Print Inspection: RL000586

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to: During the survey, the facility was home to nine residents. Random resident observations made on 10/07/24 and 10/08/24, review of the October 2024 activity calendar, and interviews with staff revealed the following: a. The October 2024 activity calendar provided to the survey team and posted in the facility indicated the following activities would occur on 10/07/24: * Morning Motivation; * Pledge of Allegiance; * Storyline; * This Day in History; * Chair Exercises; and * Sing along. On 10/02/24 between 9:00 am and 6:00 pm, the only activities observed occurred at approximately 11:20 am when four residents were observed coloring at the dining room table, and at 3:30 pm when a movie was put on the television. However, by 4:30 pm, no residents were watching the movie. Although television or music played continuously, no other activities were observed between 9:00 am and 6:00 pm. b. On 10/08/24, the activity calendar noted the following activities would occur: * Morning Motivation; * Pledge of Allegiance; * Storyline; * This Day in History; * Sit and Sip; and * Poetry. No activities were observed between 8:30 am and 12:00 pm. During an interview with Staff 4 (Universal Worker) on 10/08/24 at 11:35 am, the activity calendar was reviewed. She stated she “recently switched to days from night shift” and was unaware what Morning Motivation, Storyline, and This Day in History were. Staff 5 (Assistant Administrator/Universal Worker) was interviewed on 10/08/24 at 11:50 am. She stated that the “Med Techs and caregivers” were responsible for the activities. She acknowledged the lack of activities that occurred on 10/07/24 and 10/08/24. Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 10/08/24 at 12:30 pm. They acknowledged the findings. They further stated the activity calendar was a “corporate calendar” and would update it to meet the needs of their residents.

Refer to POC for 242 1) What action will be taken to correct the rule violation? The Administrator along with the assistant Administrator will communicate first of the week to review the Activity calendar to make sure they meet the needs, interest, physical, mental and psychosocial needs and creates opportunities for active participation in the community. The calendar from the corporate office will be reviewed and adjusted to match the needs and requests of the community. Administrator will visit with the residents on Monday to review and adjust as needed. The staff will document the activity and the residents that attended. The Administrator will review the documentation at least twice a week to ensure the forms are completed and activites are being done according to the Rule C0242. 2)How will this system be correct so this violation will not happeen again? The Administrator, the assistant of the community and the Regional Director of Operations will review the calendar weekly. The Administrator will review the log twice a week and submit the calendar for the week along with the documentation of the completed activity at the end of each week. 3) How often will the area needing correction be evaluated? This will be evaluated weekly and daily by the Administrator and Regional Director of Operations will continue to review weekly to make sure this process is working for all residents and they are being provided with activities that meet their needs and interest. 4) Who will be responsible to see that the correction area is completed/monitored? The Administrator, the assistant and the Regional Director of Operations.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 3 sampled residents (#3). Findings include, but are not limited to: Resident 3 was admitted in 02/2024 with diagnoses which included insulin dependent diabetes. His/her current physician orders and MARs, reviewed from 09/01/24 through 10/07/24, revealed the following: * Resident 3 had an order for PRN Lispro Insulin to be given in varied amounts via an insulin pen based on CBG (blood sugar) readings. * According to the 9/2024 and 10/2024 MARs, staff had documented that the resident received PRN Lispro sliding scale on 49 occasions. However, staff failed to document the exact amount of insulin given. In an interview on 10/08/24 at 11:00 am, Staff 5 (Assistant Administrator/MT/Universal Worker) and the surveyor checked the computer MARs. She stated the insulin orders had been followed, but that the amount of sliding scale had not been documented. On 10/08/24 at 12:15 pm, the need to ensure MARs were accurate was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations). They acknowledged the findings. Staff 1 stated she would re-educate staff to ensure accurate documentation of the PRN Lispro insulin.

Refer to POC for C310 1) What action will be taken to correct the rule violation? ALIS is the computer software that we use for documenting medication administration. When it comes to sliding scale, there was no where to document the amount of units. This was how the software was set up for our community. The software has been updated for our community to meet our needs. The Administrator was trained on the system on how to upload the order and to provide an area to document the dose. The Medication Aide will document in the chart the dose for a sliding scale diabetic. The amount will be charted per MD order. The Administrator along with the community licensed nurse will review this weekly to ensure the documentation is being entered. Staff will be educated on where to document the dose given. Education will be done with all staff and staff will sign written acknowledge of the training. 2)How will this system be correct so this violation will not happeen again? The Administrator, the community licensed nurse and the Regional Director of Operations will review the medication administration report along with the observation report for all residents that are on a sliding scale to ensure documentation is being done. Administrator will run a weekly report to ensure this is being done. 3) How often will the area needing correction be evaluated? This area of correction will be evaluated weekly and as needed by Administrator, community licensed nurse and Regional Operations Director. 4) Who will be responsible to see that the correction area is completed/monitored? The Administrator, the assistant, the community licensed nurse and the Regional Director of Operations.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to develop a staffing plan that outlined the staffing numbers required to meet the scheduled and unscheduled needs of all residents for each shift, and which accounted for paid and unpaid staff meal breaks. Findings include, but are not limited to: The facility used the Department-developed acuity-based staffing tool (ABST) to document the amount of time required to complete each resident’s daily care needs. The facility utilized universal workers whose duties included other tasks, such as housekeeping and cooking meals, in addition to providing direct care to residents. The facility’s ABST was reviewed on 10/07/24. For weekdays, the posted staffing plan indicated the facility scheduled one universal worker on each of the three standard 8-hour shifts: Day (6:00 am – 2:00 pm), Evening (2:00 pm – 10:00 pm) and Overnight (10:00 pm – 6:00 am). The staffing plan also indicated there was a “float” shift where one additional staff was scheduled from 10:00 am – 6:00 pm. Accounting for 30-minute meal breaks as required in the rule, this provided a total of 30 hours of care time. However, the ABST indicated the residents required between 36.39 and 37.85 hours of care per day on weekdays. Further, the time required to meet the scheduled and unscheduled needs of the residents specifically on day shift was between 16.47 and 17.6 hours and was between 15.0 and 15.58 hours on evening shift. This required the facility to schedule at least two staff on each shift, which the facility was not scheduling. For weekends, the staffing schedule indicated the facility was scheduling one staff from 6:00 am – 6:00 pm (12 hours), one staff from 6:00 pm to 6:00 am (12 hours) and one staff from 10:00 am – 6:00 pm (8 hours). Accounting for 30-minute meal breaks as required in the rule, this provided a total of 30.5 hours of care time. However, the ABST indicated the residents required between 35.39 and 36.50 hours of care per day on weekends. In an interview on 10/08/24, Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) stated they did not account for scheduled meal breaks for staff. They acknowledged that their total amount of scheduled staff hours was still below the time required to meet resident needs per the ABST, both for the entire day and for the day and swings shifts. The need to ensure the staffing plan met the scheduled and unscheduled needs of all residents for each shift as indicated by the ABST, and which accounted for paid and unpaid staff meal breaks, was reviewed with Staff 1 and Staff 2. They acknowledged the findings.

Refer to POC for C363 1) What action will be taken to correct the rule violation? The Administrator along with the assistant will review the ABST on Monday and update the schedule per the need of staff needed to meet the care needs of the admitted residents. The Administrator will review the schedule each week to ensure it matches the needs of the residents. When there is a change in a resident's condition or a new admit the ABST will be updated and schedule will revised as needed. This will be coordinated with the scheduling coordinator. All lunch breaks have been up dated and included on the schedule. 2)How will this system be correct so this violation will not happeen again? The Administrator, the assistant of the community and the Regional Director of Operations will review the schedule, hours and ABST weekly and as needed. 3) How often will the area needing correction be evaluated? Weekly and as needed. 4) Who will be responsible to see that the correction area is completed/monitored? The Administrator, the assistant and the Regional Director of Operations.

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST. This Rule is not met as evidenced by: