for Resident 8. During the observation, Staff 11 and Staff 18 donned gloves without performing hand hygiene. Staff 11 then proceeded to remove the resident's soiled brief, wipe and cleanse the resident's perineum area and touch the resident's body, clean incontinent product, clothing and bed linens while using the soiled gloves. Staff 11 failed to change gloves between clean and dirty tasks and perform hand hygiene prior to donned gloves.

The above observation was discussed with Staff 22 (Wellness Nurse, RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:33 am. They acknowledged appropriate infection control practices were not implemented.

OAR 411-054-0050 (1-5) Infection Prevention and Control

1. Actions taken to correct the rule or violation as follows: All direct care staff has been trained on Infection Control and donning off/on while providing cares, skills observations completed with Administrator, RN or lead supervisor.

2. System will be corrected so violation will not happen by ensuring that all staff completed infection control training as well as documeneted skills observing direct care staff providing cares were utilizing proper infection control methods, and hand hygiene. Direct obeservation skill have been added to community orientation and reviewed monthly in QAPI.

3. The area needing evaluated will be reviewed MONTHLY on the last Monday of the month.

4. The administrator, RN, ED or designee in charge will be responsible for the corrections being completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system. Findings include, but are not limited to:

During the re-licensure survey, conducted 04/29/24 through 05/01/24, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C282 - RN Delegation and Teaching;

* C303 - Medication and Treatment Orders;

* C305 - Resident Right to Refuse;

* C310 - Medication Administration; and

* C330 - PRN Psychotropic Medications.

The need to ensure a safe medication and treatment system was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

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

a. RN Delegation and Teaching; Medication and Treatment Orders; Resident Right to Refuse; Medication Administration; PRN Pshychotropic Medications - The following as stated above has been updated- RN delegations being tracked, residents rights to refuse being monitored and recorded- faxed to MD timely, PRN Pshychotropic Medications having individualized interventions in place prior to administration and documentation to be recorded in pass notes.

2. The systems will be corrected so this violation will not happen again by all of the above being reconciled and monitored on routine basis.

3. The above stated will be monitored and completed on quarterly basis and PRN. ALL orders are to be reviewed by a minimum of 3 clinical staff.

4. The administrator and RN/WD/WN will be responsible for ensuring that all of the above corrections are being followed and carried out to prevent error.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed and had signed written prescriber's orders for 1 of 4 sampled residents (#4) whose orders were reviewed. Findings include, but are not limited to:

Resident 4 was admitted in 11/2021 with diagnoses which included Alzheimer's, pain and anxiety.

Review of the resident's clinical record revealed the following:

a. Resident 4 had an order for Lidocaine 4% patch to be applied topically every 12 hours for pain.

The MAR, reviewed from 04/01/24 through 04/29/24, revealed staff were not administering the patch once a day as ordered.

The discrepancy was discussed with Staff 3 (RN/Wellness Director) on 04/30/24. She stated she has been trying to clarify the order with the physician.  

b. The resident had an order for morphine 20 mg/mL to be given to Resident 4 in the amount of 0.25 ml 30 minutes prior to hospice aide providing bed bath.

This medication order was not on the MAR. The order date was 04/10/24.

In an interview on 04/30/24 at 12:45 pm, Staff 3 stated she was unaware of this order.

c. Resident had an order for Haloperidol 1 ML (2 mg) to be given by mouth every evening.

Staff were documenting this medication as being given at 8:00 pm nightly.

There was no written order for this medication.

Failure to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) on 04/30/24. He acknowledged the findings. No further information was provided.

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

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

a. Resident #4's MAR has been updated to be reflective of the written violations and physician orders are being carried out as prescribed.

2. The system will be corrected so the violation will not happen again by all resident and treatment orders will be reconciled to ensure medications and treatments are dispensed and followed as ordered.

3. Medication reconciliations will be completed upon new resident move-ins, medication changes, on quarterly basis, and PRN. Additionally, ALL new orders will be reviewed and approved by a minimum of 3 clinical staff members. Futhermore, daily audits to review missing medications and PRN usage will be completed.

4. The administrator, RN/WD will be responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 3 sampled residents (#6) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia.

The resident's signed physician orders and 09/01/24 through 10/02/24 MARs were reviewed, and the following was identified:

a. The resident had an order for Lidocaine 5% patch (for pain) to be applied topically every 24 hours. The order stated that the patch should be placed on the skin at 8:00 am and removed at 8:00 pm.

The patch was not administered as ordered on the following dates:

* 09/01/24;

* 09/04/24;

* 09/06/24;

* 09/07/24;

* 09/16/24; and

* 09/18/24.

Staff 22 (Wellness Nurse) was interviewed on 10/03/24 and was not able to provide any additional information.

b. The resident had a treatment order dated 08/19/24 stating that the resident needed to be "evaluated in clinic for follow up" due to a new presentation in the resident's behavior. There was no documented evidence the order was followed.

c. The resident had a treatment order dated 08/27/24 stating "the facility crush or empty the capsule of medication due and put them in apple sauce" due to repeated medication refusals. There was no documented evidence the order was followed.

d. The resident had a treatment order dated 09/03/24 stating "if patient had a fall sustaining injury with new symptoms, they need to be evaluated in clinic. If no available appointments or if it is after hours, patient is advised to follow up in urgent care or ED." The resident had an unwitnessed fall on 09/03/24 and injuries to bilateral elbows. There was no documented evidence that the order was followed.

The need to ensure all medication and treatment orders were carried out as prescribed was reviewed with Staff 22, Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

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

a. RN Delegation/Teaching; Medication and Treatment Orders - proper documentation of medication orders ie: refused, unavailable, given to family to give later, hold per MD order, etc. ALL med staff reminder/discussion on medication/treatment orders being following appropriately and accurately per physician orders andn then appropiately documentation.

2. The systems will be corrected so this violation will not happen again by all of the above being reconciled and monitored on routine basis.

3. The above stated will be monitored and completed on quarterly basis and PRN. ALL orders are to be reviewed by a minimum of 3 clinical staff.

4. The administrator and RN/WD/WN will be responsible for ensuring that all of the above corrections are being followed and carried out to prevent error.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified if a resident refused to consent to an order for 1 of 1 sampled resident (#3) who had medication and treatment refusals. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease. The resident's 04/01/24 to 04/29/24 MAR and current medication and treatment orders were reviewed. The following was identified:

Staff documented the following medication and treatment refusals between 04/01/24 to 04/29/24:

* Cyclosporine eye drops (for dry eyes): on 12 occasions;

* Desitin cream (for rash): on six occasions;

* Divalproex (an anticonvulsant) on 11 occasions;

* Furosemide (a diuretic) on 10 occasions;

* Lactase (for lactose intolerance) on five occasions;

* Melatonin (a sleep aid) on six occasions;

* Metoprolol (for high blood pressure) on two occasions;

* Quetiapine 25 mg tab (for mood) on five occasions;

* Quetiapine 50 mg tab on six occasions;

* Refresh eye drops (for dry eyes) on 35 occasions; and

* Vitamin D3 (supplement) on one occasion.

During an interview at 9:45 am on 04/30/24, Staff 13 (MT) stated if a resident was receiving hospice services, MTs would notify the hospice provider via phone call of the refusals. There was no documented evidence hospice was notified of the above medication and treatment refusals. During an interview at 10:30 am on 05/01/24, Staff 3 (RN/Wellness Director) confirmed the lack of documentation regarding Resident 3's medication and treatment refusals.

The need to ensure the physician or other practitioner was notified if a resident refused to consent to an order was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

1. Action(s) taken to correct the rule violation is as follows:

1. Actions taken to correct this violation are as follows:

a. Resident #3's medications refusals have been followed up with PCP/ANP now that she is no longer on hospice services and communicated to family.

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

a. All residents providers have now been faxed requesting when they would like to be notified of medication/treatment refusals and missed medications.

b. When faxes are received back the providers preference will be added to the MAR for med techs to follow the instructions and sign-out on the MAR.

3. This will be audited daily, weekly and monthly by the RN, administrator or designee.

4. The administrator, RN/WD will be responsible for ensuring corrections are completed and being monitored.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included documented reasons for use and resident specific parameters and instructions for administration of PRN medications for 2 of 4 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2022 with diagnoses including Alzheimer's disease and hypertension.

The resident's current prescriber orders and 04/01/24 through 04/29/24 MAR were reviewed and the following medications lacked reasons for use:

* Cal-Cit/vitamin D3;

* Melatonin;

* Omeprazole;

* Oxycodone;

* Polyethylene glycol;

* Potassium chloride; and

* Quetiapine.

The need to ensure all medications on the MAR included the reason for use was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.

The resident's 04/01/24 to 04/29/24 MAR and current prescriber orders were reviewed and the following was identified:

a. The following medications lacked a reason for use:

* Cyclosporine;

* Divalproex;

* Furosemide;

* Lactase;

* Melatonin;

* Quetiapine;

* Refresh plus;

* Vitamin D3; and

* Acetaminophen.

b. The resident was prescribed PRN lorazepam and haloperidol for agitation. The MAR lacked resident-specific parameters instructing unlicensed staff as to which medication should be administered first.

The need to ensure residents' MARs included documented reasons for use and resident specific parameters and instructions for administration of PRN medications was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

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

a. Resident #2 MAR has been updated to be reflective for the reason medication is being taken:

- Cal-Cit/Vit D3

- Melatonin

- Omeprazole

- Oxycodone

- Polyethyleneglycol

- Potasium Chloride; and

- Quetiapine

b. Resident #3 MAR has been updated to be reflective of order of medication for the following medications:

- Cyclosporine

- Divaproex

- Furosemide

- Lactase

- Melatonin

- Quetiapine

- Refresh Plus

- Vitamin D3; and

- Acetaminophen

The PRN medications of Lorazepam and Haloperidol now has resident specific parameters and instuctions as to when medications is to be used and non-pharmocological interventions were attempted prior to administration.

2. The system will be corrected so that this violation will not happen by ensuring trained community staf perform daily MAR audit to ensure ALL medications have reason(s) for use, order of administration for multiple medications with the same reason for use, with specific parameters and insructions ALL new PO's go through a triple check where the order is initially processed by the receiving med tech/administrator/RCC or WD to ensure no delay of treatment. 2nd checks is the next oncoming med tech/RCC to verify orders are accurate and appropriate directions and parameters for staff to follow are in place. Nursing or designee to be the final check to verify ALL components are in place, and to make the updates as indicated.

Trained staff will completed weekly-monthly MAR audits to ensure any concerns with medication descrepencies, omissions, PRN effectiveness and parameters are followed up on timely.

3. The area that's needed correction will be reviewed daily, weekly and monthly basis with triple check. MAR audits and monthly continuous quality improvement. All orders will be reconciled quarterly prior to PO's being sent out to MD for review.

4. The administrator, or RN/WD will be responsible to ensure the corrections are completed and monitored.

2. Resident 1 moved into the facility in 03/2024, with diagnoses including agitation associated with dementia.

Review of Resident 1's MAR, dated 04/01/24 through 04/29/24, and current physician's orders, indicated the resident was prescribed PRN psychotropic medications including lorazepam 0.5 mg twice daily "for severe anxiety."

a. The record lacked resident-specific parameters to direct staff on how the resident displayed severe anxiety.

b. There was no documented evidence non-pharmacological interventions were tried and ineffective prior to administration of the PRN lorazepam on 15 occasions between 04/01/24 and 04/25/24.

In an interview with Staff 12 (Medication Manager) on 04/30/24 at 11:00 am, it was confirmed there was no documented evidence of non-pharmacological interventions having been tried prior to administration of the PRN lorazepam.

The need to ensure PRN medications given to treat a resident's behaviors had written, resident-specific parameters and there was documentation that non-pharmacological interventions had been tried with ineffective results prior to administration was discussed with Staff 1 (Administrator) on 05/01/24 at 12:35 pm. He acknowledged the findings.

3. Resident 4 was admitted to the facility 11/2021 with diagnoses including dementia and mood disorder.

Review of the resident's 04/01/24 through 04/29/24 MAR and 04/03/24 hospice orders showed the following:

* Olanzapine ODT 5mg tab, ½ tablet (2.5 mg) by mouth every six hours as needed for agitation or hallucinations.

The olanzapine was administered nine times between 04/03/24 and 04/11/24.  

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety or hallucinations. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medication.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator) and Staff 3 (RN/Wellness Director) on 05/01/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administering PRN psychotropic medications for 3 of 3 sampled residents (#s 1, 3, and 4) who had orders for PRN psychotropic medications. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including Alzheimer's disease.

Review of the resident's 04/01/24 to 04/29/24 MAR and current prescriber orders indicated the resident was prescribed the following:

* Haloperidol concentrate 2 mg/ml, take 0.25 ml by mouth every four hours as needed for hallucinations, agitation, nausea, and/or vomiting.

a. The record lacked resident-specific parameters to direct staff on how the resident displayed agitation.

b. There was no documentation that non-pharmacological interventions were tried with ineffective results prior to administration of the PRN haloperidol on two occasions between 04/01/24 and 04/29/24.

The need to ensure resident-specific parameters and documentation that non-pharmacological interventions were tried with ineffective results prior to administration of PRN psychotropic medications was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

OAR 411-054-0055 (6) Systems: Psychotropic Medication

1. Actions taken to correct this rule violation is as follows:

a. Resident #3 MAR has been updated with resident specific parameters ro direct staff on how the resident displays agitation and personalized non-pharmacological interventions have been added to PRN medications.

b. Resident #1 MAR has been updated to have resident specific parameters to direct staff on how resident shows severe anxiety. On PRN medications personalized non-pharmacological interventions have been put into place to be attempted prior to administration.

c. Resident #4 has been updated to have personalized resident specific parameters for direct care staff to follow prior to administration and description on how the resident expresses anxiety or hallucinations.

2. The system is being corrected to eliminate further/future violations, as follows:

a. ALL new/incoming orders received or current orders will be reviewed by RN, or administrator and ensure that personalized interventions, definitions of anxiety, behaviors etc are in the medication section for staff awareness and are being followed and attempted prior to administration.

3. The area needing correction will be reviewed daily-weekly, quarterly and PRN.

4. The administrator/WD/RN or designee will be responsible for ensuring that the corrections are followed and completed.

Based on interview and record review, it was determined the facility failed to ensure an ABST assessment was completed for each resident. Findings include, but are not limited to:

On 04/30/24 at 9:55 am, Staff 1 (Administrator) was interviewed regarding the facility's ABST. He stated all residents were entered into the facility's ABST, however, there were six residents whose data was not saved.  

Upon ABST review on 04/30/24 at 10:00 am, all residents residing in the MCC were entered into the ABST. However, the required ABST elements reflected zero minutes in each category for Resident 3, Resident 4, and four unsampled residents.

The need to ensure an ABST assessment was completed for each resident was discussed with Staff 1 on 05/01/24. He acknowledged the findings.

OAR 411-054-0037(1-8) Acuity-Based Staffing Tool

1. Action taken to correct this rule violation is as follows:

a. The ODHS ABST has been updated to reflect appropriate resident service plan.

b. The ABST tool pulls the SP point system from each resident and calculates appropriate staffing based on the acuity of each individual resident.

c. Using the staffing schedule assignment to assure staffing is in accordance to the ABST tool.

2. The system is being corrected to eliminate future violations, as follows:

a. Facility corporate working to create policies and procedures related to the ABST.

b. Facility IDT will receive training related to requirements of the ABST.

c. Facility will maintain ABST at time of each resident evaluation and or with any COC.

d. Facility administrator will review staffing scheduing to ensure that the schedule is reflective of staffing requirements based on current ABST.

3. The system will be evaluated as follows:

a. Facility will update the ABST with each resident eval: intial, 30-day, quarterly, and with sig COC.

b. Facility adminustrator will review monthly staffing schedule and PRN to ensure that schedule is reflective of staffing needs per the ABST.

4. Facility administrator or designess will oversee and enure the ongoing of compliance.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly for multiple sampled and unsampled residents or with a significant change of condition for 2 of 2 sampled residents (#s 6 and 7) who had a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

The facility's ABST was reviewed at 10:29 am on 10/03/24 with Staff 36 (ALF Administrator). The following was identified:

* Twenty-four of the facility's 36 residents did not show evidence of being updated quarterly;

* Resident 6's ABST did not show evidence of being updated with his/her significant change of condition that occurred on 07/11/24; and

* Resident 7's ABST did not show evidence of being updated with his/her significant change of condition that occurred on 09/01/24.

The need to ensure residents' ABSTs were updated no less than quarterly and with significant changes of condition was discussed with Staff 27 (ED), Staff 36 and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

OAR 411-054-0037(1-8) Acuity-Based Staffing Tool

1. Action taken to correct this rule violation is as follows:

a. The ODHS ABST has been updated to reflect appropriate resident service plan.

b. The ABST tool pulls the SP point system from each resident and calculates appropriate staffing based on the acuity of each individual resident.

c. Using the staffing schedule assignment to assure staffing is in accordance to the ABST tool

2. The system is being corrected to eliminate future violations, as follows:

a. Facility corporate working to create policies and procedures related to the ABST.

b. Facility IDT will receive training related to requirements of the ABST.

c. Facility will maintain ABST at time of each resident evaluation and or with any COC.

d. Facility administrator will review staffing scheduing to ensure that the schedule is reflective of staffing requirements based on current ABST.

3. The system will be evaluated as follows:

a. Facility will update the ABST with each resident eval: intial, 30-day, quarterly, and with sig COC.

b. Facility adminustrator will review monthly staffing schedule and PRN to ensure that schedule is reflective of staffing needs per the ABST.

4. Facility administrator or designess will oversee and enure the ongoing of compliance.

Based on interview and record review, it was determined the facility failed to ensure staff demonstrated competency in assigned job duties within 30 days of hire for 1 of 2 staff (#33) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed with Staff 36 (ALF Administrator) at 1:36 pm on 10/03/24. The following was identified:

Staff 33 (CG), hired 06/17/24, did not have documented evidence of completing abdominal thrust training within the first 30 days of hire.

The need to ensure staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 27 (ED), Staff 36 and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training

within 30 days: Direct Care Staff

1. Action taken to correct this rule violation are as follows;

All Direct Care Staff have documentation of demonstrated competency, both caregivers and medication managers.

2. The system will be corrected so that violation will not

happen again by;

a. An audit of all direct care staff has been completed utilizing ODHS QM Staff Training Tracker tool.

b. Any missing competencies and trainings have been completed for currently employed staff.

3. The area needing correction will need to be evaluated with each new hire of direct care staff as part of their on-boarding process for pre-service, 30 day, quarterly and annually utilizing ODHS QM Staff Training Tracker Tool.

4. The Administrator, Wellness Director and Assisted Living Coordinator will be

responsible to see that the corrections are completed

and monitored.

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code and to provide fire and life safety instruction on alternate months. Findings include, but are not limited to:

Six months of fire drill and fire and life safety training's were requested on 04/29/24. During an interview at 1:54 pm on 04/29/24, Staff 4 (Business Office Manager) stated the former maintenance director maintained the fire and life safety records but no one currently working at the facility knew where the documentation was. She provided documentation of a building-wide fire drill that took place on 04/25/24; however she stated the fire drill was for staff only and no residents were evacuated or participated. The documentation did not address any of the following required rule components:

* Date and time of day;

* Location of simulated fire origin;

* The escape route used;

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

* Evacuation time period needed;

* Staff members on duty and participating; and

* Number of occupants evacuated.

The need to ensure fire drills were conducted in accordance with the Oregon Fire Code fire and life safety instruction was provided to staff on alternate months was discussed with Staff 1 (Administrator) on 05/01/24. He acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

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

a. Written fire drill records will be kept that include the following:

- escape route used

- problems encountered and comments relating to residents or failed to participaye in the drills;

- evacuation time period needed; and

- number of occupants evacuated

- alternate escape routes used.

2. System will be corrected so that the violation will not happen again by;

a. comprehensive review of current fire drill forms to ensure they meet all the required components.

b. In servicing provided to administration and or designee conducting fire drills and education on process and documentation required.

3. The stated area needing correction will be evaluated on a monthly basis.

4. The administrator, maintanence director and or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to conduct fire drills per OFC and to instruct staff in fire and life safety topics on alternate months from fire drills. This is a repeat citation. Findings include, but are not limited to:

Facility fire drill and fire and life safety records from 06/30/24 to 10/02/24 were requested and reviewed with Staff 36 (ALF Administrator) at 10:18 am on 10/03/24.

a. A fire drill completed on 08/29/24 lacked the following documentation:

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

* Evacuation time period needed;

* Staff members on duty and participating; and

* Number of occupants evacuated.

b. Staff 36 confirmed at 10:18 am on 10/03/24 there was no documented evidence staff were trained in fire and life safety procedures on alternate months from fire drills.

The need to ensure fire drills were conducted per OFC and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 27 (ED), Staff 36 and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

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

a. Fire and Life Safety instruction was provided to all staff on 10/10/24 that included; designated points of safety, alternate exit routes, emergency assemby points, areas of refuge, types of evacuations, roles of direct and non direct care staff during evacutions, and evacuating nonambulatory residents. A walkthrough of the community identifying fire doors and mechaninsms, fire panel, points of refuge, fire extinguishers, safety points outside, and importance of residents signing in/ out of building.

b. Fire and Life Safety education was provided to residents that included areas of refuge, types of evacuations, outside evacuation safe zones, alternate routes, use of pull alarm, sprinklers, location of smoke detectors and sprinkler in facility and resident apartments, staff duties during evacuation and assistance to residents, and importance of signing in and out of building, as well as a handout covering evacuation procedures.  

c. Unannouced fire drills were scheduled for 10/23/24 and 10/24/24 on alternate shifts utilizing fire drill form that includes;

*Date and time of drill,

*Location of simulated fire origin,

*Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to particpate in the drills;

* Evaucation time period needed; and

* Number of occupants evacuated.

* Alternate  escape routes used.

2. System will be corrected so that violation will not

happen again by;

a. Comprehensive review of current fire drill forms

to ensure they meet all required components.

b. Fire & Life Safety Training for Residents will be instructed within 24hrs of move-in, and reinstructed annually thereafter.

b. All resident fire and life safety documentation will be filed and kept on-site,

c. Facility will keep an on-going spreadsheet of residents' admission dates, and dates of re-instruction.

d. Facility Maintenance Director will bring all fire & life safety training for residents, to Quality Improvement Meetings for review.

3. This system will be evaluated as follows:

a. Within 24hrs of a new resident admission, &

b. Annually thereafter,

c. Facility administrator will review fire & life safety for residents, at least once monthly to ensure compliance.

4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

Based on observation, interview, and record review, 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 C231, C260, C270, C280, C295, C303, C361, C420, Z155, and Z164.

OAR 411-054-0105 (2-4) Inspections

and Investigation: Insp Interval

Refer to C231, C260, C270, C280, C295, C303, C361, C420, Z155 and Z164.

Concerns were identified in the following areas and the facility was provided with technical assistance:

H1517: Individual Privacy: Own Unit. OAR 411-004-0020(2)(d):

(d) Each individual has privacy in his or her own unit.

Concerns were identified in the following areas and the facility was provided with technical assistance:

H1518: Individual Door Locks: Key Access. OAR411-004-0020(2)(e)

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Concerns were identified in the following areas and the facility was provided with technical assistance:

H1580: Limitations: Threats to health and safety. OAR 411-004-0020(2)(d) to (2)(j):

Ensure the residential setting applies individually based limitations when conditions may not be met due to threats to the health and safety of an individual or others.

Refer to H1518.

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 152, C 155, C 231, C 295, C 361, C 372, and C 420.

OAR 411-057-0140 (2) Administration Compliance

Please reference the following tags/sections: Refer to C 152, C 155, C 231, C 295, C 361, C 372, and C 420

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 C150, C156, C231, C295, C361, C372,  and C420.

OAR 411-057-0140(2) Administration Compliance

Refer to C150, C156, C231, C295, C361, C372, and C420.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 18, 19 and 20) completed all required orientation, pre-service, and competency training within required timelines, and 2 of 2 sampled direct care staff (#s 7 and 10) completed a total of 16 hours of in-service training annually based on date of hire, including six hours of annual dementia care training. Findings include, but are not limited to:

Training records were reviewed with Staff 4 (Business Office Manager) on 05/01/24. The following deficiencies were identified:

a. Staff 18 Care Manager (CM) was hired 11/01/23, Staff 19 (CM) was hired 04/01/24 and Staff 20 (CM) was hired 04/01/24. The following training requirements were not met:

* Staff 18, 19, and 20 did not complete orientation training on "Standard Precautions for Infection Control" prior to beginning job duties;

* Staff 19 and 20 did not complete orientation training on "HCBS" prior to beginning job duties;

* Staff 18 did not complete orientation training on "HCBS" by 03/31/24;

* Staff 19 and 20 did not complete pre-service dementia training on the topic of  "Environmental Factors that are Important to a Resident's Well-Being"; and

* Staff 18, 19, and 20 did not complete pre-service dementia training on the topic of "Use of Supportive Devices with Restraining Qualities in MCCs" prior to working independently.

b. Staff 18 did not complete abdominal thrust within 30 days of hire.

c. Staff 6 (Housekeeping Supervisor) was hired 05/10/22. The following training requirements were not met:

* Staff 6 did not complete annual training on "Standard Precautions for Infection Control" annually or HCBS by 03/31/24.

d. Staff 7 Medication Care Manager (MCM) was hired on 06/05/21. For the calendar year 2022/23, Staff 7 completed 12.5 hours of annual in-service training, of which 4.25 hours were on dementia-related topics.

Staff 7 did not complete "Standard Precautions for Infection Control" annually or HCBS by 03/31/24.

e. Staff 10 (MCM) was hired on 10/11/21. For the calendar year 2022/23, Staff 10 completed 8 hours of annual in-service training, of which 2.25 hours were on dementia-related topics.

The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, and that veteran direct care staff completed 16 hours of in-service training annually based on date of hire, including six hours of annual dementia care training, was reviewed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN/Wellness Director), and Staff 4 on 05/01/24. They acknowledged the findings.

OAR 411-057-0155(1-6) Staff Training Requirements

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

a. A file with ALL required training will be kept and managed by BOM and administrator for all newly hired care staff to complete the orientation training prior to working independently and that veteran staff complete the required 16 hours of annual in-service training and 6 hours of dementia care training.

b. a check-list of topics for each care staff will be kept and ensured that the required trainings are annually completed as required.

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

a. all staff will be provided Relias login at hire and PRN from the BOM and tools in order to complete the annual required trainings.

3. This area will be reviewed on a monthly and quarterly basis to ensure that facility care staff is in compliance.

4. The administrator, BOM, ED or designee will be responsible to ensure that the corrections are completed and followed through with.

Based on interview and record review, it was determined the facility failed to ensure 6 of 8 sampled medication technicians (#s 7, 12, 14, 26, 38, and 39) demonstrated knowledge and performance in any duty they were assigned prior to providing care services to residents, 3 of 3 newly hired staff (#s 33, 38, and 40) completed all required pre-service orientation training, 1 of 2 caregivers (# 23) demonstrated competency in assigned job duties within 30 days of hire, 1 of 3 (#32) long-term care staff completed required Home and Community-Based Services (CBS) training, and failed to develop a system to track annual training for long-term direct care staff. Six MT's were working independently and lacked documentation of competency in medication administration, which put the residents for which they administered medications at risk for serious harm. This is a repeat citation. Findings include, but are not limited to:

1. Employee training records were reviewed on 10/02/24 at 5:46 PM with Staff 36 (ALF Administrator). The following was identified:

Staff  7 (MT) was hired 06/05/21, Staff 12 (MT) was hired 02/06/23, Staff 14 (MT) was hired 07/26/22, Staff 26 was hired 03/03/22, Staff 38 (MT) was hired 07/01/24, and Staff 39 (MT) was hired 04/29/22. Each of these staff had been working in the facility independently as an MT, which included administering medications to residents. The facility was unable to provide documentation that their knowledge and performance in administering medications had been reviewed and each had been determined competent to administer medications unsupervised.

On 10/02/24 at 5:46 PM, the survey team requested an immediate plan of correction (PC) to ensure MT's whose job it was to administer medications to residents were trained by appropriate facility staff and there was documentation to show they had observed and evaluated the MT's ability to perform safe medication administration unsupervised. On 10/02/24 at 6:17 PM, the facility submitted a PC that was accepted by the survey team.

The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

2. Staff training records were reviewed with Staff 36 at 1:36 PM on 10/03/24. The following was identified:

Staff 33 (CG), hired 06/17/24, Staff 38 (MT), hired 07/01/24, and Staff 40 (Cook), hired 09/03/24, lacked one or more of the following pre-service orientation training requirements:

* Written job description; and

* CBS training.

3. Staff 23 (CG), hired 08/05/24, did not have documented evidence of demonstrating competency in job duties within 30 days of hire.

4. Staff 32 (Server), hired 12/15/21, did not have documented evidence of completing required CBS training.

5. During an interview at 10:03 am on 10/04/24, Staff 36 stated there was no system to track annual training for long-term direct care staff in the memory care community.

The need to ensure the facility had a process to ensure all direct care staff had documentation of demonstrated competency in any duty they were assigned, all newly hired staff completed pre-service orientation training, all long-term staff completed HCBS training, and all long-term employees completed annual training requirements was reviewed with Staff 27 (ED), Staff 36, and Staff 37 (Chief Wellness Officer) on 10/04/24. They acknowledged the findings.

OAR 411-057-0155 (1-6) Staff Training Requirements

1. Actions taken to correct the rule violations are as follows: Immediate corrective action completed and documented competencies were completed day of and signed off by RN.

2. System will be corrected so this violation will not happen again by ALL staff missing training requirements will have been completed for current staff, ongoing use by facility of QM Staff Training Tracker has been utilizied and audited for ALL missing training and will be continued used for ALL staff moving forward.

3. Area needing correction will be evaluated weekly and as needed per training tracking tool requirements for pre-service, 30 day, 60 day, 90 day, and bi-annual. Those not in compliance will be removed from the scheule.

4. The administartor, RN, business office and/or designee in charge will be responsible that the corrections are completed/monitored.

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, C 270, C 280, C 282, C 300, C 303, C 305, C 310, and C 330.

OAR 411-057-0160(2b) Compliance with Rules Health Care

Reference the following tags/sections: C260, C270, C280, C282, C300, C303, C305, C310; and C330.

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 C260, C270, C280, and C303.

OAR 411-057-0160(2b) Compliance with Rules Health Care

Refer to C260, C270, C280, and C303.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and documented in the resident's service or care plan for 2 of 4 residents (#s 3 and 4) whose records were reviewed. Findings include, but are not limited to:

Resident's 3 and 4's current service plans were reviewed during survey. Each of the service plans 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 (Administrator) and Staff 3 (RN/Wellness Director) on 05/01/24. They acknowledged the findings.

OAR 411-057-0160(2)©(A)(B) Nutrition and Hydration

1. The actions taken to correct the rule violation is as follows:

a. Resident #3 SP has been updated to reflect a personalized nutrition and hydration needs plan for team members to follow.

b. Resident #4 SP has been updated to reflect a personalized nutrition and hydration needs plan for team members to follow.

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

a. Staff communication on needs and changes of each individual resident and their needs.

3. individualized nutrition and hydration status and needs will be made during initial, move in, quarterly and PRN if needs change.

4. The administrator and RN/WD or designee will be responsible for the corrections made and ensuring that they are completed and accurate.

Based on observation, interview and record review, it was determined the facility failed to evaluate residents and create individualized activity plans based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, and 4's service plans offered some information about the residents' interests, however, the facility had not fully evaluated the residents':

* 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.

Observations and interviews indicated the residents were dependent on staff to initiate activities.

On 05/01/24 the need to ensure the facility provided meaningful activities based on an activity evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED), who acknowledged the findings.

OAR 411-057-0160(2d) Activities

1. The actions taken to correct the rule violation is as follows:

a. Resident(s) #1, #2, #3, and #4 and/or family members have all been interviewed/evaluated for abilities, likes and dislikes and social engagement to form an IAP.

2. Resident(s) #1, #2, #3, and #4 all have Individualized Activity Plans that include the following:

- current abilities and sills

- emotional and social needs/patterns

- physical abilities and patterns

adaptations necessary for the resident to particiapte; and

- activites that could be used to help as a behavioral intervention

3. The area needing correction will routinely be reviewed quarterly and PRN if changes are needed.

4. The administrator, RN/WD and Life Enrichment coordinator will be responsible for ensuring corrections are completed and followed through with.

Based on observation, interview, and record review, it was determined the facility failed to provide meaningful and individualized activity plans based on their activity evaluations, for 2 of 3 sampled residents (#s 6 and 8) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the memory care community (MCC) in 07/2020 with diagnoses including dementia.

The resident's service plan, dated 06/23/24, stated:

* Resident "is no longer able to hold conversations or verbally interact with others ..."; and

* Resident "enjoys 1:1 interaction with staff."

The resident was observed during the survey to require full assistance with activities of daily living (ADLs) due to physical and cognitive limitations and was dependent on staff to initiate activities.

On 10/02/24 between 1:10 pm and 4:00 pm and 10/03/24 between 9:15 and 10:45 am, Resident 8 was observed in his/her geriatric chair in the common area near activity table. The television was continuously on. At approximately 1:15 pm on 10/02/24 and at 9:30 am on 10/02/23, there was a staff member-led artificial flowers activity and block activity at the activity table, but the staff did not offer the flowers activity and block activity nor a one-on-one sensory activity to the resident during the observation.

The facility provided some information about the residents' interests, however, the facility had not fully developed an individualized activity plan and/or did not provide structured and non-structured activities in the service or care plan as appropriate.

On 10/04/24 at 10:33 am, the need to ensure the facility provided meaningful activities based on an activity evaluation and an individualized activity plan for each resident was discussed with Staff 22, Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer). They acknowledged the findings.

2. Resident 6 was admitted to the facility in 06/2023 with diagnoses including dementia.

The resident's service plan, dated 07/01/24, stated the resident required "moderate assist" with activities, including requiring staff to assist him/her with activities by reminding him/her of times and activities of the day.

On 10/02/24 between 10:30 am and 3:00 pm and 10/03/24 between 10:30 am and 2:30 pm, the resident was observed in the memory care facility. There was no attempt to engage the resident in an activity during the time s/he was observed. The resident was often observed wandering the hallways, sitting alone, or attempting to access the locked kitchenette, which was one of his/her known behaviors.

Between the dates of 08/16/24 and 10/01/24, the resident's record showed that the resident exhibited behaviors including:

*Hitting staff;

*A resident-to-resident altercation; and

*Tendency to walk into other resident apartments.

Under the section of the activity evaluation titled "identification of activities for behavioral intervention", the evaluation stated the resident "requires redirection from staff to an activity". There was no additional information.

The facility did not have documented evidence of an activity plan which included a selection of daily structured and non-structured activities.

The need to ensure the facility provided meaningful activities based on an activity evaluation and had an individualized activity plan which included a selection of daily structured and non-structured activities for each resident was reviewed with Staff 22 (Wellness Nurse/RN), Staff 27 (ED), Staff 36 (ALF Administrator) and Staff 37 (Chief Wellness Officer) on 10/04/24 at 10:53 am. They acknowledged the findings.

OAR 411-057-0160(2d) Activities

1. Actions taken to correct rule violations are as follows:

a. Personalized activity plan for resident #6 and #8 have been audited for 1:1 activites were added per there past histories, occupations, preferences and current cognitive abilities for care staff and life enrichment to follow. Personalized activite kits have been created and available to staff at ALL times.

2.1:1 or mulit-sensory inclusion training has been provided on how to engaged residents of all cognitive levels and life skills based on current and passed preferences.

3. Area needing correction will be evaulated quarterly or with each changes of condition.

4. Life Enrichment, MC Administrator, direct care staff and RN will be responsible for the corrections being completed/monitored. *Ensuring direct care staff have access based on needs and preferences of residents.  

Based on observation and interview, it was determined the facility failed to ensure outdoor furniture was of sufficient weight, stability and design, to prevent resident injury or aid in elopement. Findings include, but are not limited to:

The facility grounds of the memory care community were toured on 04/29/23 at 11:10 am. Outdoor furniture was observed in both courtyards, to which residents had free access. The furniture was movable, and not of sufficient weight to prevent injury or elopement.

On 05/01/24 at 11:05 am the outdoor courtyards were toured with Staff 1 (Administrator). The need to maintain outdoor furniture of sufficient weight was discussed with Staff 1, and he acknowledged the findings.  

OAR 411-057-0170(6) Secure Outdoor Recreation Area

1. The actions taken to correct the rule violation as follows:

a. Patio furniture will be adequately weighed down so it is not easily moveable by a resident and properly and safely secured.

2. To ensure the system is corrected and this violation does not happen again is as followed:

a. For any reason the furniture is replaced or in need of repair the stated above will be followed through with and if unable to be done it will be removed from the patio until able to do so.

3. The area needing correction will be evaluated quarterly and PRN.

4. The administrator, ED, and maintenance director will be responsible to see that the corrections are completed and monitored.