Print Inspection: R2F9

Based on observation and interview, conducted during a site visit on 11/09/23, it was confirmed the facility failed to post the current staffing plan. Findings include, but are not limited to:

During a walkthrough of the facility, a posted staffing plan was not observed.

During an interview, Staff 1 (Connections for Living Director) confirmed the facility's current staffing plan was not posted.

It was determined the facility failed to post the current staffing plan.

On 11/09/23, the findings were reviewed and acknowledged by Staff 1 (Connections for Living Director).

Verbal plan of correction: By the end of day, 11/10/23, the ED will post current staffing plan.

a. Based on interview and record review, conducted during a site visit on 11/09/23, it was confirmed the facility failed to complete quarterly service plans for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

During an interview, Staff 1 (Connections for Living Director) and Staff 2 (Connections for Living Coordinator) stated the following:

-Resident 1 was admitted to the facility on February 9, 2022.

-Resident 1 moved out of the facility on May 15, 2023.

-Resident 1 was no longer a resident of the facility, and because of that, Staff 2 was not able to access his/her service plan.

-Resident 1's records may be in "purge".

-The facility's ownership changed on April 7, 2023.

-Resident 1 was not part of their current data entry system and was entered into a previous system.

-Due to the change in ownership, there were no progress notes or temporary service plans the facility could access for Resident 1.

On 11/09/23, CS requested Resident 1's records between May 2022 through May 15, 2023, including any prior service plans, evaluations, progress notes, or any temporary service plans.

A review of the available facility records found by Staff 1 and Staff 2 and provided to the CS for Resident 1 indicated the following:

-An Initial Screening & Evaluation Tool, dated 11/09/23, was located and printed.

-Resident 1 moved out of the facility May 15, 2023.

-The service plan located and printed was dated 04/28/23.

-A "Needs and Services Plan" dated 05/09/23 was located.

-There was no documented evidence of service plans prior to 04/28/23.

Due to the change in ownership for the facility, Resident 1's records were not transferred in full to the new owners in accordance with OAR 411-054-0019(3), which states: "Resident records maintained by the licensee must be turned over to the new owner when the license application is approved and the new licensee assumes possession or control of the facility."

On December 15, 2023 at 10:57am, via email, the CS requested all Resident 1's records prior to 04/28/23. Staff 1 was provided a deadline of December 18, 2023 at 5:00 pm to provide the requested records. The facility did not respond to the request for records.

The findings were not reviewed by facility staff.

It was confirmed the facility failed to complete quarterly service plans for Resident 1.

b.Based on interview and record review, conducted during a site visit on 11/09/23, it was confirmed the facility failed to complete quarterly service plans for 3 of 3 sampled residents (#2, 3, and 4), failed to include how often the services shall be provided for 2 of 3 sampled residents (#2 and #3), and failed to date and initial changes made to the service plan for 1 of 3 sampled residents (#4). Findings include, but are not limited to:

During an interview, Staff 2 (Connections for Living Coordinator) stated the following:

-The facility's system indicates when residents' service plans are to be updated;

-There were three service plans due by the end of November 2023;

-The facility has been without a director, and have gone through 4-5 directors within the last six months;

-Staff 2 and Staff 1 (Connections for Living Director) have been working to get service plans up to date; and

-The facility's home office has been coming to assist with updating service plans.

During an interview, Staff 7 (CG) stated Staff 1 and Staff 2 were responsible for updating resident service plans.

A review of Resident 2, 3, and 4s' service plans indicated the following:

a. Resident 2's "Needs and Services Plan," dated 05/10/23, indicated s/he requires physical assistance with ADLs, lacked how often care is to be provided in the following areas:

*Toileting; and

*Transferring.

b. Resident 3's "Needs and Services Plan" was dated 06/28/23, indicated s/he requires physical assistance with ADLs, and lacked how to and how often care is to be provided in the following areas:

*Ambulation;

*Dressing;

*Fall mat;

*Toileting; and

*Transferring.

c. Resident 4's "Needs and Services Plan" was dated 05/09/23 and included handwritten modifications without notating dates and initials of staff making the changes.

It was confirmed the facility failed to complete quarterly service plans; failed to include how often the services shall be provided, and failed to date and initial changes made to the service plan.

On 11/09/23, the findings were reviewed and acknowledged by Staff 1 (Connections for Living Director).

Verbal plan of correction: Staff 1 to have another staff member step into his/her role regarding staffing so s/he can complete the outdated service plans. The facility is currently in the process of auditing service plans. All service plans should be in compliance and completed by January 1, 2024.