Print Inspection: 4R94

The findings of the re-licensure survey, conducted 8/30/2021 through 9/1/2021, 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 C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 survey to the relicensure survey of 09/01/21, conducted 12/20/21 through 12/21/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 09/01/21, conducted 02/16/22, are documented in this report. It was determined the facility was in substantial compliance with OARS 411 Division 54 for Residential Care and Assisted Living Facilities, OARS 411 Division 57 for Memory Care Communities and OARS 411 Division 004 for Home and Community Based Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure allegations of suspected abuse involving a resident-to-resident altercation and repeated incidents of being found on the floor were promptly investigated to rule out abuse/neglect and were reported to the local SPD office if  abuse and/or neglect could not be reasonably ruled out for 2 of 2 sampled residents (#s 1 and 3). Findings include but are not limited to:

1. Resident 1 was admitted to the facility in March 2021 with diagnoses including dementia. Observations of Resident 1 from 8/30/21 to 9/1/21 revealed the resident was mostly non-verbal and required staff assistance for all ADL care, including 2-person transfer and incontinent care.

a. On 5/4/21 staff documented the resident "attached [sic] another resident from the back by pulling from the back of [his/her] sweatshirt, not only scarring [sic] [him/her] but almost chocking [sic] [him/her]."

There was no evidence the facility conducted an immediate investigation to rule out abuse or potential abuse nor was the incident reported to the local SPD office.

The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 8/31/21 prior to survey exit.

The need to ensure allegations of suspected abuse involving a resident-to-resident altercation were immediately investigated and reported if necessary was discussed with Staff 1 (ED) and Staff 2 (RN). No further information was provided.  

b. A review of the resident's clinical records, 3/6/21 through 8/30/21, showed the resident had unwitnessed falls on 7/3/21, 7/10/21, 7/15/21 and 7/18/21 and indicated the following:  

* On 7/3/21 staff documented on a facility Incident Report Investigation that "resident was found on the floor lying on [his/her] right side, complaining of neck pain and right arm pain ... staff called 911 ..." Staff failed to document response of staff at the time of the event, follow-up action or administrator review. The incident was not reported to SPD.

* On 7/10/21 staff documented "Resident was found on the ground. Resident reported no pain or discomfort. Resident was able to stand with staff assist." Staff failed to document individuals present, a complete description of the event and indicated abuse had been ruled out without documentation of a thorough investigation.

* On 7/15/21 staff noted "Resident was hear [sic] falling, found on the ground, reported hitting [his/her] head ...." The resident was sent to the hospital. Staff failed to document the time and individuals present, a complete description of the event, or staff response at the time of the incident.

* On 7/18/21 staff noted "Resident had an unwitnessed fall, found on the ground ..." Staff failed to document individuals present, a complete description of the event, or staff response at the time of the incident.

Resident 1 experienced four unwitnessed falls from 3/6/21 through 8/30/21, and on the 7/3/21 and 7/15/21 falls the resident was sent to the emergency room related to complaints of pain or signs/symptoms of injuries. There was no evidence the facility conducted an immediate investigation to reasonably conclude that the above incidents were not the result of abuse or neglect nor were the incidents reported to the local SPD.  

The need to investigate incidents of suspected abuse and neglect and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21.

Staff 1 confirmed she had not reported the above incidents to the local unit, at which time the surveyor requested Staff 1 to immediately report the incidents. Confirmation that the incidents were reported was received on 9/1/21 prior to the survey team exiting the facility.

2. Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia and his/her 8/11/21 service plan indicated he/she was dependent on staff for all ADLs.

A review of the resident's clinical record revealed he/she fell on 6/24/21. Staff completed an electronic incident report form and wrote a progress note that resident was on alert for an unwitnessed fall.

There was no documented evidence the facility conducted an immediate investigation to rule out abuse or potential abuse or reported the incident to the local SPD office.

The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 9/1/21 prior to survey exit.

On 9/1/21 the need to investigate incidents to determine if there was abuse and/or neglect, and to report the incident to the local SPD office if abuse and/or neglect could not be reasonably ruled out, was discussed with Staff 1 (ED). She acknowledged the findings.

All staff are being trained on abuse reporting and investigations packet.  The med techs will notify the ED/RCC/RN and start the report.  Any witnesses will fill out a statement and the incident will be reported to APS via fax.  The ED/RCC/RN will complete the investigation using our facility Abuse and neglect investigation packet

We will train quarterly on this process and upon new hire of staff.

The ED will ensure this is being completed

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

On 8/30/21 at 10:50 am the kitchen was observed to need cleaning and/or repair in the following areas:

* Door and walls had food splatters and spills, black marks and chips and gouges in the paint;

* Cabinet doors, drawer fronts and all around the kitchen island had food splatters, spills and drips;

* Cabinets shelves had food particles;

* Windows above sink had a build-up of gray matter;

* Microwave had food particles, splatters and drips inside;

* Toaster had a build-up of brown matter on the top and sides;

* Stove top had food particles, splatters and drips;

* Oven had dried black/brown matter on the bottom and glass door;

* Freezer had food particles on bottom shelf;

* Refrigerator had opened containers that were not dated, some of which had sticky food splatters on the outside;

* Refrigerator had rusted shelves and food particles, splatters and sticky brown matter on bottom shelf;

* Bottom of upper cabinet doors to the right of the sink was coming unglued;

* Water heater tray had build-up of gray matter and splatters; and

* Food debris, splatters and drips on the floor.

Observations on 8/30/21 revealed the Food Sanitation Rules were not being followed in the following areas:

* There was an uncovered cup of berries in the refrigerator;

* A baking tray was stored between water pipes in the dry storage area next to the water heater;

* There were stacks of boxes containing food piled in front of the shelving in the dry storage area;

* The garbage can did not have a cover;

* There was no bleach solution or test strips available; and

* The dishwasher wash cycle was observed to reach 130 degrees F, not the manufacturer's recommended 150 degrees F.

The dishwasher rinse cycle was observed to reach 170 degree F temperature recommended by the manufacturer and chemicals were being used with the washing cycle. Staff 5 stated someone would be called to fix the dishwasher immediately.

In addition, there was a package of meat in a pitcher in the sink with cold water running over it. Staff 5 (Cook) stated he was thawing the meat for lunch. The water temperature was 67 degrees F, as taken by surveyor. Staff 5 opened the package of meat and it was observed to be mostly frozen.

The areas needing cleaning and/or repair and food safety were discussed with Staff 1 (ED) and Staff 5 on 8/30/21.

The need to comply with the Food Sanitation Rules and keep the kitchen clean and in good repair was discussed with Staff 1 and Staff 2 (ED) on 8/31/21. They acknowledged the findings.

The facility will start a food committee, first meeting to be held October 15th and then monthly after, we will also involve family in dietary preferences if resident is unable.  the staff will ensure snacks are handed out 3x's daily. The kitchen will post and hand out the weekly menu and a daily menu will be set out to inform residents if there are changes

Kitchen will be using a deep cleaning task list that has already been given to them and the RCC/ED will walk through weekly to ensure it is done

We have ordered replacement shelves for the fridge, installed 9/21/21

We had a repair person out to fix the dishwasher

Bleach solution is available and strips are in the kitchen

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests and opportunities for active participation in the community at large. Findings include, but are not limited to:

The following observations were made on 8/30/21 through 9/1/21:

* There were no scheduled activities after 3:00 pm.

* Coffee Chat, scheduled for 8/30/21 at 10:00 am and Hand Massages, scheduled for 8/30/21 at 11:00 am, did not take place.

* On 8/30/21 at 11:30 am, observed "Bingo" activity in dining room, which was scheduled for 8/30/21 at 3:00 pm. No other activity was observed.

* Staff did not provide any individualized activities to residents.

During the survey, there was a lack of unscheduled and scheduled activities that occurred for residents who were unable to self-initiate activities or the community at large. The primary activity observed included residents sitting out in the common area for long periods of time watching movies or other TV shows, wandering the halls, or remaining in their rooms.

On 9/1/21 at 2:55 pm Staff 1 (ED) stated the activity staff was out of sick and he had returned to work that day. The failure to provide an activity program based on individual and group needs was reviewed with Staff 1 during the survey. She acknowledged the findings.

A new activities person will be hired to ensure activities are going on start date 9/28/21

All service plans are being updated and will include activity plans for each resident

Activity staff will ensure that they are providing both group and individual activities

We will follow up with th residnts monthly during activity committee the first to be held on October 15th

The activity coordinator and ED will be responsible to ensure this is happening

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. This is a repeat citation. Findings include, but are not limited to:

During the re-visit survey conducted 12/20/21 through 12/21/21, there was a lack of scheduled and unscheduled activities provided for residents living in the memory care community.

a. The December 2021 activity calendar provided during the entrance conference indicated the following activities would occur on 12/20/21:

* 10:00 am  Coffee Chat;

* 11:00 am  Exercise;

* 3:00 pm  Read aloud; and

* 6:00 pm Movie and snack.

On 12/20/21 the only activities observed between 9:00 am and 4:00 pm were coffee and snacks at 10:45 am and bingo at 3:30 pm.

b. On 12/21/21 the activity calendar indicated the following activities would occur:

* 10:00 am Coffee Chat;

* 11:00 am Bowling;

* 2:00 pm Paint Nails; and

* 6:00 pm Movie and Snack.

On 12/20/21 the only activities observed between 8:00 am and 4:00 pm were a Christmas movie shown in the common living room at 11:05 am, another movie was shown in the living room at 1:25 pm, and a staff member engaged a few residents in a card game in the dining area at 3:05 pm.

Multiple observations of the memory care unit on day shift and swing shift between 12/20/21 and 12/21/21 showed a lack of group or individualized activities provided for the residents. Multiple residents were observed sitting in the common areas alone, watching TV, wandering the halls and sitting in their rooms.

During an interview with Staff 1 (Executive Director) and Staff 2 (RN) on 12/21/21, Staff 1 stated the facility had been without a person to direct activities. Care staff, who were assigned to provide ADL care, cleaning, laundry, serving meals and medication administration "helped out" and provided activities to the residents when they were able.

The lack of an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large was discussed with Staff 1 and Staff 2 on 12/21/21. They acknowledged the findings.

On 12/28 a new activities director started.  We have a calendar up and she will be here tue-sat providing both group and individual activities. She has completed her orientation and will be doing activities with the residents on 1/4/22.  The calendar has been adjusted the 2 days she will not be here so that activities will still be held and staff will initiate those activities, if activities are changed the calendar will be changed to reflect the change.  All residents have been given copies of the calendar and will be invited daily to attend as per their preferences. Going forward if we have no one in the activity directors position the BOM, RCC, other staff and Ed will split activities to ensure the calendar is being followed The activity director, rcc and ed will be responsible for ensuring activities happen.

3. Resident 1 was admitted to the facility in March 2021 with diagnoses including dementia.

The resident's 6/6/21 quarterly evaluation and 7/29/21 change of condition evaluation were not reflective of Resident 1's status or care needs in the following areas:

* Transfer status;

* Vision status;

* Bathing assistance needs:

* Fall interventions including use of floor mattress; and

* Fall risks.

The need to ensure evaluations were accurate and reflective of the resident's condition and care needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements, for 1 of 1 newly admitted resident (#2) and failed to complete quarterly evaluations for 2 of 2 sampled residents (#s 1 and 3), whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in August 2021 with diagnoses including dementia.

The move-in evaluation, dated 8/12/21, was reviewed and revealed the following elements were missing:

* Personality including how the person copes with change or challenging situations;

* How a person expresses pain or discomfort; and

* Environmental factors which impact the resident's behavior (e.g., noise, lighting, room temperature).

The need to address all required elements in the move-in evaluation was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.

A review of the resident's 7/15/21 quarterly evaluation revealed it was not reflective of his/her current status or care needs in the following areas:

* Skin breakdown risks and interventions;

* Weight changes;

* Sleep aids;

* Dietary needs;

* Meal assistance needed;

* Bathing assistance needed;

* Use of fall mat;

* Assistive and/or supportive devices used; and

* Life enrichment activities.

The need for quarterly evaluations to accurately reflect the current status and needs of the resident was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21. They acknowledged the findings.

The resident evaluation form has been updated to include all required sections.

All service plans are being updated and meetings will be held with residents/responsible parties before October 31st and quarterly or with changes moving forward

The nurse will address significant changes moving forward.

An activity profile is being added upon admission and all evaluations will be completed prior to or within 8 hours of admit

The ED/RCC/RN will ensure these are completed

2. Resident 1's service plan, updated 8/11/21, and subsequent temporary service plans were reviewed during the survey and were not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas:

* Bathing status;

* Transfer status:

* Toileting status;

* Eating status;

* Risk of fall and fall interventions;

* Use of floor mattress; and

* Signs and symptoms of aggressive behaviors and interventions.

The need to ensure resident service plans were reflective of the resident's current status and provided specific instruction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. The staff acknowledged the findings.

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

1. Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.

Resident 3's current service plan, updated with handwritten notes on 8/11/21, was not reflective of his/her current status and needs and did not provide clear direction in the following areas:

* Risk for skin breakdown and interventions;

* Use of a fall mat;

* Use of a geri-chair;

* Use of an air scoop mattress;

* Swallowing precautions; and

* Activities.

The need for service plans to accurately reflect residents'  current status and needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21. They acknowledged the findings.

The RCC/ED/Rn will ensure that the service plans accurately reflect the residents needs and are individualized to the resident.  These will be updated with changes and quarterly.  This will also be done at move in and then updated within 30 days

These will also contain interventions/instructions for the interventions and all necessary assessments

Based on observation, interview and record review, it was determined the facility failed to ensure short-term changes were evaluated; specific resident interventions determined and documented and the condition monitored with weekly progress noted until resolved for 1 of 2 sampled residents (#1) who experienced short-term changes in the area of skin and medication.  The facility failed to evaluate and monitor service-planned interventions for 2 of 2 sampled residents (#s 1 and 3) who had repeated falls. Resident 1 continued to have falls with injury. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in March 2021 with diagnoses including dementia.

Observations of the resident from 8/30/21 to 9/1/21 noted the resident used a floor mat next to the bed, required staff assistance with transfers and bladder and bowel management.

a. The resident's clinical records dated 3/6/21 through 8/30/21 indicated the following:

* 4/12/21 staff documented on a facility progress note that the resident was on alert for a fall on 4/12/21. " ...resident fell face first on carpet causing a rug burn of [his/her] left side of nose and cheekbone ..."

The resident had experienced a fall, was evaluated to be at risk for falls and the service plan failed to be reflective of the fall risk and there were no identified interventions to minimize falls.

b. Reviewing the resident's progress notes and incident reports noted the following:

* On 6/24/21 staff documented on a facility incident report "Resident fell while staff present. Resident reported pain in [his/her] left leg ..."

* On 7/1/21 "Resident fell backward from standing and hit the back of [his/her] head on a dining room chair ..." The resident was sent to the hospital.

* On 7/3/21 staff documented on a facility Incident Report Investigation that "resident was found on the floor lying on [his/her] right side, complaining of neck pain and right arm pain ... staff called 911 ..."

* On 7/15/21 staff noted "Resident was hear [sic] falling, found on the ground, reported hitting [his/her] head ...." The resident was sent to the hospital. Hospital reported to have stables on [his/her] head from a previous head laceration.

* On 7/18/21 staff noted "Resident had an unwitnessed fall, found on the ground ..."

* On 7/23/21 staff noted they saw the resident "stand up from recliner and take a couple steps, [he/she] lost balance and nose dived into a cornered wall ...notice a big ball on right side of forehead." The resident was sent to emergency department and received a new diagnosis of a fractured nose.

* On 8/4/21 staff noted that the resident fell backwards hitting the back of [his/her] head on closet doors.

There was no documented evidence the facility developed actions or interventions to address the resident's falls noted between 6/24 and 8/4/21.  

c. On 7/10/21 staff documented "Resident was found on the ground. Resident reported no pain or discomfort. Resident was able to stand with staff assist." The incident report directed staff to make sure the resident was always wearing shoes, but the intervention was not documented on the temporary service plan for all staff to review, and there was no documented evidence the intervention was monitored for effectiveness.

The resident experienced 9 falls between 3/6/21 and 8/30/21, had multiple emergency department visits due to the falls and some resulted in physical injuries including a head laceration with staples and a fractured nose. The facility failed to thoroughly review each incident in order to determine if the resident's specific actions or interventions were developed, documented, provided clear direction to staff, were communicated to all staff and were monitored for effectiveness. This placed Resident 1 at further risk of repeated serious injury.

d. Resident 1's clinical records dated 3/6/21 through 8/30/21 were reviewed during the survey and revealed the following:

* 4/4/21 - Resident-to-resident altercation;

* 4/12/21, 6/24/21, 7/3/21, 7/18/21 and 8/4/21 - Falls;

* 7/23/21 - Bruise on forehead, fall with ER visit and a new diagnosis of nose fracture;

* 7/30/21 - Discontinue on Melatonin; and

* 8/4/21 - Three new medications to treat dementia, mental health disorder and dry eyes.

There was no documented evidence the resident's short-term changes of condition were consistently monitored and progress documented weekly to resolution.

The need to ensure resident-specific actions or interventions were developed, communicated to all staff and monitored for effectiveness when Resident 1 experienced short-term changes of condition was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.

A review of the resident's clinical record revealed the following:

a. Resident 3 experienced a fall on 6/24/21. A progress note dated 6/24/21 stated staff should "continue to monitor for any changes in pain, mobility." There was no documented evidence the resident was monitored after the fall.

b. A physician order dated 5/26/21 provided direction to staff for changing the dressing on a wound on Resident 3's left buttock. There was no documented evidence the wound was monitored through resolution.

In interviews on 8/31/21 and 9/1/21 the need to monitor short-term changes of condition and document progress at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (RN), They acknowledged the findings.

Short term changes of condition will be addressed using a temporary service plan,

Significant changes will be added to the service plan and all staff inserviced on them and the needed interventions

If a change will not be resolved it will be added to the residents service plan

Significant changes will be monitored weekly until they resolved by the RCC/Nurse

The staff will utilize the 24 hour report to document that they have notified all parties of the change in the resident

They will also document an alert note if the resident is on alert charting for the change

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, or updated the service plan for 1 of 1 sampled resident (# 1) who experienced a significant change of condition and 7 of 17 residents (#s 1, 3, 4 , 5, 6, 7 and 8) reviewed for weight changes. Residents 1, 3, 5, 6 and 7 experienced significant weight changes. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in March 2021 with diagnoses including dementia.

Observations of the resident from 8/30/21 to 9/1/21 showed the resident required staff assistance with transfers and meal intake.

Clinical records dated 3/6/21 through 8/30/21 including progress notes, alert charting, health assessments/evaluations, service plans, after visit summaries, physician faxes and incident reports were reviewed during the survey and revealed the following:

* The resident experienced 9 falls between 3/6/21 and 8/30/21;

* Had multiple emergency department visits due to the falls including 7/1/21, 7/15/21 and 7/23/21;

* Physical injuries identified including a head laceration with staples on and a fractured nose on 7/23/21;

* No longer ambulating, staying bed;

* No longer transfer independently, needing 2-person assistance with transfer; and

* RN assessment for the changes of condition completed on 7/29/21 did not address findings, resident status, and interventions made as a result of the assessment.

The lack of an RN assessment regarding Resident 1's significant change in condition was reviewed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

2. A review of Resident 1, 3, 4, 5, 6, 7 and 8's weight records revealed each resident had a significant to severe amount of weight change.  

a. Resident 1's weight record revealed the following:

* 3/2021 (Admission) - 121 pounds;

* 5/2021 - 110.6 pounds;

* 7/2021 - 106 pounds; and

* 8/2021 - 100.8 pounds.

From 3/2021 to 5/2021, Resident 1 lost 10.4 pounds or 8.59% of his/her body weight in 2 months, which represented a significant change of condition.

From 5/2021 to 6/2021, additionally, the resident lost 4.0 pounds or 3.22% of his/her body weight in a month.

From 6/2021 to 8/2021, Resident 1 again lost 5.8 pounds or 4.82% of his/her body weight in 2 months, which represented a severe weight loss.

Resident 1 continued experiencing a significant weight loss.

b. Resident 3's weight record revealed the following:

* 3/2021 - 133.4 pounds; and

* 6/2021 - 144.6 pounds.

From 3/2021 to 6/2021, Resident 3 gained 11.2 pounds or 8.39% of his/her body weight in three months. This represented a significant change of condition.

On 8/31/21 the resident weighed 149.8 pounds, revealing an ongoing weight gain.

c. Resident 4's weight record revealed the following:

* 5/2021 - 181.4 pounds;

* 7/2021 - 172 pounds; and

* 8/2021 - 165.6 pounds.

From 5/2021 to 7/2021, Resident 4 lost 10 pounds or 5.5% of his/her body weight in 2 months.

From 7/2021 to 8/2021, additionally, the resident lost 6.4 pounds or 3.52% of his/her body weight in a month which represented a significant weight loss.

From 5/2021 to 8/2021, Resident 4 lost a total of 16.4 pounds or 9.1% of his/her body weight in 3 months which represented a significant change of condition.

d. Resident 5's weight record revealed the following:

* 1/2021 - 144.8 pounds;

* 3/2021 - 152 pounds;

* 5/2021 - 160 pounds; and

* 8/2021 - 163.3 pounds.

From 1/2021 to 3/2021, Resident 5 gained 7.2 pounds or 4.97% of his/her body weight in 2 months.

From 3/2021 to 5/2021, additionally, the resident gained 8.0 pounds or 5.52% of his/her body weight in 2 months which represented a significant change of condition.  

From 5/2021 to 8/2021, Resident 5 gained 3.3 pounds or 2.27% of his/her body weight in 3 months which represented a severe weight change.

Residents 5 continued experiencing a significant weight gain.

e. Resident 6's weight record revealed the following:

* 1/2021 - 91.6 pounds;

* 2/2021 - 97.0 pounds;

* 3/2021 - 103 pounds;

* 6/2021 - 136.4 pounds; and

* 8/2021 - 127.8 pounds.

From 1/2021 to 2/2021, Resident 6 gained 5.4 pounds or 5.89% of his/her body weight in a month which represented a significant change of condition.

From 2/2021 to 3/2021, additionally, the resident gained 6.0 pounds or 6.55% of his/her body weight in a month.

From 3/2021 to 6/2021, Resident 6 gained 33.4 pounds or 36.4% of his/her body weight in 3 months which represented a severe weight change.

Residents 6 experienced a severe weight gain.

f. Resident 7's weight record revealed the following:

* 3/2021 - 109 pounds;

* 6/2021 - 131.2 pounds;

* 7/2021 - 135.2 pounds; and

* 8/2021 - 138.8 pounds.

From 3/2021 to 6/2021, Resident 7 gained 22.2 pounds or 20.36% of his/her body weight in 3 months which represented a significant change of condition.

From 6/2021 to 7/2021, additionally, the resident gained 4.0 pounds or 3.66% of his/her body weight in a month.

From 7/2021 to 8/2021, Resident 7 gained 3.6 pounds or 3.30% of his/her body weight in a month which represented a severe weight change.

Residents 7 continued to experience severe weight gain.

g. Resident 8's weight record revealed the following:

* 1/2021 - 151.8 pounds;

* 3/2021 - 145.7 pounds; and

* 6/2021 - 137.6 pounds.

From 1/2021 to 3/2021, Resident 7 lost 6.1 pounds or 4.01% of his/her body weight in 2 months.

From 3/2021 to 6/2021, additionally, the resident lost 8.1 pounds or 5.55% of his/her body weight in 3 months which represented a significant change of condition.

There was no documented evidence the RN had assessed any of the residents for weight changes. On 9/1/21, Staff 2 (RN) stated she was not aware of the weight changes and confirmed that she had not assessed residents' weight changes.

The facility's failure to implement an effective system for monitoring residents' weights led to multiple residents experiencing significant weight changes.

The lack of an RN assessment regarding multiple residents identified with weight loss or weight gain, was reviewed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

A new weight scale has been purchased to ensure accurate weights, nurse to address significant changes related to weights and ensure interventions are in place and staff trained on them.  Staff to document notification to nurse, pcp and family when resident is placed on alert charting or with any changes. Facility will ensure all parties are notified and all recommendations/interventions/orders are documented.

RCC/ED/RN to monitor and ensure that this is completed.  We will do a weekly meeting to ensure resident changes are being addressed

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers for 1 of 2 sampled residents (# 1) who received outside services.  Findings include, but are not limited to:  

Resident 1 was admitted to hospice in March 2021 with diagnoses including dementia.

Clinical records indicated Resident 1 was receiving palliative care from an outside provider. The facility failed to ensure the following recommendations, made by the outside provider, were initiated and/or communicated to staff:

* 6/29/21: clean wound, (R) knee instruction;

* 7/06/21: push fluid;

* 7/19/21 and 8/5/21: fall follow-up;

* 7/23/21: Hospital discharge summary including a fractured nose home care instructions;

* 8/02/21: bowel suppository instructions; and

* 8/04/21: monitoring and reporting guidelines for head injury.

The need to ensure the outside provider recommendations were implemented and communicated to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. They acknowledged the findings.

All orders/recommendations will be reviewed staff will ensure that they are documented and staff is aware/trained on anything needing done utilizing a TSP and the emars

RCC/ED/nurse to review and check orders to ensure they are being documented and followed

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 1) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in March 2021. Resident 1 had signed physician orders for scheduled and as need morphine for pain and as needed Lorazepam for agitation.

Resident 1's Controlled Substance Disposition logs and MARS were reviewed from 8/1/21 - 8/30/21. The following deficiencies were identified:

* An 8/5/21 dose of PRN morphine was documented as being removed from storage on the disposition log at 10:00 am, but it was documented as being administered on the MAR at 2:50 pm, 5 hours 50 minutes later.

* An 8/20/21 dose of PRN morphine was documented as being removed from storage on the disposition log at 2:20 pm, but it was documented as being administered on the MAR at 12:47 am, 10 hours 27 minutes later.

* On three occasions, 8/11/21, 8/17,21 and 8/20/21, staff documented scheduled morphine was administered on the MAR at 8:00 pm. There was no documented evidence on the Controlled Substance Disposition log the medication was dispensed on those days.

* On four occasions, 8/18/21, 8/19/21, 8/26/21 and 8/27/21, dose of PRN morphine was documented as being removed from storage on the disposition log. There was no documented evidence on the MAR the dispensed medication was administered to Resident 1 on those days.

* On six occasions, 8/21/21, 8/26/21, 8/27/21 x 2, 8/28/21 and 8/29/21, PRN Lorazepam was documented as being removed from storage on the disposition log. There was no documented evidence on the MAR the dispensed medication was administered to Resident 1 on those days.

On 8/31/21 and 9/1/21, inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 8/31/21 and 9/1/21 with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Narc count is to be done at the beginning and end of each shift.  Staff will check that the narc book reflects the narc count in the card.  Staff to ensure that narcs are signed out in the emar and follow up documented if they are prns

RCC/Nurse/ED to monitor monthly and ensure this is accurate

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 2 sampled residents (# 1) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1's current physician orders and 8/1/21 - 8/30/21 MARs were reviewed and indicated the following medication or treatment orders were not carried out as prescribed:

a. An order for Celexa (an anti-depression medication) was discontinued by the physician on 7/27/27, after 5 days of use. The MAR indicated staff continued to administer the medication to Resident 1 in 8/2021 MAR.

b. An order for Memantine (a medication to treat dementia) was discontinued by the physician on 7/27/21. The MAR indicated staff continued to administer the medication to Resident 1 in 8/2021 MAR.

c. An order for Rivastigmine (a medication to treat dementia) was discontinued on the 8/2021 MAR, but there was no physician order to discontinue the medication.

d. An order for Senna (a medication to help bowel movement) 8.6 mg twice daily as needed but carried out on the MAR as one time daily, not two times daily as prescribed.

e. An order for Perphenazine (an anti-psychotic medication) 2 mg two times daily was prescribed on 7/27/21, but was there was no indication the order was transcribed to the MAR.

f. A 7/2/21 order for instructions when the resident was wandering the facility and instruction for blood glucose monitoring and reporting monthly were not transcribed to the MAR.

g. An order for PRN Lorazepam 1mg for "seizure" and 0.5 mg for "anxiety/agitation/restlessness".

Resident 1's 3/6/21 through 8/30/21 progress note and Controlled Substance Disposition logs from 8/1/21 - 8/30/21 revealed the resident was administered 1.0 mg of Lorazepam for agitation on 8/21/21, not 0.5 mg as prescribed.

The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21 and 9/1/21. They acknowledged the findings.

ars will be reconcilled at the end of every month, new orders will be triple checked.  Final check to be done by the RCC/Nurse.  All orders to be faxed to the pharmacy to be put on the emar.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 2 of 4 sampled residents (#s 6 and 11) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 moved into the facility in 2016 with diagnoses which included hypertension, gout and chronic pain.

Physician orders and MARs for Resident 11, reviewed from 12/01/21 - 12/20/21, revealed the following orders were not followed:

* Tylenol 500 mg 1 tablet four times a day: the 12:00 pm dose was not administered on 12/07/21 and 12/10/21; and

* Allopurinol (given for gout) 100 mg 1 tablet once a day: was not administered on 12/07/21.

On 12/21/21 at 12:45 pm, the surveyor and Staff 3 (RCC) observed/checked the MARs and medication supply. The Allopurinol tablet for 12/07/21 was still in the card. Staff 3 was unable to verify if the Tylenol had been given.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 12/21/21 at 3:30 pm. They acknowledged the findings. No further information was provided.

2. Resident 6 was admitted 01/2021 with diagnoses which included hypertension.

S/he had an order for Metoprolol (antihypertensive) 25 mg 1 tablet twice a day. Staff were instructed to hold the medication if the systolic blood pressure (upper number) was less than 100 or pulse was less than 50.

Review of the clinical record and MARs, from 11/01/21 - 12/20/21, indicated no blood pressure or pulse had been taken prior to giving the medication.

In an interview on 12/21/21 at 10:10 am, Staff 3 (RCC) reviewed the resident's record and was unable to find documentation that the blood pressure and pulse were measured before the medication was given.  

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 12/21/21 at 3:30 pm. They acknowledged the findings. No further information was provided.

We are reviewing the PCC dashboard with all medication staff.  Staff will be trained/retrained on how to check the dashboard.  The dashboard allows them to see if meds were not passed/signed for.  We are also reviewing the process for charting if a med was held or refused.  The RCC will also be checking the dashboard when she arrives for her shift each day that she is here to ensure staff are documenting meds given.  We have added specific instructions for the blood pressure and pulse to the residents mar.  This gives them instructions to take the vitals and chart them on the mar prior to giving the medication.  This will be done for meds needing parameters/instructions like this going forward.  The Rcc and LN will be responsible for ensuring this happens.

2. Resident 9 was admitted in 01/2021 with diagnoses including dementia.

The residents 11/01/21 through 12/20/21 MARs were reviewed and revealed the following:

* Staff failed to initial on the MAR that the following medications were administered:

- Senna (for bowel care) was not given on 11/09/21; and

- Lamotrigine (for seizures) was not given on 11/09/21.

In an interview on 12/21/21 with Staff 3 (RCC), she verified the medications were given, but staff failed to document on the MAR.

On 12/21/21 the need to ensure MARs were accurate was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 4 sampled residents (#s 9 and 11). Findings include, but are not limited to:

1. Resident 11 was admitted in 2016 with diagnoses which included hypertension, gout and chronic pain.

His/her MARs were reviewed from 12/01/21 through 12/20/21 and the following was noted:

* Staff failed to initial on the MAR that the following medications were administered:

- Levothyroxine (for hypothyroidism) was not given on 12/10/21; and

- Allopurinol (for gout) was not given on 12/10/21.

On 12/21/21 at 12:45 pm, the surveyor and Staff 3 (RCC) reviewed the MAR and checked the medication cart. She verified the medications had been given, but staff failed to document on the MAR.

On 12/21/21 at 3:30 pm, the need to ensure MARs were accurate was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

We are reviewing the PCC dashboard with all medication staff.  Staff will be trained/retrained on how to check the dashboard.  The dashboard allows them to see if meds were not passed/signed for.  We are also reviewing the process for charting if a med was held or refused.  The RCC will also be checking the dashboard when she arrives for her shift each day that she is here to ensure staff are documenting meds given.   The Rcc and LN will be responsible for ensuring this happens.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were documented ineffective, for 2 of 2 sampled residents (#s 1 and 3) who had an order for PRN psychoactive medication. Findings include, but are not limited to:

Resident 1 and 3 resided in a Memory Care Community with diagnoses including dementia.

Resident 1's records indicated s/he had an order for PRN Lorazepam 1.0 mg for seizure and 0.5 mg for "anxiety/agitation/restlessness" and Resident 3 had an order for Lorazepam, 0.25 ml (0.5 mg) orally every 6 hours if needed for agitation.

Reviewing Resident 1 and 3's 8/1/21 - 8/30/21 MARs revealed that there was no instruction to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety for which staff could consider administering the medications and no listed non-drug interventions that staff should attempt prior to the administration of the PRN psychoactive medication.

Resident 1's 8/1/21 - 8/30/21 MAR and progress notes were reviewed and indicated the resident was administered PRN lorazepam (an anti-anxiety medication) on one occasion for agitation without documented, specific symptoms and without appropriate non-drug interventions being attempted with ineffective results prior to the administration.

On 8/31/21 and 9/1/21, the need to ensure staff documented the resident-specific signs and symptoms of behaviors and only after attempting non-drug interventions was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

Med staff will try 3 non-pharmacological interventions before giving a prn psychotropic medication.  Prior to giving the interventions will be documented in the progress notes and the nurse notified

RCC/Nurse to follow up and ensure this is done.  Meds list will be faxed to pcp quarterly with documentation of psychotropic med use and effectiveness

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed, including a thorough review by an RN, PT or OT prior to use and that staff were instructed on the correct use of and precautions of the device for 1 of 1 sampled residents (#3) who had a supportive device. Findings include, but are not limited to:

Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.

Observations during the re-licensure survey on 8/30/21, 8/31/21 and 9/1/21 revealed Resident 3 had an air-filled scoop mattress on his/her hospital bed. In an interview 8/31/21, Staff 13 (CG) stated the scoop mattress was to keep the resident from falling out of bed and that it worked.

There were no documented instructions to staff on the use of or precautions for the air-filled scoop mattress.

There was no documented evidence the scoop mattress had been evaluated to determine if it was a restrictive device for Resident 3.

The need to have an RN, PT or OT assess all devices with potentially restraining qualities, prior to use and quarterly, was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21. They acknowledged the findings.

Prior to the use of any restrictive devices the facility will ensure that it has documented instructions and assessments by PT/OT/RN, nurse to ensure that these are reassessed quarterly

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 9 and 15) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 8/31/21 and revealed Staff 9 (MT) and Staff 15 (CG), hired on 7/7/21 and 6/22/21 respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21. They acknowledged the findings.

We are ensuring that staff are trained in all required training by updating relias to ensure accurrate training is in place, we will also utilize handouts of trainiing material and Oregon Care Partners for pre service dementia training

All staff will be trained in CPR & Abdominal thrust by October 31st and within 30 days of hire moving forward

The BOM/ED will ensure resords are kept up and accurate

Training will be reviewed monthly

Will utilize competency checklist and an orientation record moving forward

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

Review of fire and life safety records on 8/31/21, for May 2021 through July 2021, revealed the following:

1. Training regarding fire and life safety training for staff was not consistently being provided on alternating months.

2. The facility was not consistently relocating or evacuating residents during fire drills.

3. Documentation of fire drills was lacking or incomplete regarding:

- Escape route used;

- Resident evacuation problems encountered; and

- Number of occupants evacuated.

On 8/31/21, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training on alternate months and fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1 (ED) and Staff 4 (Maintenance).They acknowledged the findings.

Fire drills will be conducted monthly for 3 months to ensure all staff are trained in the proper procedure, then every other month moving forward

Staff will receive training on fire & Life safety everyother month starting September 27th

Fire drill forms will be updated to include necessary information

Maintenance/ED will ensure this is done monthly

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Review of fire and life safety records on 8/31/21, for May 2021 through July 2021,

identified the facility lacked documented evidence of the following:  

* Alternate exit routes were used during fire drills;

* Fire and life safety training for residents upon admission and at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and

* A written record of fire safety training, including content of the training sessions and the residents attending.

On 8/31/21, the need to ensure alternate exit routes were used during fire drills, residents were being relocated during drills and fire and life safety was provided on admission and annually was discussed with Staff 1 (ED) and Staff 4 (Maintenance). They acknowledged the findings.

The facility will provide fire & life safety training to the residents in the Resident council meeting 1x per year and upon admission

Facility will ensure fire and life safety is included in the admissions packet

The ED/maint will ensure this is done

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 Z 142, Z 162, Z 164, C 242 and C 303.

Facility will be in compliance with our plan of correction by ensuring the activities programming is happening, as follows, On 12/28 a new activities director started.  We have a calendar up and she will be here tue-sat providing both group and individual activities. She has completed her orientation and will be doing activities with the residents on 1/4/22.  The calendar has been adjusted the 2 days she will not be here so that activities will still be held and staff will initiate those activities, if activities are changed the calendar will be changed to reflect the change.  All residents have been given copies of the calendar and will be invited daily to attend as per their preferences. Going forward if we have no one in the activity directors position the BOM, RCC, other staff and Ed will split activities to ensure the calendar is being followed The activity director, rcc and ed will be responsible for ensuring activities happen.

And by ensuring the mars are accurate as follows,We are reviewing the PCC dashboard with all medication staff.  Staff will be trained/retrained on how to check the dashboard.  The dashboard allows them to see if meds were not passed/signed for.  We are also reviewing the process for charting if a med was held or refused.  The RCC will also be checking the dashboard when she arrives for her shift each day that she is here to ensure staff are documenting meds given.   The Rcc and LN will be responsible for ensuring this happens.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:

During a tour of the facility on 8/30/21 and 8/31/21, the following was observed:

* Carpet throughout the common areas and hallways had spots, stains, blackened areas and uneven surface; and

* Furniture throughout the facility (including chairs, recliners and tables) had stains, exposed wood and frayed edges.

The environment was toured on 8/31/21 with Staff 1 (ED). She acknowledged the above areas needed to be cleaned and repaired.

Maintenance is working on repairing the uneven carpet

Facility will have the carpet cleaned

We are arranging to have a commercial cleaning company come in to do the kitchen and dining room areas.  Moving forward a cleaning task list will be utilized to maintain the area

We are in the process of working with a local company to replace furniture

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:

The licensee is responsible for the operation of the Memory Care Community and the provision of person-directed care that promotes each resident's dignity, independence and comfort. That includes the supervision and overall conduct of the staff.

During the re-licensure survey, conducted 8/30/21 through 9/1/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the citations issued during the survey.

Refer to deficiencies in the report.

The administrator will ensure that the rules and regulations are being met and that the facility is providing person directed care in a clean enviornment with trained staff to meet the needs of the residents

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C231, C240, C242, C372, C420, C422 and C513.  

The administrator will review and comply with both licensing rules for the facility and chapter 411, division 57

An audit of the facility to ensure compliance will be conducted quarterly

This will be done by ED/RCC/Nurse/Regional

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 242 and C 455.

We have completed a new resident activity profile for each resident that includes an activity plan for that resident .  I am attaching the form to the plan of correction.  Going forward the form will be completed upon admission and updated within 30 days to ensure that the activity plan for that resident is accurate and reflective of their needs.  The form will then be reviewed with chanes to the service plan or changes of condition.  The RCC/ED/AD will ensure the activity profile is acurate and reflects the residents needs

Facility will be in compliance with our plan of correction by ensuring the activities programming is happening, as follows, On 12/28 a new activities director started.  We have a calendar up and she will be here tue-sat providing both group and individual activities. She has completed her orientation and will be doing activities with the residents on 1/4/22.  The calendar has been adjusted the 2 days she will not be here so that activities will still be held and staff will initiate those activities, if activities are changed the calendar will be changed to reflect the change.  All residents have been given copies of the calendar and will be invited daily to attend as per their preferences. Going forward if we have no one in the activity directors position the BOM, RCC, other staff and Ed will split activities to ensure the calendar is being followed The activity director, rcc and ed will be responsible for ensuring activities happen.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 9 and 10) completed all required pre-service orientation, dementia training and 30-day competency demonstration and 2 of 3 long term staff (#s 7 and 11) completed 16 hours of annual training. Findings include, but are not limited to:

A review of staff training records revealed the following:

1. Staff 10 (CG) was hired 5/19/21. There was no documented evidence they had completed the following elements of the required pre-service orientation prior to performing any job duties:

* Resident rights and values of community based care;

* Abuse reporting requirements; and

* Fire safety and emergency procedures.

2. There was no documented evidence that Staff 6 (MA) and Staff 9 (CG), hired 6/16/21 and 7/26/21 respectively, or Staff 10 completed one or both of the following pre-service dementia care training prior to performing care and services independently:

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; and

* Use of supportive devices with restraining qualities in memory care communities.

3. There was no documented evidence that Staff 6, Staff 9 or Staff 10 demonstrated competency in their job duties within 30 days of hire in one or more of the following areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving and sanitation; and

* Other duties as applicable (e.g. medication pass, treatments).

The facility was unable to provide documentation that any of the MAs had demonstrated competency in performing a medication pass. The facility was asked to provide a plan for ensuring all MAs were trained and satisfactorily demonstrated competency in their job duties before they were scheduled to work again. The facility provided a plan 8/31/21 at 1:05 pm.

4. There was no documented evidence Staff 7 (MA), and Staff 11, hired 7/18/19 and 8/15/19, respectively, completed the required 10 hours of annual training related to provision of care in community-based care or the required 6 hours related to dementia care.

The facility's failure to ensure staff completed all required training in a timely manner was discussed with Staff 1 (ED) and Staff 2 (RN) on 8/31/21. They acknowledged the findings.

New staff will be trained upon hire and current staff will be trained in the pre-service dementia training and other necessary trainings

We will utlize an orientation checklist to ensure they are trained to care for each residents needs individually

We will utilize a 30 day competency checklist to ensue staff understand the requirements of the job and how to do them

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 C252, C260, C270, C280, C290, C302, C303, C330 and C340.

The ED will ensure that the above items are in compliance with the OARS, as listed above

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 303 and C 310.

We are reviewing the PCC dashboard with all medication staff.  Staff will be trained/retrained on how to check the dashboard.  The dashboard allows them to see if meds were not passed/signed for.  We are also reviewing the process for charting if a med was held or refused.  The RCC will also be checking the dashboard when she arrives for her shift each day that she is here to ensure staff are documenting meds given.  We have added specific instructions for the blood pressure and pulse to the residents mar.  This gives them instructions to take the vitals and chart them on the mar prior to giving the medication.  This will be done for meds needing parameters/instructions like this going forward.  The Rcc and LN will be responsible for ensuring this happens

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

Resident 3 was admitted to the facility in June 2020 with diagnoses including dementia.

Observations of lunch on 8/30/21, breakfast on 8/31/21 and lunch on 9/1/21 indicated Resident 3 needed full assistance from staff with eating.

Resident 3's 8/11/21 service plan was reviewed. The service plan lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 9/1/21. They acknowledged the findings.

Service plans are being updated to include clear direction on a residents nutrition and hydration needs

ED/RCC/Nurse to complete and review quarterly or with changes

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose activity plans were reviewed. Findings include, but are not limited to:

During the survey, the primary activities observed in the MCC included residents sitting out in the common area for long periods of time watching movies or other TV shows, wandering the halls or remaining in their rooms.

Service plans for Residents 1, 2 and 3 revealed 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.

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

The need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (ED) on 9/1/21. She acknowledged the findings.

Utilize resident activity profile to gather information for each residents individualized activity plan

Include residents / representative in making an plan specific to each resident

Activity coordinator/ED/RCC/Nurse to complete, will be reviewed quarterly with service plan

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 6, 9, 10 and 11) whose activity plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Residents 6, 9, 10 and 11's records were reviewed during the survey. Though an activity evaluation was completed for each resident, the evaluations failed to address all of the following components:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

Although the service plans did include some information regarding activities, there was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities.  

The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 12/21/21. They acknowledged the findings.

We have completed a new resident activity profile for each resident that includes an activity plan for that resident .  I am attaching the form to the plan of correction.  Going forward the form will be completed upon admission and updated within 30 days to ensure that the activity plan for that resident is accurate and reflective of their needs.  The form will then be reviewed with chanes to the service plan or changes of condition.  The RCC/ED/AD will ensure the activity profile is acurate and reflects the residents needs

Based on observation, interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 1 sampled residents (#1) with documented behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in March 2021, with diagnoses including dementia.

Resident 1's record documented behaviors including:

* Was involved in two physical altercations with other residents between 3/2021 and 8/2021 including slapping a resident and attacking another resident from behind by pulling the back of their sweatshirt and "almost" choking him/her; and

* Was administered as needed Lorazepam for being "very agitated."

The resident's current service plan did not address these behaviors and lacked individualized interventions to assist staff in minimizing the negative impact of these behaviors.  

The need to include an individualized behavior plan for residents with behavioral symptoms was discussed with Staff 1 (ED) on 8/31/21 and 9/1/21. She acknowledged the findings.

Behaviors and interventions will be added to each residents service plan and evaluated quarterly

Prn medications for behaviors will be documented after staff have tried 3 non-pharmacological interventions first which they will document in the progress notes

ED/RCC/Nurse to complete and review quarterly

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:

Observations during the survey between 8/30/21 and 8/31/21 indicated the doors to the exterior courtyards were locked and did not allow residents to exit and return without staff assistance.

A sign was observed in the dining area with "Patio Door" operation hours listed:

* April - October:  5:00 am - 10:00 pm; and

* November - March : 7:00 am - 6:00 pm

During a tour of the building on 8/31/21 with Staff 1 (ED) she acknowledged the courtyard doors were locked.

The need to ensure residents had access to secured outdoor spaces without staff assistance was discussed with Staff 1 on 8/31/21. She acknowledged the findings.

The doors to the patio will be unlocked as posted and are now alarmed so staff are alerted to when residents go out to the patio completed 9/13/21

Outdoor furniture has been chained to prevent aid in elopement completed 9/13/21