Print Inspection: TBQY

The findings of the re-licensure survey, conducted 09/28/22 through 09/30/22, 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 and 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 first revisit to the re-licensure survey of 09/30/22, conducted 09/25/23 through 09/27/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 2nd revisit to the re-licensure survey of 09/30/22, conducted 02/27/24 through 02/29/24, 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, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:

During the relicensure survey, conducted 09/28/22 through 09/30/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity, scope and number of citations.

Refer to deficiencies in report.

OAR 411-054-0025 (1) Facility

Administration: Operation

Refer to deficiencies in report.

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of records for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 10) whose records were reviewed. Findings include, but are not limited to:

During the survey, resident records were reviewed and were found to be incomplete or inaccurate multiple areas, including new move-in evaluations, quarterly evaluations, interventions, incident investigations, service plans and RN assessments.

* Resident 1's record was incomplete, did not contain information regarding an incident report or copy of the APS report for a resident to resident altercation. Resident 1's most recent service plan was incomplete.

* Resident 2's record was incomplete, and did not include a new move-in evaluation, the facility was not able to provide a copy of the incident report related to a resident to resident altercation;

* Resident 3's record was incomplete, the facility was not able to provide a copy of the incident report for a resident to resident altercation on 08/16/22;  

* Resident 5 and Resident 10's records were incomplete. The facility was unable to provide a copy the APS reports, documented as submitted to SPD, for resident to resident altercations on 01/10/22 and 02/14/22.  

On 09/30/22, the need to ensure facility records were accurate and complete was discussed with Staff 1 (Administrator) and Staff 2 (RN). No further information was provided.

OAR 411-054-0025 (8) Facility Administration: Records

1. What actions will be taken to correct the rule violation for each example/ resident?

a. Resident's 1, 2, 3, 5, and 10 will be audited for content by the Regional Director of Memory Care and any missing items that can be located within the facility will be added to the chart.

2. How will the system be corrected so this violation will not happen again?

a. The Administrator will be trained by the Regional Director of Memory Care on required content of each resident record.

b. Care staff and Administrator will be trained by the Regional Director of Memory Care on documentation, records maintenance, resident chart contents, filing and regulations for resident records.

c. Resident records chart audit tool will be used to audit records by the Administrator and/or RN.

d. Administrator will ensure records are filed appropriately by auditing all current residents records.

e. Administrator and/or RN will pull a report of chart notes daily Monday through Friday and compare the notes with supporting documentation such as incident reports.

3. How often will the area needing correction be evaluated?

a. The Administrator will audit resident charts on a quarterly basis for content.

4. Who will be responsible to see that the corrections are completed/monitored?

a. The Administrator will be responsible to ensure that each record is audited quarterly and documents are maintained according to regulation.

Based on observation, interview and record review, it was determined the facility failed to thoroughly investigate allegations of suspected abuse involving a resident-to-resident altercation and failed to report the incidents to the local Seniors and People with Disabilities (SPD) office when unable to reasonably conclude the incidents were not abuse and/or neglect for 2 of 4 sampled residents (#s 1 and 5) who experienced resident to resident altercations. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia. Resident 1 required a wheelchair for mobility.

During the acuity interview on 09/28/22, Resident 1 was identified to be involved in resident-to-resident altercations on multiple occasions.

Resident 1's clinical records were reviewed during the survey and revealed s/he was involved in the following resident-to-resident physical altercations:

* 05/26/22: Resident 1 hit another resident in the hallway;

* 06/21/22: Progress note indicated Resident 1 was involved in a resident-to-resident altercation on 06/18/22; and

* 09/22/22: Resident 1 was pushed by another resident which resulted in skin injuries and an emergency department visit.

There was no documented evidence the incidents had been thoroughly investigated to rule out the possibility of abuse and there were no documented evidence the incidents were reported to the local SPD.

In an interview with Staff 1 (MCC Program Manager), 09/30/22 at 3:35 pm, she confirmed she could not locate the reports to APS, at which time surveyor requested Staff 1 to report the incident.

On 09/30/22 at 10:17 am, the need to thoroughly investigate allegations of suspected abuse involving a resident-to-resident altercation and immediately notify the local SPD office of the incidents was discussed with Staff 1 and Staff 2 (RN/MCC Wellness Director). They acknowledged the findings. No further documentation was provided prior to survey exit.

2. Resident 5 was admitted to the memory care community in 06/2020 with diagnoses of dementia, hypertension and depression.

During the acuity interview on 09/28/22, Resident 5 was identified as having been involved in resident-to-resident altercations.

Resident 5's clinical records were reviewed during the survey, and indicated the resident was involved in the following resident-to-resident physical altercations:

* 01/10/22 - Resident 5 was in physical altercation with another resident in the hallway; and

* 02/14/22 - Resident 5 walked up behind another resident in the television room, and "smacked [him/her] on the left cheek".

In an interview with Staff 1 (MCC Program Manager) on 09/29/22, the surveyor requested documented evidence the altercations had been reported to the local SPD office.

Staff documentation on facility incident report forms indicated "APS" had been notified for both altercations. Staff 1 confirmed "APS" had been notified, however was unable to locate any other documentation regarding the incidents. No documentation the  reports had been submitted to APS were provided prior to survey exit.  

On 09/30/22 the need to immediately notify the local SPD office of all resident-to-resident altercations was discussed with Staff 1. She acknowledged the findings. No further information was provided.

OAR 411-054-0028(1-3) Reporting& Investigating Abuse - Other Action.

1. What actions will be taken to correct the rule violation for each example/resident?

a. Resident 1 all incidents will be thoroughly investigated and reported to SPD and documentation of the reporting will be maintained.

b. Resident 5, all incidents will be thoroughly investigated and reported to SPD and documentation of the reporting will be maintained.

2. How will the system be corrected so this violation will not happen again?

a. Training for all staff will be conducted by the Regional Director of Memory Care to review policies and procedures for the prevention of Abuse and Neglect and reporting of suspected abuse and/or neglect as well as documentation of the notifications. This training will include managing the incident, notifications, management of the resident, medical needs, documentation of the incident and interventions.

b. All staff will sign acknowledgment of this training.

c. Documentation of this training will be maintained in the training record.

d. All incidents will be reported immediately to the Administrator by the staff member who witnessed or noted the incident and will be entered into the resident chart and the 24 hour communication log.

e. If abuse or neglect is suspected, witnessed or overheard, the care staff member will immediately report the incident to the SPD or the local AAA and the local Law Enforement Agency.

f. The Administrator and RN will review each incident report and conduct an investigation of the incident to determine if they can rule out abuse or neglect. The investigation will include the time, date, place and any individual present, a description of the event as reported, the staff response to the incident, any follow up action needed and any reporting completed including agency notified, time, date and mode of reporting.

g. If abuse and/or neglect is not able to be ruled out, the Administrator will immediately report to the SPD or the local AAA and the local Law Enforcement Agency.

h. If the incident includes an injury of unknown cause, that cannot be ruled out as abuse or neglect, the Administrator will immediately report the injury to the SPD or local AAA.

i. The Administrator will keep a binder of all incidents.

3. How often will the area needing correction be evaluated?

a. All incident will be reviewed during the SMART meetings conducted daily Monday through Friday and involving the RN, Administrator and Executive Director.  This review will include review of the incident, notifications, documentation of incident notifications, interventions put in place and outcome of follow up.

4. Who will be responsible to see that the corrections are completed/monitored?

a. The Administrator will monitor this process for compliance daily during SMART meetings.

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

Observation of the kitchen on 09/27/22 at 8:27 am revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:

* Door near reach-in refrigerator;

* Ceiling vents throughout the kitchen;

* Ceiling tiles near juice machine;

* Venting plate on reach-in refrigerator;

* Walls throughout the kitchen;

* Flooring and baseboards throughout the kitchen;

* Floor drains throughout the kitchen;

* Clean dish rack near steam table;

* Electrical box under steam table;

* Pillar near steam table;

* Toaster;

* Microwave;

* Shelves of steam table;

* Commercial oven;

* Stove/oven unit;

* Floor mats throughout the kitchen;

* Stand mixer;

* Shelving above stand mixer;

* Drawers throughout the kitchen;

* Spice shelf;

* Fire hydrant;

* Waffle irons in pantry;

* Pantry floors;

* Back door;

* Flooring in the walk-in refrigerator;

* Shelving in the walk-in refrigerator;

* Cooling rack in the walk-in refrigerator; and

* Warewasher pipes.

The following kitchen items needed repair:

* Doors throughout the kitchen had scrapes and/or gouges with bare wood exposed rendering the surfaces uncleanable;

* The walk-in freezer had pooled ice on the floor and around pipes leading to the fans;

* The reach-in refrigerator had a ripped seal and large cracks in the floor of the unit; and

* Tiles near rear exit were cracked in multiple places.

Observation of the MCC kitchenette on 09/29/22 at 10:14 am revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:

* Walls throughout the kitchenette;

* Floors and baseboards throughout the kitchenette;

* Cabinets throughout the kitchenette;

* Drawers throughout the kitchenette;

* Steam table;

* Warming drawer of the oven;

* Garbage disposal;

* Refrigerator / Freezer unit; and

* Venting plate of refrigerator.

The following MCC kitchenette items needed repair:

* Laminate flooring was chipped exposing subfloor;

* Wall behind steam table had holes and laminate was lifting;

* Wall behind sink had water damage with drywall exposed; and

* Cabinets and drawers throughout kitchenette had laminate lifting and bare wood exposed rendering surfaces uncleanable.

MCC kitchenette food service observations revealed the following:

* Probe thermometer was wiped with a hand towel between food items; and

* Soup was left in steam table from lunch until dinner service.

The areas in need of cleaning and repair and infection control practices were reviewed with Staff 1 (MCC Program Manager) on 09/30/22. She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident

Services Meals, Food Sanitation Rule

1. What actions will be taken to correct the rule violation for each example/resident are as follows:

a. food spills, splatters, loose food debris,

dirt and/or dust on or underneath the

following have been cleaned:

* Door near reach-in refrigerator;

* Ceiling vents throughout the kitchen;

* Ceiling tiles near juice machine;

* Venting plate on reach-in refrigerator;

* Walls throughout the kitchen;

* Flooring and baseboards throughout

the kitchen;

* Floor drains throughout the kitchen;

* Clean dish rack near steam table;

* Electrical box under steam table;

* Pillar near steam table;

* Toaster;

* Microwave;

* Shelves of steam table;

* Commercial oven;

* Stove/oven unit;

* Floor mats throughout the kitchen;

* Stand mixer;

* Shelving above stand mixer;

* Drawers throughout the kitchen;

* Spice shelf;

* Fire hydrant;

* Waffle irons in pantry;

* Pantry floors;

* Back door;

* Flooring in the walk-in refrigerator;

* Shelving in the walk-in refrigerator;

* Cooling rack in the walk-in refrigerator;

and

* Warewasher pipes.

b. The following kitchen items have been repaired:

* Doors throughout the kitchen had

scrapes and/or gouges with bare wood

exposed rendering the surfaces

uncleanable;

* The walk-in freezer had pooled ice on

the floor and around pipes leading to the

fans;

* The reach-in refrigerator had a ripped

seal and large cracks in the floor of the

unit; and

* Tiles near rear exit were cracked in

multiple places.

MCC kitchenette :

food spills, splatters,loose food debris, dirt and/or dust on or underneath the following have been cleaned:

* Walls throughout the kitchenette;

* Floors and baseboards throughout the kitchenette;

* Cabinets throughout the kitchenette;

* Drawers throughout the kitchenette;

* Steam table;

* Warming drawer of the oven;

* Garbage disposal;

* Refrigerator / Freezer unit; and

* Venting plate of refrigerator.

The following MCC kitchenette items have been repaired:

* Laminate flooring ;

* Wall behind steam table ;

* Wall behind sink; and

* Cabinets and drawers throughout

kitchenette

c. MCC kitchenette food service training completed :

* Probe thermometer use and sanitization; and

* food service time, temp and safety rules

2. How will the system be corrected so this violation will not happen is as follows:

a. Kitchen cleaning schedule now in place with audits

b. Staff training on food safety rules

3. How often will the area needing correction be evaluated is as follows:

a. Daily when working by Administrator or designee

b. Weekly by Maintenance to check for repairs

c. Weekly by Culinary Director or Designee

4. Who will be responsible to see that corrections are completed/monitored are as follows:

a. MC Administrator

b.Kitchen Culinary Director or designee

c. Maintenance Director

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

1. Resident 1 moved into the facility in 02/2022.

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

* Physical health status including list of current diagnoses and visits to health practitioner(s), ER, hospital or NF in the past year;

* Mental health issues including effective non-drug interventions;

* Cognition including memory, orientation, confusion and decision making abilities;

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

* Housework status;

* Transportation;

* Ability to use call system;

* List of treatments;

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

* History of dehydration or unexplained weight loss or gain; and

* Recent losses.

The need to ensure new move-in evaluations contained all the required elements was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director) on 09/30/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility 08/2022.

Staff 1 (MCC Program Director) was unable to provide a copy of the resident's new move-in evaluation.

The need to ensure new move-in evaluations were completed prior to a new resident's admission was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director) on 09/30/22. They acknowledged the findings.

OAR 411-054-0034 (1-60 Resident Move in and Eval: Res Evaluation.

1. What actions will be taken to correct the rule violation for each example/resident.

a. Resident 1 current evaluation reviewed and updated to ensure that it includes:

*Physical health status including list of current diagnoses and visits to health practitioner(s), ER, hospital or NF in the past year.

*Mental health issues including effective non-drug interventions;

*Cognition including memory, orientation, confusion and decision making abilities;

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

*Housework status;

*Transportation;

*Ability to use call system;

*List of treatments;

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

*History of dehydration or unexplained weight loss or gain; and

*Recent losses.

b. All current resident evaluations will be audited by the RN/Administrator/RDMC to ensure they include all aspects required in section 5 of this rule.  

2. How will the system be corrected so this violation will not happen again?

a.RN will attend the Role of the RN class

b. Administrator and RN will review each element of the evaluation which includes all required items listed in section 5 of this rule.

c. RN will author all preadmission, admission, quarterly and change of condition evaluations with input from the Administrator and care team, based on interview of resident, records review, family input and physician communications.

3. How often will the area needing correction be evaluated?

a. RN will review all evaluations with the Administrator for content before the evaluation is signed off by the Administrator.

4. Who will be responsible to see that the corrections are completed/monitored?

a. Administrator will review each preadmission, move in and subsequent evaluations for content prior to signing off on each evaluation.

2. Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia.

Resident 1 was observed to utilize a wheelchair for mobility.

a. Observations of the resident, interviews with staff, review of the current 03/15/22 service plan and clinical records during the survey revealed Resident 1's service plan was not reflective of his/her status and did not provide specific directions to staff in the following areas:

* Behaviors including interventions;

* Transfer status including level of assistance;

* Ambulation status including use of a wheelchair;

* Toileting status including level of assistance;

* Grooming and personal hygiene status including level of assistance;

* Increased pain status;

* Mental health outside provider service including when to contact and who to contact;

* Evacuation status and level of assistance needed; and

* Activity status.

b. Resident 1's service plan was last updated on 03/15/22 and therefore not updated quarterly.

The need to ensure the service plan was reflective of the resident's needs, provided clear instruction to staff, and was updated quarterly was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director) on 09/30/22. Staff acknowledged the findings.

3. Resident 3 was admitted to the facility in 02/2020, with diagnoses including dementia.

Observations, interviews with staff and review of Resident 3's clinical records revealed the following:

* There was no documented evidence the service plan dated 02/14/22, had been reviewed or updated quarterly; and

* The service plan was not reflective of the resident's fall risk and use of a low bed and fall mat.

On 09/29/22, Resident 3's bed was observed in the lowest position.

The need to ensure service plans were reviewed and/or updated quarterly and were reflective of the resident's needs was discussed with Staff 1 (MCC Program Manager) on 9/30/22. She acknowledged the findings.

4. Resident 4 was admitted to the facility in 07/2020, with diagnoses including dementia.

Observations, interviews with staff and review of Resident 4's clinical records including the service plan dated 08/04/22, revealed the service plan did not provide clear direction to staff in the following areas:

* Frequency of safety checks;

* Conflicting information documented on the service plan related to the residents ability to use the call light; and

* Resident's history of and risk for falls in the evening and night hours .

During an interview on 09/29/22 at 11:00 pm, Staff 16 (Resident Assistant) stated all residents were checked every two hours. Resident 4 was a fall risk so s/he was checked on more frequently, usually every hour.

Then need to ensure service plans were reflective of the resident's needs and provided clear direction to staff was discussed with Staff 1 (MCC Program Manager) on 09/30/22. She acknowledged the findings.

5. Resident 5 was admitted to the facility in 06/2020 with diagnoses including dementia, hypertension and depression.

Review of Resident 5's service plan, dated 12/02/21, interim service plans, observations during survey and interviews with staff determined the service plan was not reflective, or did not provide clear instructions to staff in the following areas:

* Weight monitoring;

* Skin monitoring;

* Blood pressure and pulse checks;

* Transfer assistance; and

* Interventions for behaviors.

Resident 5's service plan stated the resident "requires verbal safety reminders and occasionally a physical assist with transfers."  In an interview on 09/29/22 Staff 11 (Resident Assistant)  stated the resident normally required "strong transfer help."

On 09/29/22 at 10:55 pm, observations were made of Resident 5 in the MCC's common area. The resident was observed to require transfer assistance from one staff member with a gait belt.

The service plan stated Resident 5 had "no serious behaviors"; In an interview on 09/29/22 Staff 14 (Resident Assistant) stated Resident 5 often displayed "aggressive behaviors, both verbally and physically, and had been in several altercations."

Resident 5's most recent service plan was dated 12/02/21, indicating the service plan had not been updated quarterly.

On 09/30/22 the need to ensure service plans were reflective of residents' current status, provided clear instructions to staff and were updated quarterly was discussed with Staff 1 (MCC Program Manager). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed and updated/reviewed quarterly. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility 08/2022 with diagnoses of Vascular dementia.

Observations of the resident, interviews with staff, review of the current 09/08/22 service plan and clinical records reviewed during the survey revealed Resident 2's service plan was not reflective of his/her status and did not provide specific direction to staff in the following areas:

* Pain;

* Bathing;

* Grooming and hygiene; and

* Toileting.

In an interview with Staff 8 (Resident Assistant/Med Aide) on 09/30/22 at 9:45 am, she verified Resident 2 was a full assist for all ADL care needs except eating. Resident 2 required full assist with incidental ADL tasks including grooming and hygiene. The resident had pain in his/her feet.

The need to ensure the service plan was reflective of the resident's status and care needs and provided clear instructions to staff was discussed with Staff 1 (MCC Program Director) and  Staff 2 (RN) on 09/30/22. They acknowledged the findings.

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

1. What actions will be taken to correct the rule violation for each example/resident:

a. Resident 2 service plan will be reviewed and updated to include

*Pain

*Bathing

*Grooming and hygiene

*Toileting

b. Resident 1 service plan will be reviewed and updated to include

*Behaviors including interventions

*Transfer status including level of assistance

*Ambulation status including use of a wheelchair

*Toileting status including level of assistance

*Grooming and personal hygiene status including level of assistance

*Increased pain status

*Mental health outside provider services including when to contact and who to contact.

*Evacuation status and level of assistance needed

*Activity status

c. Resident 3 service plan will be reviewed and updated to include

* Residents fall risk

*Use of low bed and fall mat

d. Resident 4 service plan will be reviewed and udpated to include

*Frequency of safety checks

*Use of call light

*History and risk of falls

e. Resident 5 service plan will be reviewed and updated to include

*Weight monitoring

*Skin monitoring

*Blood pressure and pulse checks

*Transfer assistance

*Interventions for behaviors.

f. All current resident service plans will be reviewed by the RDMC/RN/Administrator and updated to ensure completion of all elements of evaluation, direction to staff and appropriate interventions.

2. How will the system be corrected so this violation will not happen again?

a. RN will attend the Role of the RN class

b. RN and Administrator will review each element of the evaluation/service plan which includes all required elements

c. Every element of the evaluation/service plan will be addressed including direction to the staff and interventions where appropriate for each and every service plan completed.

d. RN will author all service plans with input from the Administrator, care staff, family input, medical records, and physician communicaitons and will include appropriate direction to staff and appropriate interventions where applicable.

3. How often will the area needing correction be evaluated?

a. Each care plan completed will be reviewed for content prior to being signed by the Administrator.

b. Timeliness of move in, quarterly and change of condition updates will be reviewed during the SMART meetings held daily Monday through Friday to ensure timely updates are completed.

c. SMART meeting minutes are maintained on the Seasons dashboard.

4. Who will be responsible to see that the corrections are completed/monitored?

a. The Administrator will review every service plan for content and provide feedback as necessary prior to signing off on all service plans.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff, and were consistently implemented by staff for 2 of 4 sampled residents (#s 13 and 15) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 was admitted to the facility in 11/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 09/01/23 and progress notes dated 06/29/23 to 09/25/23 were completed. Staff indicated the resident had poor safety awareness, was able to transfer on his/her own and ambulated all over the facility. The resident could be intrusive to other residents' personal space and was sometimes difficult to redirect. The staff further indicated they provided full assistance with ADLs and encouraged the resident to help with the tasks that s/he could. The resident's service plan was not reflective, lacked resident specific direction for staff and/or was not consistently implemented by staff in the following areas:

* Safety interventions;

* Repeated invasion of others personal space and removing drinks and food items;

* Toileting schedule and assistance with incontinent care needs;

* Agitation and refusals of care;

* Ambulation assistance; and

* Resident to resident altercations and interventions/activities to utilize.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were consistently implemented was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (ED) and Staff 24 (Regional Director of Memory Care) on 09/27/23. The staff acknowledged the findings.

2. Resident 15 was admitted to the facility in 05/2023 with diagnoses including dementia and hallucinations.

Observations of the resident, interviews with staff, review of the resident's service plan dated 09/22/23, and progress notes dated 06/25/23 to 09/25/23 were completed. Staff indicated the resident had poor safety awareness, required 1-2 staff assistance with ADL care including transfers. The resident did attempt self-transfers on occasion and was a high risk for falls. The resident had frequent agitation which resulted in yelling, swearing and threatening staff and other residents. The resident's service plan was not reflective, lacked resident specific direction for staff and/or was not consistently implemented by staff in the following areas:

* Fall mat;

* One versus two person transfer and ADL assistance;

* Repositioning while in bed and air mattress use; and

* Wound care, soiled/dislodged dressings and staff responsibilities.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were consistently implemented was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (ED) and Staff 24 (Regional Director of Memory Care) on 09/27/23. The staff acknowledged the findings.

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

1. What actions will be taken to correct the rule violation for each example/resident

a. Resident #13 chart, assessment and service plan will be reviewed by the RN and updates made to reflect

*Safety Interventions, including staff instruction.

*Repeated invasion of others personal space including staff intervention.

*Removing food and drink items, including staff instruction

*Toileting schedule and assistance with incontinence care needs, including staff instruction.

*Agitation and refusals of care, including staff instruction.

*Ambulation assistance, including staff instructions

*Resident to resident aggression/altercations and interventions/activities to utilize, including staff instruction.

b. Resident #15 chart, assessment, and service plan will be reviewed and updated by the RN and updates made to reflect the following:

* Fall mat including staff instruction

*Specific assistance requred for transfers and ADL assistance, including staff instruction

*Repositioning needs while in bed and air mattress use, including staff instruction

*Wound care needs, including staff instruction for soiled or dislodged dressings and staff responsiblities.

c. All current resident service plans will be reviewed for content, specific instruction, and updates made where appropriate.

2. How will the system be corrected so this violation will not happen again?

a. RN will conduct an assessment of each resident prior to service plan updates and ensure all needs are reflected and staff instructions are included and appropriate for each service plan.

b. RN will review all service plans in collaboration with the MCPM, to include accurate content and specific staff instruction on all elements of assessment/service plan.

c. Executive Director and MCPM Administator will review all service plan updates for content before signing service plan.

3. How often will the area needing correction be evaluated?

a. Each service plan update will be reviewed by the MCPM Administrator and Executive Director for content prior to signing and give feedback to the RN as needed prior to signing.  This includes preadmission, admission, 30 day, quarterly and change of condition assessments/service plans.

4. Who will be responsible to see that the corrections are completed/monitored?

a. MCPM Administrator and Executive Director during  review of each service plan for content and specific instruction. This will include preadmission, admission, 30 day, quarterly and change of condition service plans.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes of condition were evaluated, specific resident interventions determined and documented, and the condition monitored with weekly progress noted until resolved for 4 of 5 sampled residents (#s 1, 3, 4 and 5) who experienced short term changes of condition in the area of resident-to-resident physical altercations and falls. Residents 1 had repeated physical altercations which resulted in skin injuries, increased pain and an emergency department (ED) visit. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia and agitation. Resident 1 required a wheelchair for mobility.

Observation of the resident from 09/28/22 to 09/30/22 showed the resident had bruising and complained of pain on his/her back and bottom.

Resident 1 experienced nine resident to resident altercations, some resulting in injury, between 05/23/22 and 09/22/22.

* Facility documentation noted resident to resident altercations without injury on 05/23/22, 05/26/22, 06/29/22, 06/18/21 and 09/03/22.

* On 07/16/22, resident to resident altercation resulted in a fall, skin cut and bruising;

* On 08/30/22 resident to resident altercation resulted in a fall and ED visit due to complaint of pain;

* On 09/03/22 resident to resident altercation resulted in a fall and ED visit due to increase pain; and

* On 09/22/22 resident to resident altercation resulted in a skin tear.

A 03/15/22 service plan revealed the following:

* The resident had behaviors including irritability and inappropriate or disruptive behaviors which interfered with daily functioning; and

* When the resident raised his/her voice or yelled at staff or other residents, staff would re-direct the resident and staff would have a meaningful one on one conversation.

Progress notes from 06/28/22 to 09/28/22, physician communication notes, incident reports from 05/2022 to 09/2022 and confirmed APS reports from 05/26/22 to 09/06/22 indicated the following:

* On 05/23/22 staff documented on the facility incident report that Resident 1 was involved in a resident-to-resident altercation and the resident had been verbally aggressive and threatening to other residents;

* On 05/26/22 staff documented Resident 1 hit another resident's arm in the hallway; and

* On 06/18/22 staff documented Resident 1 was involved in a resident-to-resident altercation. There was no incident report to review the circumstance of the incident including location of the altercation, who was involved in the incident or any physical injury resulting from the altercation.

The facilities interventions included the residents were separated and were placed on alert charting.

There was no documented evidence the facility thoroughly reviewed the incidents to determine the circumstance of the incidents or developed interventions to prevent future altercations.

The resident had continued involved resident-to-resident physical altercations some of which resulted in skin injuries and an ED visit on two occassions:

* 07/16/22 staff documented Resident 6 entered Resident 1's room. Resident 6 and Resident 1 came out of the room and Resident 1 pointed at Resident 6 and stated s/he "beat me up, kicked me" "look at my leg." Staff further documented Resident 1 stated s/he had fallen after s/he was hit which resulted in a small cut to the right side of Resident 1's eye, a bruise to his/her shin and a cut to the inner side of his/her lip." Staff documented Resident 1 "has been scared that [s/he] is going to beat [him/her] up again and keeps stating [s/he]'s scared." Staff documented a plan to place a "DO NOT ENTER" sign on the door and requested a behavioral therapist.

There was no documented evidence the plan was communicated to staff. During the survey, the resident's room was observed and there was no sign on the door.

* 09/01/22 staff documented on the confirmation of the APS report that on 08/30/22, Resident 7 entered Resident 1's room. Staff found Resident 1 on the floor, next to his/her bed and Resident 1 stated Resident 7 hit him/her hard and hurt his/her arm. Resident 1 was sent to the ER due to his/her right arm pain. On 08/31/22 Resident 1's Interim Service Plan (ISP) indicated s/he was sent to the ER for increased pain on the right shoulder and right rib area.

There was no documented evidence the physical altercations had been evaluated or interventions developed to help prevent future altercations.

* 09/03/22 staff documented on an incident report that Resident 9 entered Resident 1's room in the morning which resulted in a resident-to-resident altercation. Resident 1 stated Resident 9 pushed Resident 1's stomach;

* 09/03/22 staff documented on an incident report that in the afternoon, Resident 8 smacked Resident 1's leg;

* 09/21/22 RN documented on the facility "Key evaluation" that Resident 1 had a private room with a key to keep other residents out of the room. There was no documented evidence the information was communicated with staff; and

* 09/22/22 staff documented the resident was involved in a resident-to-resident altercation in Resident 1's room and that Resident 1 stated Resident 11 "pushed me". Resident 1 was sitting on the floor next to the bed and was " ...bleeding ...", had a " ...skin tear on [left] elbow and knuckles and a gash above [left] eye ..." Resident 1 was sent to the ED for increased pain on the left hip area.

There was no documented evidence the resident's condition, including resident-to-resident physical altercations were evaluated and interventions determined to prevent further incidents.

The resident experienced nine resident-to-resident altercations between 05/2022 and 09/2022 and some resulted in physical injuries including a skin tear, bruises, pain or discomfort. It was not evident the facility thoroughly reviewed each incident in order to determine if service planned interventions were followed or developed and evaluated for effectiveness.

The facility's failure to evaluate the incidents, monitor interventions for effectiveness, or develop new interventions if previous interventions were found to be ineffective placed Resident 1 and other residents at risk for continued altercations and potential injury.

On 09/30/22, the above findings were reviewed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director). They acknowledged the findings.

2. Resident 3 was admitted to the facility in 02/2020 with a diagnosis including dementia.

Observations, interviews with staff and review of Resident 3's clinical records including incident reports, service plans, interim service plans and progress notes dated 06/27/22 - 09/27/22, revealed the following:

Resident 3's service plan, dated 02/14/22, indicated Resident 3 displayed impaired cognition, had a history of "violent" behaviors and displayed behaviors of wandering, aggression, anxiety and depression which interfered with the resident's daily functioning. Behavioral interventions included staff to provide 1:1 activity or conversation, redirection to a quiet environment, food, drink or a cigarette.

a. Resident 3 was involved in the following physical altercation with other residents:

* 06/29/22- Resident 3 wandered into Resident 1's room and both residents stated they were hit by the other resident; and

* 08/16/22- Resident 2 pulled Resident 3's hair and squeezed Resident 3's arm leaving slight redness on the back of his/her arm.

There was no documented evidence the facility developed or monitored new resident specific interventions related to the resident's behaviors.

b. Resident 3 was at risk for falls, used a walker for ambulation, required staff to provide supervision to ensure stable chair placement when the resident sat down and staff were to ensure Resident 3 had his/her walker with him/her at all times.

Resident 3 experienced the following unwitnessed falls:

* An incident report, dated 06/05/22, indicated staff found Resident 3 on his/her back on a fall mat on the floor of his/her room. The resident was sent to the ER for further evaluation of back pain. The interim service plan, dated 06/06/22, did not provide new resident specific interventions to address the resident's continued fall risk and there was no documented evidence the facility had monitored the effectiveness of previous fall interventions; and

* An incident report, dated 08/09/22, indicated staff found Resident 3 on the floor of his/her room. No injury was noted. There was no documented evidence the facility developed or monitored new resident specific interventions related to Resident 3's fall risk.

The need to ensure the facility evaluated changes of condition to determine resident specific interventions and monitor previous interventions for effectiveness, was discussed with Staff 1 (MCC Program Manger) on 09/30/22. She acknowledged the findings.  

3. Resident 4 was admitted to the facility in 07/2020 with diagnoses including dementia.

Interviews with staff and review of Resident 4's clinical records including incident reports, service plans, interim service plans and progress notes dated 04/31/22 - 09/27/22, revealed the following:

Review of Resident 4's service plans dated 05/04/22 and 08/04/22, indicated the resident was oriented to self and was able to make needs known, would frequently displayed episodes of distressing hallucinations and would occasionally wake up in the middle of the night with confusion.

The resident had a history of and was at risk for falls, used a walker and required minimal assistance from staff for most ADLs. Fall interventions included placing a fall mat next to his/her bed, using a non-skid mat on his/her recliner, directing staff to check on the resident two to three times per shift during the day and two times at night, encourage the resident to lock breaks on his/her walker, ensuring pathways were free from clutter and ensuring adequate room lighting.  

* On 05/31/22 at 9:30 pm, staff found Resident 4 sitting on the floor next to his/her bed. The resident stated s/he scooted onto the floor trying to get up. No injury was noted. An interim service plan, dated 05/31/22, instructed staff to "cue and remind resident to call for assistance with ADLs" and remind the resident to use walker or wheelchair. There was no documented evidence previous fall intervention had been monitored for effectiveness.

* On 06/02/22 at 10:15 pm, Resident 4 had been experiencing hallucinations of a man outside his/her window signaling for help and fell as staff was walking towards him/her to assist. Staff noted the resident had redness on his/her knee and complained of left shoulder pain. On 06/03/22 the resident was sent to the ER and was diagnosed with an impacted humeral neck fracture.

Interim service plans dated 06/02/22 and 06/03/22 did not provide new resident specific interventions related to fall prevention or hallucinations and there was no documented evidence previous fall interventions had been monitored for effectiveness.

* On 06/19/22 at 11:45 pm, staff found Resident 4 on the floor next to his/her bed. No injury was noted.

An interim service plan was developed to monitor for injury but did not provide any new resident specific interventions related to fall prevention. There was no documented evidence previous fall intervention had been monitored for effectiveness.

The need to ensure the facility evaluated changes of condition to determine resident specific interventions and monitor the change of condition, to include monitoring for effectiveness of interventions, was discussed with Staff 1 (MCC Program Manger) on 09/30/22. She acknowledged the findings.

4. Resident 5 was admitted to the memory care community 06/08/20 with diagnoses including dementia, hypertension and anxiety.

Interviews with staff and review of Resident 5's progress notes, dated 01/01/22 through 09/28/22, service plan dated 12/02/21, interim service plans, and incident reports indicated Resident 5 was involved in the following resident to resident altercations:

* 01/10/22 - Resident 5 was in a physical altercation with Resident 10 in the hallway;

* 02/14/22 - Resident 5 walked up behind Resident 10 in the television room, and "smacked [him/her] on the left cheek"; and

* On 09/05/22 - Progress notes stated Resident 5 was "yelling at other residents" in the dining room.

The following interim service plans were created to address the resident to resident altercations, but lacked resident-specific interventions and/or clear instructions to staff:

* 01/10/22- "Be sure when [Resident 5] and [Resident 10] are together, they need to be separated. Guide [Resident 5] to [his/her] room when [s/he] requests, so [he/she] doesn't get in wrong room";

* 02/07/22- "Please watch and monitor resident behaviors. Watch for: cussing/yelling, crying/name calling, throwing food/drinks, hitting/touching other residents or staff members. Please notify RN or MA if any concerns"; and

* 02/14/22- "Resident was involved in a Res/Res where [s/he] smacked another resident- please monitor and report increased behaviors."

The lack of interventions and/or clear instructions to staff potentially contributed to the reoccurrence of negative behaviors and resident to resident altercations. This placed residents at risk for harm.

On 09/28/22 the need to develop and document resident-specific interventions, provide clear instructions to staff, and monitor the interventions for effectiveness was discussed with Staff 1 (MCC Program Manager). No further information was provided.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring.

1. What actions will be taken to correct the rule violation for each example/resident?

a. Resident 1, 3, 4, 5 chart, service plan and EMR will be reviewed by the RN for behavior concerns.  

b. Behavior mapping and a behavior strategy plan will be put in place for all residents with behaviors and the results communicated with staff, their physician and family.

c. Service plans for all residents will be reviewed by the RN/Administrator/RDMC for content and updated to reflect accurate care needs, instruction and interventions and will be reviewed with staff.

2. How will the system be corrected so this violation will not happen again?

a. RN will attend the Role of the RN class

b. All care staff will be trained by the RDMC on identifying change of condition, protocols for reporting changes and putting ISP's in place with monitoring for effectiveness of interventions

c. RN, Administrator and Executive Director will have weekly one on one meetings to discuss and review residents at risk, change of conditions and coordination of care and review weekly nursing documentation regarding changes until basline is reached.

d. All residents with change of condition will be discussed in SMART meeting to ensure all required COC documentation has been completed.

e. All residents with change of condition will be placed on alert charting for ongoing monitoring and an ISP will be put in place for care staff to review at the beginning of their shift until the RN has evaluated the change and updated the service plan to reflect the new needs or resident returns to baseline.  ISP's are reviewed daily during SMART meeting.

f. A white board will be installed in the RN office to track change of conditions.  HIPPA will be maintained.

3. How often will the area needing correction be evaluated?

a. Weekly during RN, Administrator, Executive Director one on one meetings.

4. Who will be responsible to see that the corrections are completed/monitored.

a. Administrator during weekly one on one meetings.

b. Administrator during daily SMART meetings Monday through Friday.

Based on observation, interview and record review it was determined the facility failed to ensure incidents were investigated, evaluated effectiveness of current interventions, determined additional interventions as indicated and monitored progress weekly through resolution for 3 of 4 sampled residents (#s 1, 13 and 15) reviewed for changes in condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 13 was admitted to the facility in 11/2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's service plan dated 09/01/23 and progress notes dated 06/29/23 to 09/25/23 were completed.

a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Emergency room visit;

* Medication changes;

* Resident to resident altercations;

* Injury and non-injury falls; and

* Bruising to both arms.

b. Staff indicated the resident had a decline in condition and required full assistance for all care. The resident had poor safety awareness and wandered throughout the facility. The resident was difficult to redirect and had no awareness of others personal space.

* An incident report dated 07/01/23, indicated the resident had a witnessed fall in the common area. The resident landed on his/her bottom and hit their head on the corner of the wall. The resident had no complaints of pain or visible injuries.

* An incident report dated 08/29/23, indicated the resident was found seated on the floor in the common area. The resident had been ill for last few days. The resident had no visible injuries.

* An incident report dated 08/31/23, indicated the resident was found on the floor in the common area. Staff were nearby but did not see the resident fall. The resident had no visible injuries. The resident was assisted to bed and was still showing a decline with a hospice admission pending.

There was no documentation in the resident's record the facility had completed thorough investigations of the incidents and potential injuries to determine the cause, minimize reoccurrence, develop and implement interventions and to re-evaluate existing interventions for appropriateness and effectiveness.  

The resident was unable to answer any questions about his/her care or the falls.

In interview on 09/27/23, Staff 1 (Administrator), acknowledged the investigation of the incidents was not complete. She had no further documentation regarding any interventions they attempted as a result of the falls.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (ED) and Staff 24 (Regional Director of Memory Care) on 09/27/23. The staff acknowledged the findings.  

2. Resident 15 was admitted to the facility in 05/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 09/01/23 and progress notes dated 06/29/23 to 09/25/23 were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Medication changes;

* Resident to resident altercations;

* Injury and non-injury falls; and

* Hallucinations.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (ED) and Staff 24 (Regional Director of Memory Care) on 09/27/23. The staff acknowledged the findings.

3. Resident 1 was admitted to the facility in 02/2022 with diagnoses including a history of falls and dementia.

The resident's charting notes dated 06/26/23 through 09/24/23, service plan, interim service plans (ISPs) and incident reports were reviewed. The following change of condition was identified.  

On 08/15/23, staff documented Resident 1 was involved in a resident-to-resident altercation which Resident 1 kicked another resident. There was no documented evidence the facility evaluated the resident, determined, or documented actions or interventions needed, or monitored the change of condition through resolution.

The need to ensure changes of condition were evaluated to determine what actions or interventions were needed, actions or interventions were communicated to staff on each shift, and conditions were monitored with progress noted at least weekly through resolution was discussed Staff 1 (Administrator), Staff 3 (ED) and Staff 24 (Regional Director of Memory Care) on 09/27/23. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. What action will be taken to correct the rule violation for each example/resident?

a. Resident #13 chart and service plan will be reviewed by the RN and a change of condition will be completed for  identified changes including:

*Emergency Room visits

*Medication Changes

*Resident to resident altercations, including new interventions

*Injury and non-injury falls

*Bruising to both arms

b. Resident #15 chart, assessment and service plan will be reviewed by the RN and a change of condition will be completed for identified changed including:

*Medication changes

*Resident to resident altercations, including new interventions

*Injury and non-injury falls

*Hallucinations

c. RN/MCPM will enlist the support of behavior health for any resident who requires additional intervention for behaviors.

d. Skin communication forms will be reviewed during SMART meetings to capture skin changes.

e. Emergency room discharge paperwork will be reviewed by the RN during SMART meeting to determine COC needs.

f. Medication changes are reviewed by the RN following the 3 bin system of orders review.  All medication changes will be addressed by the RN.

g. All incidents will be reviewed during SMART meetings and COC addressed by the RN during investigation of incidents.

2. How will the system be corrected so this violation will not happen again?

a. Change of Condition Interpretive Guidelines given to the RN for review and reference going forward.

b. RN will conduct a new assessment, enter chart notes and update service plan for any change of condition as described in the Interpretive guidelines in a timely manner according to regulation.

c. All resident changes will be discussed during SMART meetings.  SMART meeting minutes will be maintained by the Executive Director.

d. All residents with COC will be placed on alert charting and an ISP put in place until the RN can do a COC update.

e. RN and ED will discuss any resident changes during their weekly 1:1 meetings to ensure COC has occurred where appropriate.

f. Med Tech and Caregiver communications binders will be reviewed daily by the RN and MCPM to capture resident changes that are documented during communication.

g. All resident changes will be placed on Alert Charting and will have weekly notes by the RN until a new baseline is reached.

h. Chart notes will be reviewed weekly to ensure RN knowledge of changes documented by Med Techs.

3. How often will the area needing correction be evaluated.

a. All residents on alert charting will be reviewed daily.

b. All residents with an ISP will be reviewed daily to determine need for change of condition.

c. RN, MCPM and ED will review resident changes during weekly 1:1 meetings.

4. Who will be responsible to see that the corrections are completed/monitored?

a. ED, MCPM Administrator and RN during weekly 1:1 meetings.

b. ED, MCPM Administrator and RN during SMART meetings that occur Monday through Friday.  SMART meeting minutes are maintained by the ED.

Based on observation, interview and record review, it was determined the facility failed to ensure a Registered Nurse assessed, documented findings and developed interventions for 1 of 1 sampled resident (# 1) who experienced a significant change of condition in ADLs. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia.

Observations of the resident from 09/28/22 to 09/30/22 revealed the resident required a wheelchair for mobility.

During the acuity interview on 09/28/22, the resident was identified to have experienced a significant change of condition in multiple ADLs after a resident-to-resident altercation which resulted in a ground level fall and lower back pain.

During the survey, Staff 9 (Resident Aide) and Staff 14 (Resident Aide) reported the resident had an overall decline in ADL status after a resident-to-resident altercation which resulted in a fall on 09/22/22. Changes were noted in the following areas:

* The resident was independent in most ADLs prior to 09/22/22;

* Currently the resident required a 1-person assist with transfers, and ambulated with a wheelchair instead of walker; and

* Needed additional staff assistance with bladder and bowel management.

Those multiple changes represented a significant change of condition for the resident.

There was no RN assessment which included documented findings and a development of interventions for the significant change of condition.

The failure to conduct an RN assessment following a significant change in status was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director) on 09/30/22. They acknowledged the findings.

OAR 411-054-0045 (1) (a-f) (A) (C-F) Resdient Health Services

1. What actions will be taken to correct the rule violation for each example/resident?

a. Resident 1 service plan will be  reviewed and updated by the RN to accurately reflect residents needs including instruction to staff and interventions where applicable. Documentation of this review will be entered into the resident chart notes and reviewed with staff.

b. All current resident service plans will be reviewed by the RN/RDMC/Administrator for content and will be updated to reflect current and accurate residet needs.  This review will be documented in the resident chart notes and results will be reviewed with staff.

2. How will the system be corrected so this violation will not happen again?

a. RN will attend the Role of the RN class

b. RN will perform a new evaluation for any resident who has a change in condition and update the service plan to reflect the changes identified including specific direction to staff and interventions where appropriate.  These updates will be reviewed with staff.  RN will enter documentation of changes in resident chart notes.

c. All resident changes will be placed on alert charting and an ISP will be put in place.

d.  RN, Administrator and Executive Director will have weekly one on one meetings to review and discuss resident changes.

e. Care staff will be trained by the RDMC on use of the Service Plan Addendum tool to identify and report noted changes to resident needs.

3. How often will the area needing correction be evaluated?

a. All ISP's and alert charting will be reviewed during the daily SMART meeting Monday through Friday.

b. Weekly during the Administrator/RN/Executive Director one on one meetings.

4. Who will be responsible to see that the corrections are completed/monitored:

a. Administrator during weekly one on one meetings and daily SMART meetings.

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

Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia.

Resident 1's clinical record, dated 03/15/22 through 09/28/22, was reviewed during the survey and revealed the following:

* On 09/21/22, a progress note entered by Staff 2 (RN/MCC Wellness Director) indicated a behavioral specialist had visited Resident 1 and left interventions for staff.

* On 09/29/22 Staff 1 (MCC Program Manager) confirmed the interventions had not been communicated to staff or implemented.

On 09/30/22, the need to ensure on-going coordination of care was discussed with Staff 1 and Staff 2. Staff acknowledged the findings.

OAR 411-054-0045 (2) Resident Health Services: on and Off site Heath Services

1. What actions will be taken to correct the rule violation for each example/resident?

a. Resident 1 chart, service plan and behavior specialist communications will be reviewed by the RN and updates to the service plan will be made and reviewed with staff for new interventions.

b. ISP's will be put in place reflective of all communicaitons with changes from behavior specialist.

c. Alert charting will be put in place for all behavior changes.

2. How will the system be corrected so this violation will not happen again?

a. Communication forms will be completed by all On and Off site Health Service Providers.  Receptionist will remind providers when screening them for entry.

b. completed communication forms will be palced in the RN box for review.

c. RN will review all provider communicaiton documents, sign off on them and create ISP's for any recommendations to notify staff of changes.  

3. How often will the area needing correction be evaluated?

a. Communication forms will be reviewed daily during SMART meeting Monday through Friday.

4. Who will be responsible to see that the corrections are completed/monitored?

a. Administrator and RN will review communication forms with each SMART meeting and ensure ISP's have been put in place.

Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 1 of 4 sampled residents (# 1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia.

Review of Resident 1's clinical records revealed the following:

Resident 1 had a physician's order, dated 06/03/22, to administer Hydrocodone-Acetaminophen 5-325 mg every 8 hours as needed for pain.

Resident 1's 09/01/22 through 09/28/22 MAR revealed the medication was administered to the resident between 5 hours and 35 minutes apart on 09/25/22, not 8 hours between doses as prescribed.

On 09/30/22, the physician's orders and the MARs were reviewed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director). They acknowledged the findings.

OAR 411-054-0055 (1) (f-h) Systems: Treatment Orders

1. What actions will be taken to correct the rule violation for each example/resident?

a. Resident 1 orders will be reviewed by the RN and compared to the MAR entries for accuracy.

b. Physician order reconciliation will be printed for each resident, reviewed by the RN and sent to the physician for review and signature.

c. Parameter restrictions will be entered into QMAR by the RN/RDMC on each PRN medication that will prompt Med Tech of last administration and time permitted for next administration.

2. How will the system be corrected so this violation will not happen again?

a. Medication Technicians will be trained by the RN/RDMC on medication administration, PRN medications and how and when they can be administered.   All Med Techs will be required to pass a competency test following training. Documentation of this training and competency testing will be maintained with training records.

b. All new orders will be processed through the 3 bin system for triple check accuracy of orders to ensure each order is signed and entered into the MAR correctly with parameter restrictions on all PRN's.

3. How often will the area needing correction be evaluated?

a. Monthly the Administrator/RN will audit 10 MAR's for compliance.  

b. All new orders will go through a triple check system including the Med Tech, Administrator and RN for accuracy.

c. PRN administrations will be reviewed each day during SMART meetings Monday through Friday.

4. Who will be responsible to see that the corrections are completed/monitored?

a. RN and Administrator

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to orders for 2 of 3 sampled residents (#s 1 and 2) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 2's clinical records and MARs were reviewed during the survey and revealed that between 09/01/22 and 09/28/22 s/he refused the following medications and treatments;

* Metoprolol;

* Daily weights;

* Ashwaganda 500 mg;

* Centrum Silver;

* Finasteride 5mg;

* Vitamin B-12;

* Vitamin D3;

* Covid screening; and

* Slow release iron.

There was no documented evidence the facility notified the physician when the resident refused consent to their orders.

On 09/30/22 the failure to notify the physician of the documented medication refusals was reviewed with Staff 1 (MCC Program Director) and Staff 2 (RN). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia.

The 09/01/22 to 09/28/22 MAR and TAR and physician's orders were reviewed.

Facility staff documented on the MAR that the resident refused administration of the following medications:

* Vitamin B-1 100 mg on multiple occasions;

* Vitamin B-12 2500 mcg on 09/01/22, 09/02/22, 09/06/22, 09/15/22, 09/16/22, 09/19/22, 09/21/22 and 09/27/22; and

* Daily blood pressure check on 09/19/22.

There was no documented evidence the facility notified the physician of each refusal.

The need to notify the physician or other legally recognized prescriber each time a resident refused to consent to orders was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director) on 09/30/22. No additional information was received.

OAR 411-054-0055 (1) (j-k) Systems: Resident Right to Refuse

1. What actions will be taken to correct they rule violation for each example/resident?

a. Resident 1 and 2 MAR will be reviewed by the RN/RDMC and notification to the physician will be made of all medication refusals.

b. All current residents MARs will be reviewed by the RN/RDMC and notification to the respective physicians will be made of all medication refusals.

2. How will the system be corrected so this violation will not happen again?

a. Medication Technicians will be trained by the RN/RDMC on managing refusals of medications and strategies.

b. Every order refusal will be documented on the Medication Refusal Notification form and will be faxed to the provider office the same day. Documentation of this communication will be maintained in the resident record.

c. Medication refusal notifications will be placed in the RN bin for the RN to review.

d. RN will discuss refusals with resident and family to determine why the resident is refusing and attempt to find a solution.

e. Residents refusing medications will be placed on alert charting for monitoring. Alert charting will be reviewed daily during the SMART meeting, Monday through Friday.

3. How often will the area needing correction be evaluated?

a. Medication refusals will be reviewed daily during SMART meetings Monday through Friday.

b. Medication refusals will be reviewed by the Executive Director, Administrator and RN during weekly one on one meetings.

4. Who will be responsible to see that the corrections are completed/monitored?

a. Administrator during SMART meetings and weekly one on one meetings.

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

1. Resident 3 was admitted to the facility in 02/2020 with diagnoses including dementia.

Review of the resident's 09/01/22 through 09/28/22 MAR and physician's orders revealed the following:

Resident 3 was prescribed three medications to treat anxiety;

* Lorazepam 1mg 1 tab 3 times a day;

* Lorazepam 0.5mg 1 tab every 8 hours PRN; and

* CPS ABH [a compound of Ativan/Lorazepam (anti-anxiety medication), Benadryl (anti-histamine medication), Haldol (anti-psychotic medication)] 1mg Gel - apply 1mg every 6 hours PRN.

The MAR did not include medication specific instructions or parameters to provide direction to staff as to when each medication could be safely administered in relation to the others.

The need to ensure the MAR included medication specific instruction and parameters for PRN medications was discussed with Staff 1 (MCC Program Manager) on 09/30/22. She acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

1. What actions will be taken to correct the rule violation for each example/resident?

a. Resident 3 MAR will be reviewed by the RN for accuracy and complete medication administration instructions including parameter instructions where indicated.

b. All current residents MARs will be reviewd by the RN/RDMC for accuracy and complete medication administration instructions including parameter instructions where indicated.  

2. How will the system be corrected so this violation will not happen again?

a. Medication Technicians will be trained by the RN/RDMC on entering, reviewing and approving order entries.

b. All new orders will be processed though the 3 bin system which requires 3 reviews of each order by the Med Tech, Administrator and RN.  These bins are checked and contents processed daily.

c. RN during their review will ensure all instructions are accurate and parameters are specific including instructions for outside of parameter actions.

3. How often will the area needing correction be evaluated?

a. Daily the Med Tech/Administrator/RN will process all new orders in their bin for accuracy and instruction content.

4. Who will be responsible to see that the corrections are completed/monitored?

a. RN during her final check of each order.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use and documented instructions to caregivers on the correct use and precautions of the device for 1 of 1 sampled resident (#4) who had side rails on their bed. Findings include, but are not limited to:

1.  Resident 4 was admitted to the facility in 07/2020 with diagnoses including a history of dementia.  

The Interim Service Plan (ISP), dated 06/10/22, instructed CGs to cover the bed rail with a pillowcase and to ensure the rail and the mattress were always touching. The current service plan available to staff, dated 08/04/22, failed to document the correct use and precautions related to the side rails.

Observations during the survey on 09/29/22 revealed Resident 4 had a hospital bed. Bilateral side rails were observed to be loose, in the raised position and not covered by a pillowcase.

During interviews on 09/29/22, Staff 7 (Resident Assistant) and Staff 8 (Med Aide/Resident Assistant) were unable to verbalize resident specific safety recommendations regarding side rails.

There was no documented evidence an assessment by an RN, PT or OT was completed.

The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT or OT and completion of all required elements was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN-MCC Wellness Director) on 09/30/22. They acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

1. What actions will be taken to correct the rule violation for each example/resident?

a. Resident 4 will have a complete evaluation by the RN to assess the need for siderails.

b. Resident 4 siderails, if deemed necessary, will be evaluated for safety and stability.

c. An assistive device with restraining properties evaluation form will be completed by the RN to determine all elements are in place including safety guidelines.

d. The assistive device with restraining properties evaluation will be updated quarterly and upon COC.

e. An audit of all residents will be conducted by the RN/RDMC to identify any assistive devices with restraining properties.  

f. All identified assistive devices will have an assistive devices with restraining properties evaluation completed and added to their resident record.  These will be updated quarterly and upon COC.

g. All service plans for residents identified as having assistive devices with restraining properties will be updated to include usage instructions, safety instructions and device monitoring instructions.

h. Where applicable, in house PT/OT will evaluate device and need for use.

2. How will the system be corrected so this violation will not happen again?

a. All care staff will be trained by the RN/RDMC on assistive devices with restraining properties, indications,  uses, safety considerations for each one, interventions and monitoring of devices. Documentation of this training will be maintained with training records.  

b. Any new admnissions who require use of an assistive device with restraining properties will be evaluated for need of device and have an assistive device with restraining properties evaluation completed and added to the medical record.  This evaluatio will be udpated quarterly and with any COC.

c. In house PT/OT will evaluate device need and safety when applicable.

3. How often will the area needing correction be evaluated?

a. Quarterly during each residents quarterly service plan review and ancilliary evaluation updates.

4. Who will be responsible to see that the corrections are completed/monitored?

a.  Administrator will monitor assistive devices with restraining properties weekly during ED/RN/Administrator one on one meetings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 10, 11 and 12) completed all required training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 09/29/22 with Staff 5 (Business Office Manager). There was no documented evidence Staff 10 Resident Assistant (RA), Staff 11 (RA) and Staff 12 (RA), hired 08/10/22, 06/08/22 and 07/07/22 completed training in the area of abdominal thrust and First Aid.

The need to ensure staff completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director) on 09/30/22. They acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within

30 days: Direct Care Staff

1. What actions will be taken to correct the rule violation or each example/resident are as follows: First Aid and Abdominal Thrust documented training done for all staff to include staff 10,11, and 12.

2.How will the system be corrected so this violaton will not happen again are as follows:

 a. Business office manager will utilize training tracker for all staff during new hire process to track and audit compliance.

 b. BOM will coordinate with MC Administrator once training has been completed ,with MC Admin verifying on tracker PRIOR to employee moving forward

 c. audit of all employee training records completed

3. How often will the area needing correction be evaluated are as follows:

 a. Daily when working for each new hire until process is complete

4. Who will responsible to see that the corrections are being completed/monitored are as follows:

 a. Daily when working by BOM or designee

 b. Daily check in's by MC Administrator.  

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

Fire and life safety records, reviewed between 03/2022 and 08/2022, revealed the following:

1. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas:

* The escape route used;

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

* Evacuation time-period needed; and

* The number of occupants evacuated.

2. Fire and life safety instruction was not consistently provided to staff on alternate months.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (MCC Program Manager) on 09/30/22. She acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life

Safety: Safety

1. What actions will be taken to correct the rule violation for each axample/resident are as follows:

a. Training of Fire and Life Safety provided to ED, ED   Designee, and Maintenance Director by RDO.

b. Review of Fire Drill form to ensure understanding of the following areas was completed:

* The escape route used;

* Problems encountered, comments

relating to residents who resisted or

failed to participate in the drills;

* Evacuation time-period needed; and

* The number of occupants evacuated.

c. Fire drill with full evacutaion has been completed.

2. How will the system be corrected so this violation will not happen again are as follows:

a. Tels system will be followed for scheduled drills with use of appropriate form

b. Training calendar made to track assignement of staff training on alternate months.

3. How often will the area needing correction be evaluated are as follows:

a. Monthly per maintenance program (Tels) for drills

b. Every other month per staff training calendar

4. Who will responsible to see that the corrections are being completed/monitored are as follows:

 a. Monthly by Maintenance Director or designee

 b. Every other month by Maintenance Director, MC Admin or Designee  

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records, reviewed between 05/2023 and 09/2023, revealed the following:

The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas:

* The escape route used;

* Evidence of alternate routes used;

* Evacuation time-period needed; and

* The number of occupants evacuated.

Additionally, the records reviewed did not show fire drills were conducted on alternating shifts.

The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating shifts was discussed with Staff 3 (ED) and Staff 24 (Regional Director of Memory Care) on 09/27/23. The staff acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life

Safety: Safety

1. What actions will be taken to correct the rule violation for each example is as follows:

 a. Education has been provided to MC Adminsitrator, ED, and Maintenance Director on OFC Fire Code to include the required elements that were missing; relocate or evacuate residents during fire drills; to ensure documentation in the following areas:

* The escape route used;

* Evidence of alternate routes used;

* Evacuation time-period needed; and

* The number of occupants evacuated.

 b. Additionally, reviewed regulation for drills completed on alternating shifts

2. How will the system be corrected so this violation will not happen again are as follows:

 a. MC Administrator and or ED will review Fire Drill documentation for accuracy to OAR and OFC for required elements

 b. ED and or Maintenance Director will send/or upload to Tels the Fire Drill form for review from Director of Operation for accuracy

 c. Maintenance program Tels checked for accuracy and scheduling of drills on alternating shifts

3. How often will the area needing correction be evaluated is as follows:

 a. Every other month following drill schedule

4. Who will be responsible to see that the corrections are completed/monitored is as follows:

 a. Maintenance Director

 b. MC Administrator

 c. Executive Director

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction for residents at least annually in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

In an interview on 09/27/22 with Staff 1 (MCC Program Manager), it was determined the facility lacked documented evidence residents were being instructed on general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire at least annually.

The need to provide and document annual fire and life safety instruction for residents was reviewed with Staff 1. She acknowledged findings.

OAR 411-054-0090 (5) Fire and Life

Safety: Training for Residents

1. What actions will be taken to correct the rule violation for each axample/resident are as follows:

a. Training of Fire and Life Safety provided to ED, ED   Designee, and Maintenance Director by RDO.

b. Review of Fire and Life Safety annual Resident Acknowledgement form and requirement to meet the following requirements: residents were being instructed on general fire and life safety procedures,

evacuation methods, responsibilities and

designated meeting places inside or

outside the building in the event of an

actual fire at least annually

c. Fire drill with full evacutaion has been completed.

2. How will the system be corrected so this violation will not happen again are as follows:

a.  Resident calendar made to track resident annual training based off move in date.

3. How often will the area needing correction be evaluated are as follows:

a. Monthly per resident education calendar

4. Who will responsible to see that the corrections are being completed/monitored are as follows:

 a. Monthly by Maintenance Director or designee

b. Monthly by MC Administrtor

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

Refer to C 260, C 270, C 420, C 513,  Z 142, Z 155 and  Z 162.

OAR 411-054-0105 (2-4) Inspections

and Investigation: Insp Interval

Refer to C 260, C 270, C 420, C 513, Z

142, Z 155 and Z 162

Based on observation and interview, it was determined the facility failed to ensure all chemicals were in a locked storage unit, and failed to ensure outdoor lighting in the secured courtyard was equal to a minimum of five foot candles.  Findings include, but are not limited to:

On 09/29/22 at 8:40 am the facility's interior environment was toured. The following deficiency were identified:

There was an unlocked cabinet in the MCC's kitchenette, containing cleaning supplies and chemicals. The area was readily accessible to residents, and posed a safety risk.

On 09/29/22 at 11:05 pm the MCC's outdoor courtyard was toured. During the observation, only a few small dim yard lights located around the courtyard's perimeter and pathways were present, and several areas along the pathway were dark with no lighting.

On 09/30/22 a follow-up tour of the environment was performed with Staff 15 (Maintenance Director), to review the lack of  sufficient light in the courtyard, and the unlocked cabinet with chemicals. He acknowledged the findings.

On 09/30/22 the need to ensure the environment was kept free of safety hazards was discussed with Staff 1 (MCC Program Manager). She acknowledged the findings.

OAR 411-054-0200 (3) General Building

Exterior

1. What actions will be taken to correct the rule violation for each example/resident are as follows:

a. cabinet in the MCC's kitchenette, containing cleaning supplies and chemicals is now locked

b. lighting in the courtyard changed out and additional added

2. How will the system be corrected so this violation will not happen again is as follows:

a. training provided to all staff on chemical use and locking storge

b. audit tool for use in identifying lighting that is not sufficient or chemical cabinet not locked.

3. How often will the area needing correction be evaluated is as follows:

a. daily when working by Administrator or designee for chemical cabinet checks

b. weekly for lighting

4. Who will be reponsible to see that the corrections are completed/monitored are as follows:

a. MC Adminstrator

b. Maintenance Director for lighting

Based on observations 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:

On 09/29/22 at 8:40 am the facility's interior environment was toured. The following deficiencies were identified:

* Multiple wood door jambs showed scrapes, chips and gouges;

* Several baseboards contained scratches and marks, or were separated from walls;

* Numerous overhead lights in hallways were dim or burned out;

* Laminate countertop in common area showed damage and pieces missing;

* Wood window ledges in dining room showed many scrapes and gouges; and

* Numerous stains were visible on carpet throughout the building.

On 09/29/22 a follow-up tour of the interior environment was performed with Staff 15 (Maintenance Director) to report the issues listed. He acknowledged the findings.

On 09/30/22 the need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (MCC Program Manager). She acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls,

Elevators, Odors

1. What actions will be taken to correct the rule violation for each example/resident are as follows;

a. Repair to the following:

* wood door jambs for

scrapes, chips and gouges;

* baseboards for scratches and marks, or were separated from walls;

* lights in hallways replaced;

* Laminate countertop in common area

replaced;

* Wood window ledges in dining room

repaired of scrapes and gouges; and

* stains on carpet

throughout the building cleaned.

2. How will the system be corrected so this violation will not happen again are as follows:

a. Daily wak through with audit tool developed

b. Training provided to housekeeping and Maintence Director on the audit tool and OAR

3. How often will the area needing corrected be evaluated is as follows:

a. Daily when working by Maintenance Director

b. Daily by Housekeeping per cleaning schedule

c. Weekly by Administrtor or Designee

4.  Who will be responsible to see that the corrections are completed/monitored are as follows:

a. Maintenance Director

b. Housekeeping

c. Administrator or Designee  

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair and that the facility was free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:

Observations of the MCC on 09/25/23 through 09/27/23 revealed the following:

* Pervasive strong urine odors throughout the MCC, including resident rooms. Room 150 had an intense pungent urine odor that did not dissipate;

* Multiple pieces of furniture throughout the MCC had spills, stains, and odors;  

* There were dark carpet stains throughout the MCC, including resident rooms;

* The baseboards along the perimeter of the dining room and the community room had extensive damage. Baseboards were cracked, gouged, and splintered;

* The floor transition strip in the dining room was gapping and buckling; and

* There were numerous areas of chipped paint and scuffs on the walls in the dining room.

 The areas above were shown to and discussed with Staff 1 ( Administrator), Staff 3 (ED) and Staff 24 ( Regional Director of Memory Care) on 09/27/23. The findings were acknowledged.

OAR 411-054-0200 (4)(d-i) Doors, Walls,

Elevators, Odors

1. What actions will be taken to correct each rule violation is as follows:

* Pervasive strong urine odors

throughout the MCC, including resident

rooms. Room 150 had an intense

pungent urine odor that did not dissipate

 a.  Resident apt cleaned and flooring is being replaced

* Multiple pieces of furniture throughout

the MCC had spills, stains, and odors

 b. Furniture throughout the MC has been cleaned, and or replaced/removed from community.

* There were dark carpet stains

throughout the MCC, including resident

rooms

 c. Carpet stains have been shampooed in common areas as well as resident rooms

* The baseboards along the perimeter of

the dining room and the community room

had extensive damage. Baseboards were cracked, gouged, and splintered

 d. Baseboards were repaired and or replaced in perimeter of dining room

* The floor transition strip in the dining

room was gapping and buckling

 e. transition strip repaired and or replaced in dining room

* There were numerous areas of chipped

paint and scuffs on the walls in the dining

room

 f. areas of chipped paint and scuffs were re-painted

2. How will the system be corrected so this violation will not happen again are as follows:

 a. MC Administrator and Maintenance Director/and or designee will complete daily, when working, walk throughs of the community to coordinate repairs, painting, extra housekeping, carpet shampooing

3. How often will the area needing correction be evaluated is as follows:

 a. Daily when working

4. Who will be responsible to see that corrections are completed/monitored are as follows:

 a. MC Administrator

 b. Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures were maintained within a range of 110 -120 degrees Fahrenheit. Findings include, but are not limited to:

On 09/29/22 hot water temperatures were checked in the MCC's following locations:

            Room 157- 123.4 Fahrenheit (F)

            1st floor restroom- 119.2 F

            Kitchenette sink- 121.6 F

On 09/30/22 at 10:30 am hot water temperatures were checked in the following locations:

            Room 154- 122.8 F

            Room 157- 123.4 F

            Restroom- 124.1 F

In an interview on 09/30/22 Staff 15 (Maintenance Director) was informed the water temperatures were above the required range. Staff 15 stated he would attempt to adjust the water system accordingly.

On 09/30/22 at 3:00 pm, Staff 15 stated to the surveyor that the water temperatures had been adjusted, and were currently within the required range. Staff 15 accompanied the surveyor to check water temperatures in the following locations:

             Room 154- 112.4 F

             Room 159- 114.2 F

             Kitchenette sink- 113.6 F

On 09/30/22 the need to maintain hot water temperatures within a range of 110-120 degrees Fahrenheit was discussed with Staff 1 (MCC program Manager). She acknowledged the findings.

OAR 411-054-0200 (9) Plumbing

Systems

1. What actions will be taken to correct the rule violation for each example/resident is as follows:

a.Room 154- 112.4 F

Room 159- 114.2 F

Kitchenette sink- 113.6 F adjusted on 09/30/22 to maintain water temperatures within a range of

110-120 degrees Fahrenheit

2. How will the system be corrected so this violation will not happen again are as follows:

a. Tels program followed for water temperatures with audit for recording completed

b. All areas/rooms water temperatures checked

3. How often will the area needing correction be evauated is as follows:

a. monthly

4. Who will be responsible to see that the corrections are completed/monitored is as follows:

a. Maintenance Director with Administrator oversite

Based on observation and interview, the facility failed to ensure resident room entrance doors were lockable. Findings include, but are not limited to:

Observations of the MCC on 09/25/23 through 09/27/23 showed 32 of the 35 resident rooms did not have locking door knobs on their apartments.

In an interview on 09/25/23 Staff 1 (Administrator) indicated the only rooms with locking door knobs were those residents who could manage a key and could unlock the door on their own.

In an interview on 09/26/23 Staff 3 (ED) indicated he was unaware all rooms should have the ability to lock.

The need to ensure all resident apartments had locking door knobs, residents were evaluated for their ability to use a key, and to ensure a key was provided for those residents who could operate the door lock was discussed with Staff 1, Staff 3 and Staff 24 (Regional Director of Memory Care) on 09/27/23. They acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door

Locks: Key Access

1. What actions will be taken to correct the rule violation for each example is as follows:

 a. 32 resident rooms door knobs were changed out to the correct knobs that have ability to lock with key access

 b. all residents have current lock/key assessment completed

2. How will the system be corrected so this violation will not happen again are as follows:

 a. door knobs will be checked during walk throughs for any damage and to esure all in working order

 b. residents will have key assessment per OAR

3. How often will the area needing correction be evaluated is as follows:

 a. Daily when working during walk throughs

 b. At each resident MI or quarterly with each assessment/SP review

4. Who will be responsible to see that corrections are completed/monitored is as follows:

 a. MC Administrator

 b. Maintenance Director

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 150, C 155, C 231, C 240, C 372, C 420, C 422, C 510, C 513 and C 545.

OAR 411-057-0140(2) Administration

Compliance

Refer to C 150, C 155, C 231, C 240, C

372, C 420, C 422, C 510, C 513 and C

545.

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 limited to:

Refer to C 420, C 455 and C 513.

OAR 411-057-0140(2) Administration

Compliance

Refer to C 420, C 455 and C 513

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 10, 11 and 12) had documentation of completed orientation, 1 of 3 sampled newly-hired direct care staff (# 10) completed pre-service dementia training prior to performing any job duties, and 3 of 3 sampled newly hired direct care staff (#s 10, 11 and 12) completed demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 5 (Business office manager) on 09/29/22 and revealed the following:

1. Staff 10 (Resident Assistant/RA) hired 08/10/22, Staff 11 (RA) hired 06/08/22 and Staff 12 (RA) hired 07/07/22, lacked documented evidence of having completed required orientation prior to performing any job duties.

2. Staff 10, lacked documented evidence of having completed pre-service dementia training prior to performing any job duties.

3. Staff 10, Staff 11 and Staff 12, lacked documented evidence of having completed competency demonstration in all required areas within 30 days of hire.  

The need to ensure newly hired staff completed all required orientation, pre-service dementia training and competency training prior to providing care and services independently was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director) on 09/30/22. They acknowledged the findings.

OAR 411-057-0155(1-6) Staff Training

Requirements

1. What actions will be taken to correct the rule violations for each example/resident is as follows:

a. Staff 10 (Resident Assistant/RA) hired

08/10/22, Staff 11 (RA) hired 06/08/22

and Staff 12 (RA) hired 07/07/22, completed with

documented evidence of having

required orientation on job duties.

b. Staff 10, completed with documented evidence

of having completed pre-service

dementia training

c. Staff 10, Staff 11 and Staff 12, completed with

documented evidence of having

competency demonstration in

all required areas within 30 days of hire.

d All staff training files audited

2. How will the system be corrected so this violation will not happen again are as follows:

a.Business office manager will utilize training tracker for all staff during new hire process to track and audit compliance.

 b. BOM will coordinate with administrator once training has been completed .Admin will verify on tracker.

 c. audit of all employee training records completed

3. How often will the area needing correction be evaluated are as follows:

 a. Weekly when working for each new hire until process is complete but before 30 days

4. Who will responsible to see that the corrections are being completed/monitored are as follows:

 a. Weekly when working by BOM or designee

 b. Weekly check in's by Administrator   

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 18, 20, 21, and 22) completed all required elements of pre-service orientation and dementia training. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 09/26/23.

a. There was no documented evidence Staff 18 (RA), Staff 20 (RA), Staff 21 (RA), or Staff 22 (RA), hired 07/10/23, 08/10/23, 08/29/23, and 07/19/23, respectively, completed one or more of the following pre-service orientation topics:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention; and

* Fire safety and emergency procedures.

b. There was no documented evidence Staff 18, Staff 20, Staff 21, or Staff 22 completed one or more of the following pre-service dementia trainings:

* Dementia disease process including progression, memory loss, and psychiatric and behavioral symptoms;

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach;

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

* 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.

The need to ensure all new hires completed the required pre-service orientation and dementia trainings within the required time frames was discussed with Staff 3 (ED) and Staff 24 (Regional Director of Memory Care) on 09/27/23. They acknowledged the findings.

OAR 411-057-0155(1-6) Staff Training

Requirements

1. What actions will be taken to correct the rule violations for each example is as follows:

 a. Staff 18 (RA), Staff 20 (RA), Staff 21

(RA), or Staff 22 (RA), hired 07/10/23,

08/10/23, 08/29/23, and 07/19/23 have all completed OCP Pre-service Orientation

 b. Staff 18, Staff 20, Staff 21, or Staff 22 have all  completed OCP pre-service dementia trainings

2. How will the system be corrected so this violation will not happen again are as follows:

 a. OCP will be utilized with all new hires for Pre-service Orientation

 b. OCP will be utilized for all Pre-service Dementia training

 c. Audit will be completed on all training records

3. The area needing corrected will be evaluated as follows:

 a. Daily (if applicable) with each new hire during on-boarding training process through completion

 b. A monthly audit will be completed by BOM with MC Admin to check complaince

 c. Daily check in, when working, with BOM from MC Admin on new hire process and training completion

4. Who will be responsible to see that corrections are completed/monitored is as follows:

 a. Business Office Manager

 b. MC Administrator or designee

 c. ED

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 290, C 303, C 305, C 310 and C 340.

OAR 411-057-0160(2b) Compliance with

Rules Health Care

Refer to C 252, C 260, C 270, C 280, C

290, C 303, C 305, C 310 and C 340.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with 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 and C 270.

OAR 411-057-0160(2b) Compliance with

Rules Health Care

Refer to C 260 and C 270

Based on observation, interview and record review, it was determined the facility failed to ensure behavioral symptoms, which negatively impacted the resident and others in the community, were evaluated and included in the service plan for 2 of 4 sampled residents (#s 1, and 5) whose behavioral issues were reviewed. Residents 1 experienced repeated physical altercations with other residents. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 02/2022 with diagnoses including dementia and agitation.

Resident 1's most recent service plan, dated 03/15/22, provided some information related to the resident's behaviors, however, it did not address the resident's behaviors such as physical altercations with other residents and effective resident specific interventions or approaches for staff to utilize for the behaviors.

The following behaviors were documented in the resident's clinical record:

* 06/02/22 - "...talked rudely...", threatening to hit staff and roommate;

* 06/20/22 - "...was rude to staff...", screaming and stated "beat them up" when other residents walked down on the hallway;

* 06/29/22 Placed an alert for resident-to-resident altercation and documented "hit" each other; and

* 07/17/22 Placed on alert for resident-to-resident altercation on 07/16/22. The resident had behaviors, threatening to hit and kick staff and other residents who walked down the hallway.

Resident progress notes, incident reports, and temporary service plans from 05/23/22 through 09/28/22 indicated the resident had at least nine documented incidents of physical resident-to-resident altercations on 05/23/22, 05/26/22, 06/18/22, 06/29/22, 07/16/22, 08/30/22, two instances on 09/03/22 and 09/22/22. Those incidents included physical aggression such as hitting other residents or being hit, pushed or kicked by other residents.

Temporary service plan interventions to address the behaviors included separating residents and monitoring. There was no documented evidence the facility had evaluated the resident's behaviors, including resident-to-resident physical altercations and physical aggression towards other residents, or updated the resident's service plan.

The facility's failure to evaluate and develop an individualized behavior plan to address Resident 1's behaviors resulted in continuation of the behaviors and put this resident and other residents at risk of physical and emotional abuse.

On 09/30/22, the need to ensure resident behavioral symptoms which negatively impacted the resident and others were evaluated and included on the service plan was discussed with Staff 1 (MCC Program Manager) and Staff 2 (RN/MCC Wellness Director). They acknowledged the findings.

3. Resident 5 was admitted to the memory care community 06/2020 with diagnoses including dementia, hypertension and anxiety.

Interviews with staff, and review of Resident 5's progress notes, dated 01/01/2022 through 09/28/22, behavior plan, dated 03/29/22, interim service plans, and incident reports indicated Resident 5 was involved in the following altercations:

* 01/10/22 - Resident 5 was in a physical altercation with another resident in the hallway;

* 02/14/22 - Resident 5 walked up behind another resident in the television room, and "smacked [him/her] on the left cheek"; and

* On 09/05/22 - Progress notes stated Resident 5 was "yelling at other residents" in the dining room.

Review of Resident 5's clinical records indicated the 03/29/22 behavior plan included several behavioral intervention such as, removing resident from a noisy environment and calmly reminding resident not to yell at other staff or residents, however, there was no evidence the behavioral plan had been reviewed or updated quarterly.

On 09/30/22 the need for quarterly updates of individualized service plans for behavioral symptoms which negatively impact the resident or others was discussed with Staff 1 (MCC Program Manager). She acknowledged the findings.

OAR 411-057-0160 (e Behavior

1. What action will be taken to correct the rule violation for each example/resident?

a. Resident 1 and 5 chart and service plan will be reviewed and updated to include identification of behaviors, interventions and instruction to staff for identifying and managing behaviors.

b. Request for referral to outside behavior services will be made where applicable.

c. Behavior mapping and behavior strategy plans will be put in place for all current residents who exhibit behaviors.  

2. How will the system be corrected so this violation will not happen again?

a. Care staff will be trained  by the RN/RDMC on behavior identification, interventions and approaches, prevention, documentation, management strategies and proactive approach.

b. Behavior mapping and strategy planning will be put in place anytime there is a new or worsening behavior or new onset of behaviors. These plans will be shared with families and providers where appropriate.

c. All care staff members will sign off on behavior plans to indicate understanding of plan.

d. Interventions will be placed in the QMAR for all PRN medications ordered for behavior management.

e. Service plans will be updated with behavior strategies, interventions and staff instructions.

3. How often will the area needing correction be evaluated?

a. All residents with behaviors will be discussed by the RN, Administrator and Executive Director during weekly one on one meetings.

b. Non pharmacologic interventions attached to PRN psychotropic medications will be reviewed daily during SMART meetings Monday through Friday.

4. Who will be responsible to see that the corrections are completed/monitored?

a. Administrator will be responsible to ensure all resident behaviors are discussed and addressed appropriately during weekly one on one meetings.