Print Inspection: KOW5

The findings of the relicensure survey conducted 06/27/22 through 06/29/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the relicensure survey of 06/29/22, conducted 09/21/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 06/29/22, conducted 12/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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 third revisit to the re-licensure survey of 06/29/22, conducted 04/10/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to:

At entrance on 6/27/22, the survey team was informed there was no activity director for the memory care unit, and that caregivers were responsible for providing activities in addition to their regular duties.

During the survey, many residents in the MCC were observed in their rooms for most of the day. Approximately eight residents were observed sitting in the TV room or walking around the units at some point during the daytime.

Review of the MCC activity calendar indicated four scheduled activities for 06/27/22:

*  10:00 am "Balloon bat",

*  01:00 pm "Bingo with Rolando",

*  02:00 pm "walk about in the community" and

*  03:00 pm "color crew".

Observations by the survey team throughout the day revealed none of the scheduled activities occurred.

On 6/28/22 the survey team did observe a staff person attempt to initiate kicking a ball between a group of seated residents, however, none of the 06/28/22 scheduled activities or any other unscheduled activities occurred.

The need to ensure the facility provided a daily program of social and recreational activities for residents was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training). They acknowledged the findings.

1. Ensure that posted daily activities are taking place per calender.

2. Memory Care Administrator to monitor and ensure activities are resident centered and taking place regularly.

3. Twice weekly

4. Memory Care Administrator and Executive Director

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for of 1 of 1 sampled resident (#5) who recently moved in. Findings include, but are not limited to:

Resident 1 was admitted to the facility on 06/07/22. The resident's move-in evaluation was dated 06/07/22. The following elements were not addressed in the move-in evaluation:

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

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

The need to ensure resident evaluations addressed all of the required components was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training). They acknowledged the findings.

1. Ensure new move in evaluation is completed prior to move in, unless emergency, in which case, Orchard Heights will work with licensing for possible exception.

2. Community will train staff to conduct new resident evaluation per current guidelines.

3. Upon each new move in evaluation.

4. Memory Care Administrtor and Executive Director

2. Resident 1 was admitted to the facility in 03/22 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan, dated 04/21/22 and progress notes showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Home health services and daily exercise program,

* Diabetic dietary restrictions, and

* Walking assistance and safety.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training). They acknowledged the findings.

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

1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan, dated 05/31/22 and progress notes showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Mobility and assistance needed in wheelchair;

* Foam cushion in wheelchair;

* Finger foods;

* Fall matt next to bed;

* Behavior pattern of wandering/shopping;

* Lower extremity edema with interventions; and

* Recurrent lower extremity wounds.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in Training) on 06/29/22. They acknowledged the findings.

1. Community will audit sampled residents' service plans and ensure all are resident centered.

2. Community will audit all service plans for current residents and ensure each are resident centered.

3. Quarterly and upon change of condition

4. Memory care administrator and Executive director

3. Resident 5 was admitted to the facility in 04/2018 with diagnoses including dementia.

Interviews with staff and review of the service plan revealed the service plan was not reflective in the following areas:

* Assistance needed for eating;

* Change in the amount and type of food eaten; and

* Open area on coccyx.

The need to ensure the resident's service plan was reflective of the care and services to be provided by staff was discussed with Staff 3 (Regional RN) and Staff 15 (LPN) on 09/21/22. Staff acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.

a. Resident 2's most recent service plan dated 08/22/22 included the interventions

"now has a fall alarm that stay attached to shirt and where [s/he] is sitting or laying", "hospice has provided a fall alarm tab for [Resident 2]. This is attached to [him/her] at all times", and "now has a fall alarm placed where [s/he] is sitting".

Observations on 09/21/22 showed Resident 2 seated in the TV room, the dining room, and the activity room, without the fall alarm.

Interviews with staff revealed they only used the tab alarm at night when Resident 2 was sleeping, and observations on 09/21/22 showed the fall alarm on the bed.

b. Resident 2's most recent service plan dated 08/22/22 included the intervention "Hospice is asking that Med Techs are to offer Tylenol first due to possibly pain before giving the PRN lorazepam".  

In interview on 09/21/22, Staff 3 (Regional RN) acknowledged the information on the service plan was not being followed.

On 09/21/22, the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 3 and Staff 4 (ED). They 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 provided clear direction to caregiving staff regarding delivery of services for 3 of 3 sampled residents (#s 2, 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 02/2020 with diagnoses including dementia.

Interviews with multiple staff members, on 09/21/22, identified Resident 6 was having exit seeking behaviors. Resident 6's service plan, dated 08/11/22, was not reflective of the resident's current status and failed to provide clear instructions to staff related to exit seeking behaviors.

On 09/21/22, the need to ensure service plans were reflective of residents current needs and provided clear directions to staff was discussed with Staff 3 (Regional RN) and Staff 4 (ED). They acknowledged the findings.

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

1. A review and audit of resident #2, 5 and 6 service plan accuracy has been completed. Any inaccuracies identified have been updated to ensure they are reflective of resident needs and status.

2. A full audit of resident care plans to be completed and updated to reflect current resident needs and status. The care planning process to be updated to include a larger collaberative process to ensure care plans are reflective of the most accurate needs by ensuring care staff are documenting daily deviations in care.

3. This to be evaluated at the daily HS team review meeting.

4. This to be monitored by ED, EXD, AHSD       

2. Resident 6 was admitted to the facility in 02/2020 with diagnoses including dementia and was recently admitted to hospice.

Observations of the resident and interviews with staff were conducted during the survey. The current service plan dated 10/26/22, the "Bedside Individual Service Plan" dated 12/20/22, and progress notes from 11/05/22 through 12/20/22 were reviewed.

The service plan was not reflective and did not provide clear instructions in the following areas:

* One to two person transfer assist;

* Ambulation assist;

* Meal assist;

* Hospice services being provided;

* Bowel incontinence;

* Medication refusals; and

* Fall history, including interventions.

The need to ensure service plans were reflective and provided clear instruction was discussed with Staff 17 (Interim Administrator), Staff 15 (LPN), and Staff 18 (RCC) on 12/20/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs, provided clear direction to staff regarding the delivery of services, and/or were reviewed and updated when residents experienced a significant change of condition for 2 of 2 sampled residents (#s 6 and 7) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 02/2015 with diagnoses including dementia.

Observations, interviews, and review of Resident 7's clinical record, including service plans, MARs dated 11/05/22 through 12/19/22 and progress notes dated 11/05/22 through 12/19/22, identified the following:

During the acuity interview on 12/20/22, the facility reported Resident 7 experienced a recent change of condition following a hospital stay related to a fall which resulted in a hip fracture. The facility reported Resident 7 returned to the MCC facility on 12/16/22, with high ADL care needs and required one to two staff members to assist with transfers and bowel/bladder management.

During interviews on 12/20/22, Staff 9 (MT) and Staff 16 (CG/MT) stated  prior to the resident's hospitalization s/he was independent with most ADLs, but upon return to the MCC facility the resident required one to two staff members to assist with transfers. Staff stated they were providing bowel and bladder care while the resident was in bed, as s/he was not able to transfer out of the bed. Staff 16 stated the resident was able to transfer to a wheelchair one time on 12/19/22, with staff assistance.

Review of Resident 7's service plan dated 11/29/22, and "Bedside Individual Service Plan" dated 12/20/22, revealed the resident was independent with transfers, ambulation, and toileting and required reminders from staff for dressing and grooming. There was no documented evidence the service plans had been updated to reflect the resident's significant change in condition and change in care needs when the resident returned from the hospital and/or the service plans did not provide clear direction to staff related to the following care areas:

* Transfer assistance needs;

* Bowel and bladder management needs;

* Management and monitoring of surgical incision;

* Dressing assistance needs;

* Ability to remember to use call light; and

* Fall risk related to recent fall resulting in a hip fracture.

The need to ensure service plans were reflective of residents' care needs, provided clear direction to staff regarding the delivery of services, and were updated when residents experienced a significant change of condition was discussed with Staff 17 (Interim Administrator) and Staff 15 (LPN) on 12/20/22. They acknowledged the findings.

OAR 411-05-0036 (1-4) Service Plan:   General

1.  Service plans will be updated to reflect current needs and preferences.

2.  Executive Director will review 5 service plans a week for memory care to ensure all needs have been addressed.

3.  Executive Director will have 1:1 weekly with the RSN/LN to ensure move in, COC and quarterlies are done timely.  

4.  Upon COC, quarterly evaluation or additional assessment, the Expressions Director, RSN/LN will interview care staff for hands on transcription of care to the service plan.

5.  Service plans will include personal choices, preferences and needs to be person-centered and specifically relevant to the individual resident.  

6.  Staff will be in-serviced/educated on who, how, when and why to report resident changes.

7.  5 days weekly, RSN/LN, RCC and Executive Director will meet to review the service plan schedule and schedule of completion will be determined at that time.

8.  The Executive Director, Expressions Director and/or RCC will communicate with the RSN/LN to ensure that move in assessments, quarterlies and COC service plans are meeting regulations and Prestige policy.    

2. Resident 1 was admitted to the facility in 03/22 with diagnoses including dementia.

Interviews with staff, observations of the resident, and review of the resident's 05/31/22 service plan, 04/26/22 through 06/26/22 temporary service plans, progress notes, and incident investigations were reviewed.

Resident 2 experienced the following changes of condition between 04/01/22 and 06/26/22:

* 04/05/22: Injury fall with cut on head requiring stitches,

* 04/09/22: Injury fall with two abrasions on back, and

* 04/10/22: Injury fall with cut on head.

The need to ensure residents who had short-term changes of condition were monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training) on 06/29/22.  No further documentation was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were monitored to resolution at least weekly for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.

Interviews with staff, observations of the resident, and review of the resident's 05/31/22 service plan, 04/26/22 through 06/26/22 temporary service plans, progress notes, and incident investigations were reviewed.

Resident 2 experienced the following changes of condition between 04/26/22 and 06/26/22:

* 05/25/22: Resident to resident altercation;

* 05/28/22: Two vascular wounds on the left leg and one on the right leg;

* 06/01/22: Skin tear right arm and left wrist; and

* 06/11/22: Cut on head and skin tear to the left elbow.

There was no documented evidence the facility monitored the changes of condition to resolution at least weekly.  

The need to ensure residents who had short-term changes of condition were monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training) on 06/29/22.  No further documentation was provided.

1. Audit and ensure sampled residents have been assessed for any changes of condition and appropriate monitoring is put into place.

2. Audit current residents for change of condition, consulting nurse to complete training with memory care staff to ensure proper change of condition steps are folllowed and appropriate monitoring enacted.

3. RN to complete change of condition assesment via phone or video PRN

4. Consulting nurse, Memory care administrator and Executive director

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was performed for all residents who had significant changes of condition, with interventions communicated to staff and service plans updated for 1 of 1 sampled resident (# 2) who experienced a significant change of condition. Findings include, but are not limited to:

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

Review of the resident's clinical records indicated that on 05/18/22, Resident 2 experienced a fall which resulted in a left hip injury and pain. The record indicated that after the fall, the resident was unable to ambulate and used a wheelchair for mobility.  

Resident 2 was observed multiple times during survey sitting in a wheelchair. Staff provided assistance for all wheelchair mobility.

Staff 10 (MT) reported on 06/28/22 that prior to the fall, the resident did not use a wheelchair, but was able to stand and walk around independently.  Since the fall, Staff 10 stated the resident was able to stand with assist for toileting and transfers but was no longer able to walk.  This constituted a significant change of condition.

There was no documented evidence the RN had assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

The need to ensure an RN assessment was completed for all residents with a significant change of condition was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in Training) on 06/29/22. They acknowledged the findings.

1. Audit and ensure sampled residents have been assessed for any changes of condition and appropriate monitoring is put into place.

2. Audit current residents for significant change of condition. Consulting nurse to complete training with memory care staff to ensure proper change of condition steps are folllowed and appropriate monitoring enacted.

3. RN to complete significant change of condition assesments in a timely manner.

4. Consulting nurse, Memory care administrator and Executive director

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

Resident 2's 05/01/22 through 06/26/22 MAR was reviewed and revealed the following:

*  PRN Morphine Sulphate and PRN Lorazepam were both ordered for symptoms including shortness of breath.  The MAR lacked medication-specific parameters for how to determine which medication to administer for shortness of breath.

* PRN Acetaminophen was ordered in both liquid and suppository forms for mild pain/fever. The MAR lacked parameters for how to determine which medication to administer for mild pain/fever.

The need to ensure MARs were accurate and included clear parameters for PRN medications was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN), and Staff 4 (ED in Training) on 06/29/22. They acknowledged the findings.

1. Review and correct parameters for prn medications for sampled residents

2. Audit all prn orders for parameters and make corrections as needed

3. Every prn order

4. Consulting nurse, Memory care administrator and Executive director

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications used to treat a resident's behaviors and anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 1 of 1 sampled resident (#2) who was prescribed PRN psychotropic medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.

Review of the resident's 05/01/22 through 06/26/22 MAR and current physician orders showed the following psychotropic medications:

* Lorazepam 0.5 mg (a psychotropic medication) every two hours as needed for anxiety, restlessness or shortness of breath.

The facility administered the Lorazepam to the resident on four occasions in May 2022.

* Haloperidol 0.5 mg (a psychotropic medication) every two hours as needed for nausea, hallucinations, agitation or delirium.

The facility administered the Haloperidol on 16 occasions between 05/01/22 and 06/26/22.

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

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety, restlessness, agitation, hallucinations and delirium and that non drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in Training) on 06/29/22. The staff acknowledged the findings.

1. Review and update service plan and MAR for sampeld residents to include non-drug interventions

2. RN will review all residents' MARs and service plans to ensure non-drug interventions are in place and when to administer medications

3. Each time a new medication is added.

4. Consulting nurse, Memory care administrator and Executive director

Based on interview and record review, it was determined the facility failed to complete an Acuity-Based Staffing Tool (ABST) assessment for each resident and develop the facility's staffing plan based on the ABST. Findings include, but are not limited to:

During entrance on 09/21/22 the ABST assessment was reviewed with Staff 3 (Regional RN). She confirmed the ABST tool was in use for determining the facility's staff plan.

The ABST tool showed four residents had information entered into the system for determining the staffing plan, however, the facility census was 17.

Staff 3 acknowledged the tool was incomplete, and 13 residents residing in the facility had not yet had information entered into the ABST.

The need to complete an accurate assessment of each resident and promptly enter the information into the ABST was reviewed with Staff 4 (ED) and Staff 3 on 09/21/22. No further information was provided.

In reference to OAR 411-054-0037

Acuity Based Staffing Tool

1) ED, EXD, Health Services Team re-trained on entering information into the ABST upon move-in, within 30 days and every quarter or when change of condition as necessary.  Training also provided on pulling the tool to review staffing requirements based off acuity tool.

2) ABST will reflect the aquity based needs of each individual resident and will be updated for each resident and then continued updates will occur upon next assessment or during change of condition as necessary.

3) Upon Move-in, 30-day, quarterly and upon change of condition.

4) The ED, EXD, HS team will maintain updated staffing plans in accordance with state regs.  

5)  Monitored by ED, EXD and AHSD during daily Health Services Meeting.

Based on observation, interview, and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 2 of 2 sampled residents (#s 6 and 7). This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 12/20/22 it was reported that Residents 6 and 7 required increased ADL assistance due to significant changes of condition which affected their ADL care needs.

Reviews of  Resident 6 and 7's service plans, 11/05/22 through 12/20/22 progress notes, interviews with multiple care staff, and observations of the residents were completed.

The ABST failed to accurately reflect Resident 6's current ADL care needs in the following areas:

* Time spent transferring in or out of bed or chair:

* Time spent on ambulation, escorting to and from meals;

* Time spent supervising, cueing, or supporting while eating; and

* Time spent on non-drug interventions for behaviors.

The ABST failed to accurately reflect Resident 7's current ADL care needs in the following areas:

* Time spent on monitoring of physical conditions;

* Time spent transferring in or out of bed or chair;

* Time spent on bowel and bladder management;

* Time spent on dressing or undressing; and

* Time spent on responding to call lights.

The need to ensure the ABST tool was reviewed and updated with a significant change of condition was discussed with Staff 17 (Interim Administrator), Staff 15 (LPN), and Staff 18 (RCC) on 12/20/22. Staff acknowledged the findings.

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

1.  Community will ensure that frequency of updates to the ABST are completed prior to move in, with changes noted to ABST within first 30 days as appropriate.  

2.  COCs will be noted to the ABST as they occur.

3.  ABST will also be updated as quarterly assessments occur.  

4.  Expressions Director will review schedule weekly to ensure staffing matches or exceeds the ABST.  

5.  RCC and Staffing Coordinator will be in-serviced to ensure that they understand how to schedule staff based on ABST needs.  

6.  ABST will reflect resident needs, preferences and choices.  The service plan and ABST will match and be person-centered.  

7.  The ABST will reflect time-spent per task with each resident.  To include, all ADLs, transfers, call-lights and any monitoring of both physical and behavioral issues.

8.  Expressions Director will review the ABST of 5 residents weekly to ensure accuracy in care, needs, preferences and choices.  

9.  Expressions Director will notify RSN when updates are completed for RSN to review.    

Based on interview and record review, it was determined the facility failed to meet requirements for fire and life safety drills, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 06/28/22 with Staff 6 (Maintenance Director) identified the following:

*There was no documented evidence that fire drills were conducted on alternating months.

On 06/28/22 the need to ensure all requirements were met for fire and life safety drills and instruction, in accordance with the OFC was discussed with Staff 1 (ED).  He acknowledged the findings.

1. Impliment memeory care fire drill schedule as per regulations

2. Bi-monthly per regulation fire drills, ensure training is happening in opposing months

3. Bi-monthly drills and opposing months training

4. Maintenance director, Memory care administrator and Executive director

Based on 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 C 260 and Z 155.

In reference to OAR 411-054-0105

Inspections and Investigation:  Insp Interval

1. A review and audit of resident #2, 5 and 6 service plan accuracy has been completed. Any inaccuracies identified have been updated to ensure they are reflective of resident needs and status.

2. A full audit of resident care plans to be completed and updated to reflect current resident needs and status. The care planning process to be updated to include a larger collaberative process to ensure care plans are reflective of the most accurate needs by ensuring care staff are documenting daily deviations in care.

3. This to be evaluated at the daily HS team review meeting.

4. This to be monitored by ED, EXD, AHSD

Based on 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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 260 and C 361.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

1.  The Executive Director, Expressions Director and RSN will schedule a call weekly to ensure that this POC as well as previous POCs are in place.

2.  Continuing forward, the community will remain compliant with inspections, investigations and corrections as noted in Chapter 411, Division 57.

3.  The Executive Director, Expressions Director, RSN and RDO will meet post inspection or investigation to ensure that the POC is in place and practiced within the predetermined time frame.   

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 420.

1. Ensure that posted daily activities are taking place per calender.

2. Memory Care Administrator to monitor and ensure activities are resident centered and taking place regularly.

3. Twice weekly

4. Memory Care Administrator and Executive Director

1. Impliment memory care fire drill schedule as per regulations

2. Bi-monthly per regulation fire drills, ensure training is happening in opposing months

3. Bi-monthly drills and opposing months training

4. Maintenance director, Memory care administrator and Executive director

Based on 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, C 420 and C 455.

In reference to OAR 411-057-0140

Administration Compliance

1) ED, EXD, HS Team and Maintenance Director have reviewed POC from survey dated 06/29/2022.  Team reviewed all areas on POC, identified areas of inaccurances and complaince need.  Team will correct all areas to be in regulatory compliance.

2)  ED, EXD, HS Team and Maintenance Director will monitor for regulatory compliance per department as noted in previous plan of correction for 6/29/22 survey.

3)  Each department will follow-up weekly, monthly, quarterly and as needed.   

4)  ED, EXD, HS Team and Maintenance Director to review POC and monitor through daily stand up, health services meetings and quality assurance audits.  

Based on 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 and C 455.

OAR 411-057-0140(2) Administration Compliance

1.  All facets of compliance will be in place through our Quality Assurance audits which are completed monthly.

2.  Quality Assurance audits will be reviewed by the Executive Director and RDO.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff completed the required number of annual in-service training hours. Findings include, but are not limited to:

Staff training records were reviewed with Staff 2 (ED Support) on 06/28/22.

There was no documented evidence Staff 9 (MT), hired 10/10/16 and Staff 12 (MT), hired 06/07/17 completed the required number of annual in-service training hours.

The facility's failure to ensure staff completed the required number of training's annually was discussed with Staff 1 (ED) on 06/28/22.  He acknowledged the findings.

1. Ensure sampled staff complete required in-service hours

2. Audit of employees and ensure each have completed required in service hours

3. Audit monthly

4. Memory care administrator and Executive director

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 252, C 260, C 270, C 280, C 310 and C 330.

1. Community will audit resident service plans and ensure all areas are resident centered

2. Will audit all service plans for current residents and ensure each are resident centered

3. Quarterly and upon change of condition

4. Memory care administrator and Executive director

1. Update evaluations

2. Audit current residents for change of condition, consulting nurse to complete training with memory care staff to ensure proper change of condition steps are folllowed

3. RN to complete change of condition assesment via phone or video PRN

4. Consulting nurse, Memory care administrator and Executive director

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 260.

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

1. A review and audit of resident #2, 5 and 6 service plan accuracy has been completed. Any inaccuracies identified have been updated to ensure they are reflective of resident needs and status.

2. A full audit of resident care plans to be completed and updated to reflect current resident needs and status. The care planning process to be updated to include a larger collaberative process to ensure care plans are reflective of the most accurate needs by ensuring care staff are documenting daily deviations in care.

3. This to be evaluated at the daily HS team review meeting.

4. This will be monitored by ED, EXD, AHSD        

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 260.

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

1.  All facets of compliance will be in place through our Quality Assurance audits which are completed monthly.

2.  Quality Assurance audits will be reviewed by the Executive Director and RDO.

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, or were followed for 4 of 4 sampled residents (#s 1, 2, 3  and 4) whose MCC service plans were reviewed. Findings include, but are not limited to:

Resident's 1, 2, 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information, staff instructions related to individualized nutrition and hydration status and needs, or were not followed by staff members providing care.

The need to develop individualized service plans addressing residents' nutrition and hydration needs, and ensure that any plans that were in place were followed, was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training) on 06/29/22.  No further documentation was provided.

1. Ensure each of the sampled residents service plans are reflective of current nutritional and hydration needs

2. Audit all residents to ensure service plans are reflective of current nutritional and hydration needs and ensure new move in assessments/service plans address this.

3. Upon move in, change of condition, and/or every 90 days

4. Memory care administrator and Executive director

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 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

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

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

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

Observations on 06/27/22 and 06/28/22 showed multiple residents wandering the halls and residents seated in the TV area for extended periods of time without consistent interaction or intervention from staff.

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 all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training) on 06/29/22.  They acknowledged the findings.

1. Ensure that posted daily activities are taking place per calender

2. Activities director and Memory care administrator are ensuring activies are resident centered and in line with memory care programing.

3. Twice weekly

4. Memory care administrator and Executive director

Based on 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 5 sampled residents (#1) with documented behaviors. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 03/22 with diagnoses including dementia.

Resident 1's record revealed documented behaviors including exit seeking by attempting to leave the unit through the locked door, hitting staff when redirected, verbal outbursts, touching other residents, and following them into their rooms without permission.

The resident's service plan, dated 04/21/22 lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 06/29/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 2 (ED Support), Staff 3 (Regional RN) and Staff 4 (ED in training). They acknowledged the findings.

1. Review and update service plans for sampled residents reflective of behavioral symptoms and interventions.

2. Audit current residents' service plans, consulting nurse to complete training with memory care staff to ensure proper service plans steps are folllowed and are reflective of behavioral symptoms and interventions.

3. RN to review and update service plans as indicated for changes of condition.  

4. Consulting nurse, Memory care administrator and Executive director