Print Inspection: BBWU

The findings of the re-licensure survey, conducted 01/22/24 through 01/25/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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 re-visit to the re-licensure survey of 01/25/24, conducted 06/04/24 through 06/05/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 01/25/24, conducted 09/03/24 through 09/04/24, 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 Services Regulations.

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 sampled resident (# 2) whose move-in evaluation was reviewed and failed to address the needs and current condition of the resident as a foundation to be used as the basis of the resident's quarterly service plan for 2 of 2 sampled residents (#s 1 and 3) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 12/2023.

The new move-in evaluation failed to address the following elements:

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

* Indicators of nursing needs including potential for delegated nursing tasks;

* Complex medication regimen;

* Recent losses;

* Unsuccessful prior to placements;

* Elopement risk or history; and

*Environmental factors that impact the resident's behavior including noise, lighting, room temperature.

The need to ensure the move-in evaluation included all required elements was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN), on 01/25/24. Staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 06/2021 with diagnoses including Alzheimer's disease.

Observations, interviews with staff, and review of the most recent quarterly evaluation and service plan, each dated 01/14/24, revealed the evaluation was not the basis of the resident's quarterly service plan in the following areas:

* Verbal communication;

* Bath/shower frequency;

* Skin integrity;

* Dressing assistance;

* Transfer assistance; and

* Cognition.

The need to ensure the quarterly evaluation identified the resident's physical health status, mental status, current needs, or preferences with sufficient information to be the basis of the resident's quarterly service plan was reviewed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN) on 01/25/24. They acknowledged the findings.

3. Resident 1 moved into the facility in 09/2023 with diagnoses including Parkinson's disease and dementia.

Review of the clinical record, including the most recent quarterly evaluation, dated 12/12/23, and the service plan, dated 12/27/23, revealed the following:

The evaluation was not the basis of the resident's quarterly service plan as follows:

* Information on continence management, including frequency of toileting assistance to be provided, was included on the evaluation but not in the service plan;

* Information related to behavior and mental health needs, including potential for physical and verbal aggression, resistance to care and wandering was included on the evaluation but not addressed in the service plan; and

* Information related to pain, including a history of migraine headaches and chronic foot pain was included on the evaluation but not in the service plan.

The evaluation did not address the following required elements or was not reflective of the resident's needs in the following areas:

* History of treatment and effective non drug interventions for depression, thought disorders, or behavioral or mood problems;

* Pain: non-pharmaceutical interventions and how a person expresses pain or discomfort; and

* Environmental factors that impact the resident's behavior including, but not limited to, noise and lighting.

The need to ensure the quarterly evaluation was reflective of the resident's needs and preferences and was used as the basis to develop the quarterly service plan was reviewed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC), and Staff 10 (Regional RN) on 01/24/24. They acknowledged the findings.

C252 - Res Evaluation

1) Res #2 admission evaluation will be completed and will address presence of depression, thought disorders/behavioral /mood problems, history of treatment, and effective non-drug interventions, as well as indicators of nursing needs including potential for delegated nursing tasks, complex medication regimen, recent losses, unsuccessful interventions prior to placement, elopement risk or history, and environmental factors that impact the resident's behavior including noise, lighting, room temperature.

Res #3 - Quarterly evaluation dated 1/14/24 will be updated to reflect current level of care needs pertaining to verbal communication, bath/shower frequency, skin integrity, dressing assistance, transfer assistance, and cognition.

Res #1 - Service plan will be updated to reflect current needs recorded in quarterly evaluation related to continence management, frequency of toileting assistance, behavior and mental health needs, including potential for physical and verbal aggression, resistance to care, and wandering, pain management related to history of migraine headaches and chronic foot pain.

Quarterly evaluation will be updated to reflect current needs related to history of treatment and effective non-drug inerventions for depression, thought disorders, or behaviors or mood problems.  Non-pharmaceutical interventions  and how a person expresses pain or discomfort will be included. Environmental factors will also be addressed as it pertains to the resident's behavior including, but not limited to, noise and lighting.

2)  The system will be corrected by implementation of Generation's Supplemental Oregon Evaluation Addendum, as well as Admission and Ongoing Care Evaluation Checklists to assist health services team in tracking evaluations and service plan completion.  

Training will be completed for staff who create or update evaluations including RCC, HSD, and RN.

An audit will be conducted to ensure all current residents have the required information in their service plans and to ensure accurate and current needs are reflected.

3) ED will follow up weekly with any concerns or required changes noted from review of checklist and evaluations.  Once final review by ED is complete, with date/signature, check list will be scanned into PCC chart for reference.  

4)  Review of evaluations will be completed by the following positions, in the following order:

New Move In Eval - HSD, ED

30 Day Post Admission - RCC, ED

Quarterly Eval - RCC/HSD, ED

COC - RN, HSD, ED

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all elements for 1 of 1 sampled resident (#7) whose new move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 05/2024 with diagnoses including dementia and idiopathic neuropathy. The move-in evaluation dated 05/27/24 was reviewed.

Review of the resident's record revealed the move-in evaluation lacked the following elements:

* Decision making abilities;

* Pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Nutrition habits and fluids preferences; and

* Recent loses.

The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 2 (ED ALF), Staff 3 (MCC Director), Staff 4 (LPN, Health Services Director), and Staff 5 (RCC) on 06/05/24. They acknowledged the findings.

C252 - Evaluations

1) Resident #7 evaluation will be completed and will address decision making abilities, pharmaceutical and non-pharmaceutical interventions including how a person expresses pain or discomfort; nutrition habits and fluids preferences, and recent losses.

2) The system will be corrected by training with Director, RCC, HSD, and RN to ensure understanding of all documentation required in evaluations and not using abbreviations on evaluations that can be misinterpreted. Generations Oregon Evaluation Addendum, Admission and Ongoing Care Evaluation checklists will be utilized with each evaluation.

3) Evaluations will be reviewed in daily clinical meeting to ensure completeness. Attendance includes: ED, Director, RCC, HSD, RN.

4) Evaluation completion and comprehensiveness will be completed by Director, RCC, HSD, or RN.  Monitoring will be completed ED, Director, RCC, HSD, and RN during clinical meeting.  

2. Resident 2 moved into the facility in 12/2023 with diagnoses including Alzheimer's disease.

The most recent service plan, dated 12/21/23, and interim service plans were reviewed. The service plan did not reflect the resident's needs as identified in the evaluation and provide clear direction to staff in the following areas:

* Pain, including pain history and location of pain;

* Transfer status;

* Use of oxygen status including setting;

* Ability to use call system;

* Ambulation status; and

* Assistance of bathroom use.

The need to ensure service plans were reflective of resident needs, as identified in the evaluation, and included clear direction to staff was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC), and Staff 10 (Regional RN) on 01/25/24. They acknowledged the findings.

3. Resident 4 moved into the facility in 12/2022 with diagnoses including dementia.

The most recent service plan, dated 12/20/23 was reviewed. The service plan did not reflect the resident's needs, did not provide clear direction to staff and failed to be implemented in the following areas:

* On-going weight loss status;

* Whether to provide the nutritional supplement;

* Encourage to use left hand for meal intake;

* Level of assistance needed with meal intake ; and

* Provide "easy to pick up" foods.

The need to ensure service plans were reflective of resident needs, provide clear direction to staff and implement the service plan was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN) on 01/25/24. They acknowledged the findings.

4. Resident 3 moved into the facility in 06/2021 with diagnoses including Alzheimer's disease and hypothyroidism and had history of recent falls.

The most recent service plan, dated 01/14/24, and interim service plans were reviewed. The service plan did not reflect the resident's needs as identified in the evaluation and did not provide clear direction to staff in the following areas:

* Shower status;

* Transfer status;

* Ambulation status;

* Skin integrity;

* Fall interventions currently in place and as identified in fall incident reviews;

* Ability to communicate; and

* Dressing assistance.

The need to ensure service plans were reflective of resident needs, as identified in the evaluation, and included clear direction to staff was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC), and Staff 10 (Regional RN) on 01/25/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, needs and preferences and provided clear direction to staff, and were implemented for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 09/2023 with diagnoses including Parkinson's disease and dementia, had a recent history of falls and ongoing behaviors. The most recent service plan, dated 12/27/23, and interim service plans were reviewed. Incident reports with a review of fall incidents were also reviewed.

The service plan did not reflect the resident's needs as identified in the evaluation and provide clear direction to staff in the following areas:

* Pain, including pain history, location of pain and non-pharmaceutical interventions;

* Fall interventions currently in place and as identified in fall incident reviews; and

* Behavior interventions for staff to implement when behaviors occurred: including, but not limited to, when resisting care, physically aggressive, intrusive behaviors, wandering into other resident units and running from a situation.

The need to ensure service plans were reflective of resident needs, as identified in the evaluation, and included clear direction to staff was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC), and Staff 10 (Regional RN) on 01/24/24. They acknowledged the findings.

C260 Service Plan

1) Res #1 - Service plan updated to reflect resident's needs identified in the most recent evaluation and to give clear instruction to staff in the following areas:

Pain - including pain history, location of pain, and non-pharmaceutical interventions.

Falls -  interventions currently in place and as identified in incident reports.

Behaviors - interventions for staff to implement when behaviors occurr, including, but not limited to:  when resisting care, physically aggressive, intrusive behaviors, wandering into other resident units, and running from a situation.

Res #2 - Service plan updated to reflect resident's needs identified in the most recent evaluation and to give clear instruction to staff in the following areas:

Pain, including history and location

Transfer status

Use of oxygen, including setting

Ability to use call system

Ambulation status

Assistance needed for bathroom use

Res #4 - Service plan updated to reflect resident's needs identified in the most recent evaluation and to give clear instruction to staff in the following areas:

Weight loss status, including interventions/supplements

Cueing for use of left hand for meal intake

Level of assistance needed with meal intake

Current diet orders, including texture

Res #3 - Service plan updated to reflect resident's needs identified in the most recent evaluation and to give clear instruction to staff in the following areas:

Showers

Transfers

Ambulation

Skin integrity

Fall interventions, currently in place and as identified in incident reviews

Dressing assistance

2)  The system will be corrected by updating and implementing Generation's Supplemental Oregon Evaluation Addendum, along with the training for all health services team members who create or update service plans including RCC, HSD, and RN.

An audit will be conducted to ensure all current residents have the required information in their service plan.

Process update will include implementation of a service plan check list to be used for all levels of service planning including New move in, 30 day post admission, Quarterly, and Change of Condition.  Check list will be signed and dated by RCC, HSD, or RN when service plan is completed and turned in to ED for final review.

3) ED will follow up during weekly clinical meetings with any concerns or required changes noted from review of check list and service plan.  Once final review is completed by ED w/date and signature, check list will be scanned into PCC chart for reference.

4) Review of service plans will be completed by the following positions in the following order:

New move in eval - HSD, ED

30 day post admission - RCC, ED

Quarterly - RCC/HSD, ED

COC - RN, HSD, ED

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's current health status, needs and preferences and provided clear direction to staff, and were implemented for 3 of 5 sampled residents (#s 5, 7, and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 05/2010 with diagnoses including dementia.

The most recent service plan, dated 03/27/24, was reviewed. The resident was observed and staff were interviewed. The service plan did not reflect the resident's needs, did not provide clear direction to staff, and/or failed to be implemented in the following areas:

* Hospice services;

* Staff assistance for each meal and snacks;

* Diet texture;

* Food preferences;

* Nutritional supplement;

* Use of a wheelchair;

* Use of pillows to reposition in a Geri-chair;

* Interventions for when the environment was too loud;

* PRN assistance for mobility versus scheduled assistance;

* Use of glasses when family visits;

* The use of a right hand grip;

* Use of powder inside hands; and

* Conflicting information relating to safety checks eight times per shift versus four times per shift.

The need to ensure service plans were reflective of resident needs, provided clear direction to staff, and were implemented was discussed with Staff 2 (ED ALF), Staff 3 (MCC Director), Staff 4 (LPN, Health Services Director), and Staff 5 (RCC) on 06/05/24. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 08/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 06/03/24 service plan, 03/25/24 through 06/04/24 temporary service plans, progress notes, physician communications, and incident investigations were completed.

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

* One to two person transfer assist;  

* Blood thinner medication daily;

* Meal assistance;

* Roho cushion in wheelchair; and

* Use of pillow for positioning in bed.

The need to ensure resident service plans were reflective of current care needs and  provided clear direction to staff  was discussed with Staff 2 (ED ALF), Staff 3 (MCC Director), Staff 4 (LPN, Health Services Director) and Staff 5 (RCC) on 06/05/24. The staff acknowledged the findings.

2. Resident 7 was admitted to the facility in 05/2024 with diagnoses including dementia and idiopathic neuropathy.

The most recent service plan, dated 05/28/24, and temporary service plans, dated 05/29/24 through 06/04/24, were reviewed. The resident was observed and staff were interviewed. The service plan did not reflect the resident's needs, provide clear direction to staff, and/or failed to be implemented in the following areas:

* Bathing preferences;

* Grooming and personal hygiene routine including clear direction to staff;

* Nutrition and fluid preferences;

* Meal supervision including to ask the resident if s/he would like to sit in a dining room chair during the meal;

* Current activity interest and abilities;

* Pain management and monitoring;

* Mobility including assistive devices used;

* Transfer ability and number of staff needed;

* Skin integrity including clear direction to staff;

* Insomnia interventions;

* Use of eye glasses;

* Use of nonskid socks;

* The use of non-skid strips on bedroom floor; and

* Placement of wheelchair while resident was in bed.

The need to ensure service plans were reflective of resident needs, provided clear direction to staff, and were implemented was discussed with Staff 2 (ED ALF), Staff 3 (MCC Director), Staff 4 (LPN, Health Services Director), and Staff 5 (RCC) on 06/05/24. They acknowledged the findings.

C260 - Service Plan

1) Resident #5 service plan will be updated to include current care needs including: hospice service changes, staff assistance for meals and snacks, diet texture, food preferences, nutritional suppplements, use of wheelchair, use of pillows for repositioning in geri-chair, interventions for when environment is too loud, PRN assistance for mobility versus scheduled assistance, use of glasses when family visits, the use of right hand grip, use of powder inside hands, and number of safety checks per shift. Clear direction to staff will be included.

Resident #7 service plan will be updated to include bathing preferences, grooming and personal hygiene routine including clear direction too staff, nutrition and fluid preferences, meal supervision including to ask the resident if they would like to sit in a dining room chair during meals, current activity interests and abilities,pain management and monitoring, mobility including assistve devices uses, transfer ability and number of staff needed, skin intergrity including clear direction to staff, insomnia interventions, use of eye glasses, use of nonskid socks, the use of nonskid strips on the floor, and placement of wheelchair while resident was in bed.

Resident #8 service plan will be updated to include variable transfer status, blood thinner medication daily, meal assistance, roho cusion in wheelchair, and use of pillow for positioning in bed.

2) Admission, Quarterly, and Change of condition service plans will be reviewed weekly between RCC and Director during weekly one-to-one meetings to ensure they are reflective of current care needs and provide clear direction to staff.

3) ALL service plans will be reviewed for accuracy. Ongoing, weekly review of all admission, quarterly, and change of condition service plans will be completed during weekly RCC and Director one-on-one meetings.

4) RCC, HSD, and Director will be responsible to ensure corrections are completed.  Service Plan checklist will be utilized during this process to ensure accuracy and comprehensive completion.  

3. Resident 4 was admitted to the facility in 12/2022 with diagnoses including dementia.

During the acuity interview on 01/22/24 Resident 4 was identified to need cuing during meals and as having had weight loss.

The resident's service plan, dated 12/20/23, progress notes, dated 03/07/23 through 11/20/23, RN assessments and weight records were reviewed.

Weight records showed Resident 4 experienced a significant and ongoing weight loss between 01/03/23 and 01/18/24:

* 01/03/23: 138.8 pounds;

* 02/16/23: 127.0 pounds;

* 03/30/23: 121.0 pounds;

* 05/01/23: 115.2 pounds;

* 06/29/23: 113.2 pounds;

* 11/02/23: 109.2 pounds; and

* 01/18/24: 107.8 pounds.

Between 01/03/23 and 03/30/23 the resident experienced a significant weight loss of 17.8 pounds, or 12.8 % of his/her total body weight, in three months. The facility RN completed RN assessment on 03/07/23 and documented the resident had weight loss and updated service plan including to assist the resident with eating, encourage to use left hand to eat, provide easy to pick up foods and supplement daily."

From 03/30/23 through 06/29/23 the resident experienced a further 7.8 pound weight loss, or 6.44 % of his/her total body weight. There was no documented evidence the facility addressed the changes of ongoing weight loss including the resident's health status, document the change and update the service plan as needed.

A 11/20/23 quarterly evaluation identified the resident "has history of or is at risk for weight loss." Resident 4 continued to experience weight loss, with no monitoring or progress documented.

The current 12/20/23 service plan showed the following:

* "Requires assistance with eating";

* Encourage to use [his/her] left hand to eat;

* "Provide easy to pick up foods"; and

* "Provide [nutritional supplement] at breakfast.

During the survey, Resident 4 was observed during the lunch and dinner meal on 01/24/24 and lunch meal on 01/25/24. The following was identified:

* The resident received meals with regular diet and chopped food including mashed potatoes with gravy and rice, which were not "easy to pick up foods";

* The resident rested or paused eating frequently during the mealtime;

* Staff did not encourage him/her to eat or assist with meal intake;

* On 01/24/24 during the lunch observation, the resident had a few bites of chopped, steamed vegetable and did not touch the mashed potato or chopped hamburger. During dinner observation on 01/24/24, the resident had one piece of fish and a few pieces of fries; and

* Staff did not provide a nutritional supplement as indicated on the service plan.

During an interview on 01/25/24, the kitchen staff provided documentation of the resident's diet instructions, which indicated "chopped, thin, 1/4 cup walnuts 1400" for the resident.

During the survey, multiple caregiving staff and kitchen staff confirmed the resident had not received a nutritional supplement due to stomachache and diarrhea over the last month. Staff further reported they were unaware of the 1/4 cup walnuts and stated "I have no idea" and nobody knew.

There was no documented evidence the interventions were communicated to staff on all shifts and implemented, and evaluated for effectiveness.

The need to evaluate changes of condition, refer changes to the facility nurse when needed, determine actions or interventions and communicate them to staff, and evaluate effectiveness of current plans was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN) on 01/25/24. Staff acknowledged the findings. No further information was received.

2. Resident 3 moved into the facility in 06/2021 with diagnoses including hypothyroidism and Alzheimer's disease.

The resident's clinical record, including progress notes, was reviewed, and interviews were conducted. The following was revealed:

The following short-term change of condition lacked documentation of resident specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and documentation of progress noted, at least weekly, through resolution:

* 11/11/23: Redness in the groin folds and perineal area;

* 11/28/23: Swelling in the hands and feet;

* 11/28/23: "Appears to have a yeast infection under [his/her] right breast, nurse to assess";

* 12/23/23: Found on floor;

* 12/25/23: Non-injury fall; and

* 01/07/23: Found on floor on his/her knees twice.

The need to ensure resident specific actions or interventions were determined and documented, communicated to staff on each shift and the conditions were monitored, consistent with resident's evaluated needs, with progress noted, at least weekly, until resolved was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN) on 01/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined and documented, communicated to staff on each shift and the conditions were monitored, consistent with his or her evaluated needs, with weekly progress noted until resolved for 3 of 4 sampled residents (#s 1, 3 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 09/2023 with diagnoses including Parkinson's disease and dementia.

a. Resident 1 had short term changes of condition when experiencing falls. The falls were reviewed and interventions were identified, however there was no documented evidence the interventions were communicated to staff on all shifts and implemented, and monitored, consistent with resident's evaluated needs, related to the following:

* 11/04/23: fall;

* 11/24/23: fall with injury;

* 12/03/23: fall with injury; and

* 01/08/24: fall with injury.

b. Resident 1 had short term changes of condition related to skin injuries. There was no documentation the injuries were monitored, with progress noted weekly until resolved, as follows:

* 11/07/23: bruising was identified to the hands and wrists;

* 11/24/23: swelling and redness to the forehead and shoulder;

* 12/03/23: bruising to the right scapula;

* 12/12/23: a bruise was noted on his/her hip; and

* 01/08/24: a bruise and redness noted to the left arm.

The need to ensure resident-specific actions or interventions were determined and documented, communicated to staff on each shift and the conditions were monitored, consistent with resident's evaluated needs, with progress noted, at least weekly, until resolved was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN) on 01/24/24. They acknowledged the findings.

C270 - COC

1)  Res #1 - Skin evaluation completed for all current skin issues.  Skin Evaluation triggers ongoing weekly evaluation of identified skin issues that will continue until issues are resolved.  Corresponding ISPs completed and implemented in order to alert staff of the issue/s and provide clear and consistent direction to staff on monitoring and/or interventions.

Res #3 - Skin evaluation completed for all current skin issues.  Skin Evaluation triggers ongoing weekly evaluation of identified skin issues that will be ongoing until issues are resolved.  Corresponding ISPs completed and implement in order to alert staff of the issue/s and provide clear and consistend direction to staff on monitoring and/or interventions.

Res #4 - Significant COC completed related to weight loss.  ISP completed and Service Plan updated to reflect current level of care needs with goal to prevent further weight loss.  Interventions include, but are not limited to needs for cueing, assistance needed for adequate meal intake, supplements, and appropriate diet texture.

ISP placed in ISP book to notifiy staff of changes and interventions.

Resident weights and interventions will be reviewed weekly in Resident at Risk meeting related to weight loss to determine if interventions are effective or if further changes need to be implemented.

2)  System will be corrected by initiation of new ISP book to alert staff of new changes, monitoring, and/or interventions.  All staff to be trained on use and requirements for review of ISPs in ISP book.  

Weekly weight review will be completed and residents demonstrating significant weight loss or gain of  of +/- 3% will be reviewed at weekly Resident at Risk meeting.  Residents will remain on weekly review for 3 months or until weight stability is demonstrated.

A Skin Evaluation will be completed for all current skin issues, which will trigger weekly monitoring requirements in PCC.  Weekly assessment will be completed until resolved.  ISPs will be generated including requirements for monitoring and/or new interventions.

ISPs will be reviewed with quarterly evals and service plan reviews.  ISPs will be included in service plan updates if appropriate.

3) Weekly follow up during Resident at Risk meetings to ensure skin assessments have been completed for new skin issues, weight reviews are completed for residents with a +/- 3 % changes of weight, and ISPs have been generated for any short term and/or significant changes of condition, including monitoring and intervention directions to staff.

4) Review of evaluations/assessments and service plans will be completed by the following positions in the following order:

Skin assessments - RN, HSD, ED

New move in eval - HSD, ED

30 day post admission - RCC, ED

Quarterly - RCC/HSD, ED

COC - RN, ED

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment included documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#4) who experienced a significant change of condition. Resident 4 continued to have weight loss. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 12/2022 with diagnoses including dementia.

During the acuity interview on 01/22/24, Resident 4 was identified as needing cueing during meals and as having had weight loss.

During the survey, Resident 4 was observed during the lunch and dinner meals on 01/24/24 and the lunch meal on 01/25/24. The resident required cueing and assistance during the mealtime.

The resident's service plan, dated 12/20/23, progress notes, dated 03/07/23 through 11/20/23, RN assessments and weight records were reviewed.

Weight records showed Resident 4 experienced a significant and ongoing weight loss between 01/03/23 and 01/18/24:

* 01/03/23: 138.8 pounds;

* 02/16/23: 127.0 pounds;

* 03/30/23: 121.0 pounds;

* 05/01/23: 115.2 pounds;

* 06/29/23: 113.2 pounds; and

* 01/18/24: 107.8 pounds.

Between 01/03/23 and 03/30/23 the resident experienced a severe weight loss of 17.8 pounds, or 12.8 % of his/her total body weight, in three months. This change in weight constituted a significant loss and indicated a significant change of condition, which required an RN assessment.

The facility RN completed an RN assessment on 03/07/23 and documented the resident had weight loss and updated the service plan, including to "assist the resident with eating, encourage to use left hand to eat, provide easy to pick up foods and supplement daily."

From 03/30/23 through 06/29/23 the resident experienced further 7.8 pound weight loss, or 6.44 % of his/her total body weight and from 01/03/23 through 06/29/23, the resident experienced a severe weight loss of 25.6 pounds, or 18.5 % of his/her total body weight, in six months. This represented a significant change of condition, which required an RN assessment.

There was no RN assessment completed that included findings, resident status, and new actions or interventions made as a result of the assessment after additional weight loss. Resident 4's weight loss between 3/2023 and 6/2023 was not assessed and as of 1/18/24 the resident had continued to lose weight.  

During the survey, any temporary service plans related to the weight loss were requested from Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN). No temporary service plan for the resident was provided.

The current service plan, dated 12/20/23, was reviewed and there was no documented evidence changes were made from 03/07/23.

The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2, Staff 3 and Staff 10 on 01/25/24. Staff acknowledged the findings. No further information was received.

C280 Res Health Services

1)  Res #4 - Significant COC completed by RN related to weight loss.  ISP completed and service plan updated to reflect current level of needs with interventions and goals to prevent further weight loss.  Interventions include, but are not limited to needs for cueing, assistance for meal intake, supplements, and appropriate diet texture.

ISP placed in ISP book to notify staff of changes and communicate clear instruction and interventions.  

2) System will be corrected with implementation of weekly Resident at Risk meeting that includes review of residents with significant weight changes of +/- 3%.  ISPs will go to new ISP book and incorporated into service plans with quarterly reviews as appropriate.  ISPs will then be scanned into PCC for reference.

3) Res #4 weight review and monitoring will be weekly via Resident at Risk meeting, and continue until next quarterly review, or until weights have stabilized.

4)  RN, HSD, and ED will be responsible to monitor SCOC status via Resident at Risk meeting.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a legal prescriber and administered by the facility, included medication specific instructions, and included resident-specific parameters for PRN pain medications for 2 of 3 sampled residents (#s 2 and 3). Findings include, but are not limited to:

1. Resident 3's 01/01/24 through 01/22/24 MAR was reviewed, and the documentation revealed blanks for the 5:30 am dose of Levothyroxine (for low thyroid) on 01/18/24 and 01/19/24.

On 01/23/24 at 10:45 am, the surveyor and Staff 24 (MA) reviewed the MAR and checked the medication cart. Staff 24 verified the medications had been given, but staff failed to document on the MAR.

The need for accurate MAR was discussed with with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC), and Staff 10 (Regional RN) on 01/25/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2023 with diagnoses including Alzheimer's disease, chronic pain and asthma.

Resident 2's 01/01/24 through 01/22/24 MAR was reviewed during the survey and found to be lacking resident-specific parameters and instructions for the following medications:

* Multiple PRN pain medications lacked clear parameters related to when and in what sequence they should be administered;

* Scheduled Prednisone 5 mg for shortness of breath directed to administer 1-2 tablets daily. There were no further instructions clarifying when to administer 1 tablet versus 2 tablets of the medication; and

* Blanks for the 5:30 am dose of Levothyroxine (for low thyroid) on 01/08/24, 01/18/24 and 01/19/24.

On 01/24/24 and 01/25/24, the need for resident-specific parameters and clear instruction for unlicensed staff was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN). Staff acknowledged the findings.

C310 Med Admin

1) Res #3 - Review of MAR and interview with staff showed med (Levothyroxine) was given, but not documented. Documentation completed as late entry for accurracy of MAR.

Res #2 - Review of MAR and interview with staff showed med (Levothyroxine) was given, but not documented.  Documentation completed as late entry for accurracy of MAR.

New orders obtained to clarify parameters for sequence of administration of multiple pain medications and instructions for Prednisone range as to when to administer 1 tab or 2 tabs.

2) System will be corrected by review of MAR administration report during daily (M-F) clinical review meeting.  This report illustrates any medication that was not given/documented during prior days' med passes.  

Physician orders to be reviewed weekly and quarterly by RN.  Review will include need for clear parameters for pain medications and any medications ordered with ranges.

3) MAR administration/missing meds will be reviewed during daily (M-F) clinica review meeting to ensure complete documentation and accurate MARs.

Physician orders to be reviewed weekly and monthly to ensure accurracy, clear parameters, and clear range instructions.

4)  RN, HSD, ED responsible to ensure MAR review is completed during daily clinical review meeting (M-F).

RN, HSD, ED responsible to ensure physicians orders are reviewed weekly and quarterly.

Based on observation and interview, it was determined the facility failed to ensure a licensed administrator was scheduled to be on-site in the facility at least 40 hours per week. Findings include, but are not limited to:

Survey entered the facility on 01/22/24 at 9:55 am and requested to speak with the administrator. The survey team was directed to Staff 3 (Director of MCC). Staff 3 confirmed she was not currently a licensed administrator. When asked who was in charge in the administrator's absence, she stated Staff 1 (ED) who was not present at the time of survey entrance.

During an interview on 01/22/24 at 11:15 am, Staff 1 confirmed he was the administrator on record, but split time between the MCC and the ALF communities.

The need to have a licensed administrator on-site in the facility at least 40 hours per week was discussed with Staff 1, Staff 2 (ED ALF), Staff 3, and Staff 10 (Regional RN) on 01/25/24. The findings were acknowledged.

C350 Administrator Qualification and Requirements

1)  ED of record will be scheduled on site in the facility 40 hours/week as required.

Director of MCC completed licensure requirements and  all info submitted to the State of OR 2/6/24.  Will send to Policy Analyst along with updated UDS as soon as license received from OR Health Licensing.

Exception filed for in coordination with Policy Analyst 2/9/24 for interim period while Director of MCC awaiting licensure.

2)  Any change of ED will require ED of record to be present in facility 40 hours/week as required.

3)  Evaluation of ED present in facility for 40 hours/week will occur anytime there is a change of ED of record.

4)  ED of record will be responsible to ensure presence at MCC for 40 hours/week as required.

Based on interview, observation, and record review, it was determined the facility failed to develop a staffing plan based on care minutes calculated by the acuity-based staffing tool (ABST) and to update the ABST to accurately reflect the time needed to provide care for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 3 (Director of MCC) on 01/23/24 at 11:10 am. The facility had implemented the ODHS ABST tool.

Staff 3 confirmed the facility was not consistently staffing according to the plan generated by the ABST for the day shifts. She reported the ABST was updated upon a resident moving into the facility, with significant changes of condition, and quarterly service plan updates.

Record review, including evaluations, service plans, 01/01/24 to 01/22/24 MARs, and progress notes, was completed. Observations were made, and interviews were conducted for three sampled residents (#s 1, 2, and 3). For each of the three residents, the ABST data was not reflective of their current care needs. Therefore, the ABST staffing plan was not reflective of the number of hours required each shift.

The need to ensure ABST entries accurately reflected resident care needs and a staffing plan was developed based on the ABST data was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3, and Staff 10 (Regional RN) on 01/23/24. They acknowledged the findings.

C361 ABST

1)  Resident #1,2,3 service plans updated to reflect current care needs.  ABST was updated to reflect changes in care needs.

2)  System will be updated utilizing Admission Checklist and Ongoing Evaluation Checklist tools which include service planning details, not limited to:  specific care needs, preferences, tasks, consideration of unanticipated needs and any new interventions related to ISPs.  

3) ABST is updated before resident move in, after 1st 30 days, with Signifcant COC, and quarterly as required.

4)  RCC/HSD are responsible for updating service plans.  RCC is responsible for updated ABST.  ED is responsible for ensuring accurracy of ABST.    

Based on interview, observation, and record review, it was determined the facility failed to develop a staffing plan based on care minutes calculated by the acuity-based staffing tool (ABST) and to update the ABST to accurately reflect the time needed to provide care for 3 of 5 sampled residents (#s 5, 7, and 8). This is a repeat citation. Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 3 (MCC Director) on 06/04/24 at 11:28 am. The facility used the ODHS ABST tool.

Staff 3 confirmed the facility was reviewing residents with significant changes of condition and quarterly, but did not realize staff needed to open and review at least one of the 22 ABST elements to confirm a quarterly review.    

Record review, including evaluations, service plans, 05/01/24 to 06/04/24 MARs, and progress notes, was completed. Observations were made, and interviews were conducted. For each of the three residents, the ABST data was not reflective of their current care needs. Therefore, the ABST staffing plan was not reflective of the number of hours required each shift.

The need to ensure ABST entries accurately reflected resident care needs and a staffing plan was developed based on the ABST data was discussed with Staff 2 (ED ALF), Staff 3, Staff 4 (LPN, Health Services Director), and Staff 5 (RCC) on 06/05/24. They acknowledged the findings.

C361 - ABST

1) Resident #5, 7, and 8 service plans updated to reflect current care needs. ABST was updated to reflect changes in care needs.

Completion of additional training with Katie Gaffney, State ABST specialist, Meghan McClain, Policy Analyst, Parkview Care team - including RCC, HSD, Director, ED, and Sr. ED completed 6/12/24 in order to better understand how to account for needs in the ABST.

2) System will be updated utilizing the RCC and Director one-on-one meetings to review Service Plans and then ABST for accuracy in specific care needs, preferences, tasks, consideration of unanticipated needs, and new interventions related to ISPs.

3) ABST will be updated before resident move in, after 1st 30 days, with Significant COC, and quarterly as required. At least one of the 22 ABST elements will be opened quarterly, even if no changes in Service Plan, in order to confirm quarterly review.

4) RCC and Director are responsible for updating service plans and ABST and ensuring accuracy of ABST.

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC) and document all required elements. Findings include, but are not limited to:

Fire and life safety records were reviewed on 01/23/24 at 11:00 am.

Fire drill documentation lacked the following required elements:

* Evacuation time period needed;

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

* Number of occupants evacuated.

During an interview on 01/23/24 at 11:10 am, Staff  9 (Maintenance Director) confirmed the residents were not being evacuated, and the drills lacked documentation of the required elements.  

On 01/24/24  the need to conduct fire drills that included all required elements according to the OFC was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC), and Staff 10 (Regional RN) on 01/25/24. The findings were acknowledged.

C420 FLS

1) Fire Drills will include documentation related to all required elements, including:

Evacuation time period

Problems encountered, comments relating to residents who resisted or failed to participate

Number of occupants evacuated.

2)  The system will be corrected to prevent further violations by Director of Plant Operations providing copies of the completed documentation to ED and Sr. ED w/in 24 hrs of the drill or training, unless otherwise communicated.

3)  Fire drills, training, and completion of documentation will be reviewed monthly, at time of receipt by ED/Sr. ED.

4)  The director of Plant Operations is responsible to provide documentation of completed Fire and Life Safety drills and trainings to ED and Sr. ED monthly.

Plant Operations Director/ED/Sr. ED are responsible to ensure documentation contains all required elements.

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

Refer to C 252, C 260, and Z 163.

C455 - Inspection and Investigation

Please refer to POC for C252, C260, and Z163

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:

Observations made on 01/22/24 and 01/25/23 revealed the following areas needed cleaning or repair:

1. In the 100 hall:

* Multiple chairs and benches on the hallway had stains;

* Room 114 bathroom door had gouges;

* Room 103 door frame had gouges;

* Baseboard from Room 101 through 108 had water damage;

* Ceiling near Room 106 was cracked and had evidence of water damage; and

* Handrail, between Room 103 and 105, was chipped.

2. Dining and theater areas:

* Chairs in the theater area had gouges and chips;  

* Baseboards throughout the dining area had water damage;

* Wall near the theater area had chips; and

* Multiple chairs and benches had stains.

3. Main kitchenette in the dining room:

* Missing and cracked linoleum floor at kitchen entrance;

* Chipped and missing laminate countertop;

* Wood paneling under the countertop had water damage;

* Missing cabinet doors under the sink, exposed pipes; and

* Brown rust colored substance under the sink.

4. In the 200 hall:

* 200 hall entrance door and door frame had chips;

* Multiple chairs and benches in 200 hall kitchenette had stains;

* Kitchenette cabinet doors had chips; and

* Carpet throughout the 200 hall had stains.

The environment was toured on 01/23/24 and 01/24/24 with Staff 3 (Director of MCC) and Staff 9 (Maintenance Director). The need to ensure all interior and surfaces were kept clean and in good repair was discussed with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 and Staff 10 (Regional RN) on 01/25/24. Staff acknowledged the findings.

C513 - Environment

1)  Items listed will be reviewed with Director of Plant Operations and Director of Housekeeping Services.  Items will be cleaned, repaired, or replaced as appropriate.  (Note: Facility replacement of furniture, floor coverings, and some cabinetry are scheduled for 2024.)

Items include:

  100 Hall:

Multiple chairs and benches w/stains

Room 114 bathroom door gouges

Room 103 door frame gouges

Baseboard from 101-108, water damage

Ceiling near Room 106, cracked, evidence of water damage

Handrail between 103 and 105 chipped

 Dining and theater areas:

Chairs in theater area gouges/chips

Baseboards throughout dining room, water damage

Wall near theater chipped

Multiple chairs and benches w/stains

 Kitchenette:

Missing and cracked linoleum at entrance to kitchen

Wood paneling under countertop, water damage

Missing cabinet doors under sink (exposed pipes)

Brown/rust colored substance under sink

 200 Hall:

200 hall entrance door and door frame chipped

Multiple chairs and benches in 200 hall kitchenette stained

Kitchenette cabinet doors chipped

Carpet in 200 hall stained

2)  Quarterly walk thru of physical plant to identify repairs will be completed by ED, Director of Housekeeping Services, and member of Plant Operations team.  TELS system will be utilized on a daily basis by MCC staff to alert Director of Plant Operations of more urgent repairs/replacements needed.

3)  Physical plant will be evaluated quarterly for repair/cleaning/replacement needs due to wear and tear.

4)  Director of Physical Plant Operations, Director of Housekeeping Services, and ED responsible for ensuring corrections are completed and environment is routinely monitored for repair/cleaning/needs.

Based on observation and interview, it was determined the facility failed to ensure exit doors to inner courtyards were equipped with an alarming device or other acceptable system for security purposes and to alert staff when residents exited the building. Findings include, but are not limited to:

During the survey, the facility was identified to have multiple exit doors to the inner courtyards. On 01/24/24 at 9:50 am, a tour of the facility with Staff 3 (Director of MCC) all the exit doors, accessible to inner courtyard, revealed the doors failed to have a working alarm device to alert staff when residents exited the building.

On 01/25/24, the lack of alarms or other acceptable system was shared with Staff 1 (ED), Staff 2 (ED ALF), Staff 3 and Staff 10 (Regional RN) and they acknowledged the findings.

C555 Call System, Exit Door Alarms, Phones, TV, Cable

1)  Alarm malfunction was resolved during survey, on 1/25/24.  

2) System will be corrected by adding interior door alarms to enclosed courtyard to TELS monthly alarm tests to ensure they are triggering the pager system, alerting staff that someone has exited the main building.

3) Alarms will be evaluated monthly to ensure proper safety and security.

4)  Director of Plant Operations and ED are responsible to ensure testing is completed monthly.

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 C350, C361, C420, C513, and C555.

Z142 Administration Compliance

Please refer to POC for:

C350

C361

C420

C513

C555

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

Refer to C 361.

Z142 Administration Compliance

Please refer to POC for C361

Based on interview and record review, it was determined the facility failed to have documented evidence of required pre-service orientation for 3 of 4 newly hired staff (#s 18, 22 and 23), pre-service dementia training completed for 4 of 4 newly hired staff (#s 8, 18, 23 and 25) and a total of 16 hours of in-service training completed annually, including six hours related to dementia care topics for 2 of 4 long-term direct care staff (#s 12 and 13). Findings include, but are not limited to:

On 01/24/24, training records were reviewed with Staff 2 (ED ALF) and Staff 26 (Staff Coordinator). The following deficiencies were identified.

1. Staff 8 (CG), Staff 18 (CG), Staff 22 (Dining Services Supervisor), Staff 23 (CG) and Staff 25 (CG), were hired on 09/25/23, 10/30/23, 11/02/23, 11/14/23, and 11/15/23 respectively.

a. Staff 18, Staff 22 and Staff 23 lacked pre-service orientation documentation in the following areas:

* Resident rights and values of CBC care.

Additionally, Staff 22 and Staff 23 lacked documentation of the following:

* Infectious Disease Prevention.

b. Staff 8 and Staff 18 lacked pre-service dementia training documentation in the following areas:

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

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

Additionally, Staff 18 lacked documentation the following:

* Environmental factors that are important to a resident's well-being;

* Family support and the role the family may have in the care of the resident; and

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

c. Staff 23 and Staff 25 lacked pre-service dementia training documentation in all required training topics.

2. Staff 12 (MT) and Staff 13 (MT), hired 10/02/19 and 06/11/19 respectively, lacked documented evidence of completion of 16 hours of annual in-service training which included at least six hours of dementia care training, reviewed by the anniversary date of the staff's hire.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (ED), Staff 2, Staff 3 (Director of MCC) and Staff 10 (Regional RN) on 01/25/24. Staff acknowledged the findings.

Z155 Staff Training Requirements

1) Staff 18, 22, 23, and 25 will complete required trainings for pre-service orientation, pre-service dementia training, and/or required annual trainings (total of 16 hours, including 6 hours related to dementia care staff.)

2)  The system will be corrected by utilizing Generation's Training and Tracking tool as well as web-based Relias trainings and transcripts.  The Generation's tracking tool indicates which trainings need to be completed pre-service.  No staff member will be allowed on the floor for orientation or shift work prior to pre-service training requirements being completed.

Annual trainings will be tracked monthly utilizing Relias transcripts.

3)  Tracking of pre-service trainings will be evaluated with each new hire utilizing the Generations tracking tool.  Progress towards annual training requirements will be tracked monthly by running transcripts for all active employees to ensure timely completion of trainings throughout the year.

4)  Staffing Coordinator and ED are responsible to ensure all pre-service trainings are compled prior to any work on the floor, as well as tracking of annual training requirements.

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, and C310.

Z162 Compliance with Rules of Health Care Services

Please refer to POC for:

C252

C260

C270

C280

C310

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

Refer to C 252 and C 260.

Z162 Compliance with Rules of Health Care

Please refer to POC for C252 and C260

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

Resident 4 was admitted to the facility in 12/2022 with diagnoses including dementia.

The resident experienced significant and ongoing weight loss between 01/2023 and 01/2024.

An 11/20/23 quarterly evaluation and current service plan, dated 11/20/23, for Resident 4 were reviewed and found to include some food and fluid preferences, but lacked individualized nutrition and hydration information. In addition, the service plan lacked staff instructions for meeting resident-specific nutrition and hydration needs. The evaluation identified that the resident "has history of or is at risk for weight loss" but the service plan did not provide direction to staff to address the risk of weight loss.

The need to develop individualized nutrition and hydration plans in resident service plans was discussed with  Staff 1 (ED), Staff 2 (ED ALF), Staff 3 (Director of MCC) and Staff 10 (Regional RN), on 01/25/24. Staff acknowledged the findings.

Z163 - Nutrition and Hydration

1)  Res #4 - Significant COC completed related to weight loss.  ISP completed and service plan updated to reflect current level of care needs with goal to prevent further weight loss.  Interventions include, but are not limited to needs for cueing, increased assistance with meal intake, supplements, appropriate diet texture, and hydration plan related to chronic diarrhea.

2)  System will be corrected by initiation of new ISP book to alert staff of new changes, monitoring, and/or interventions to support care needs.  All staff to be trained on use and requirements for review of ISPs in ISP book.

Weekly weight review will be completed and residents demonstrating significant weight loss or gain of  +/- 3% will be reviewed at weekly Resident at Risk meeting.  Residents will remain on weekly review for one quarter, or until weights have stabilized.  

ISPs will be reviewed quarterly and incorporated in service plan if applicable.  ISPs will then be scanned into PCC for reference.

3)  Weights will be monitored weekly via Resident at Risk meeting and will include review of nutrition/hydration needs.

ISPs will be reviewed quarterly and incorporated into service plan if applicable.  ISPs will then be scanned into PCC for reference.

4)  RN, RCC, HSD, and ED will be responsible to monitor and ensure corrections are completed for interventions, weight monitoring, SCOC, and service plans.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans, for 4 of 5 sampled residents (#s 5, 7, 8 and 9). This is a repeat citation. Findings include, but are not limited to:

Residents 5, 7, 8 and 9'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 was discussed with Staff 2 (ED ALF), 3 (MCC Director), Staff 4 (LPN, Health Services Director) and Staff 5 (RCC) on 06/05/24. They acknowledged the findings.

Z163 Nutrition and Hydration

1) Resident #5, 7, 8, and 9 - Service plans updated to reflect individualized nutrition and hydration status and needs, including clear instruction to staff.

2) Nutrition and Hydration status and needs will be reviewed during one-on-one weekly meetings between RCC and Director.

3) Nutrition and Hydration status and needs will be evaluated prior to move in, after 30 days, quarterly and with any significant change of condition. These evaluations will be incorporated into the weekly on-to-one meeting between the RCC and Director in order to ensure accuracy.

4) HSD, RN, RCC and Director will be responsible to ensure corrections/updates are completed, monitored and entered into service plans in PCC.