Mckenzie Manor Memory Care

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to ensure pureed textures were prepared in a manor to maintain nutritional status, proper palatability and safety, and to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service were made on 02/25/26 from 11:00 am through 12:45 pm revealed the following; a) Accumulation of, splatters, spills, drips, dust, black matter, food and other debris noted on the interior of blender base. b) The following areas/items were found needing repair: * Small openings around piping under dish machine allowing potential pest entry; and * Inadequate lighting in second dry storage. c) Nonstick sauté pan found with large scratches of protective/non stick coating removed. Green cutting board observed with multiple deep groves/burn marks in both sides of board. These cooking/food prep pieces of equipment were in need of repair or replacement. d) Multiple potentially hazardous food items were noted stored without open dates. Multiple items were found past seven days of opened/prepared date or past the posted manufacturer’s use-by date. Staff 2 (Dietary Manager) stated those items should have been discarded. e) A cook was observed to mechanicalize food product for puree texture. Surveyor reviewed the product and noted multiple chunks of different food particles. The overall texture of the food was not smooth as necessary for correctly pureed texture. Staff 2 confirmed the texture was not correct for puree. Staff were asked to continue with processing until correct texture was achieved. f) A cook was preparing pureed textures from left over meal items from previous days. Staff were not using current menu items for pureed textures. Staff were observed to puree a “turkey A-la King” with a prepared date of 02/17/26. This was day nine of the food product. Staff 2 acknowledged food items must be used by or discarded on day 7. Staff 2 verified that food product should have been discarded and not used. Staff 2 threw out the food item and a different item was used. It was another leftover food item. Staff were observed adding hot water to food product for pureeing liquid. This process diluted the flavor and nutritional status of the food product. Residents on pureed textures should be provided pureed textures of food products made fresh and similar to the daily posted menu, unless requested by the resident. g) Both cooks on duty were not able to discuss proper re-heat temperatures needed for leftovers. One cook stated the temperature he was looking for proper reheat was 140 degrees as it was “just corn.” They were not able to demonstrate the correct 165-degree reheat process. h) Multiple containers of left over items were observed in the refrigerators. Both cooks were asked to review the two-step cooling process. Neither cook was able to demonstrate the proper cooling time-temperature guidelines. i) Dietary staff member doing dishes did not have an effective hair restraint. j) Staff member was observed washing dirty dishes. The staff was observed to not clean or sanitize hands when going from the dirty task to handling clean dishes. k) Cook was observed to not properly clean and sanitize blending cup and blade while preparing pureed textures. The cook was observed to rinse the dishes. The cook did not change his gloves after handling dirty dishes and then rinsing the dishes. The cook was using visible wet and potentially contaminated gloves while continuing to prepare pureed foods. Staff 2 toured areas and observations with surveyor. Staff 2 acknowledged the areas needing correction. At 12:30 pm, all areas were reviewed with Staff 1 (ED) who acknowledged the concerns.

Staff 2 has led kitchen meeting to review SOD. (3/3) Proper puree techniques have been discussed and demonstrated. Handout from IDDSI training manual distributed."Two-step" cooling method reviewed and handout on rapid cooling distributed. Verbal quizes for kitchen staff on cooling temps and times done weekly by Staff 2. Personal & hand hygene discussed; hair must be covered with hair/beard net and hands must be washed/sanitized befor handling clean dishes. Review of proper glove/utensil use completed. Labeling system altered to include open and discard date. Blender has been replaced (3/5) and cleaning base has been added to cleaning log, completed 2x/day. Light in dry storage area installed (3/6). Maintenance has purchased and will install pipe collars under sink by 3/13. Saute pan has been discarded and replaced. Re-education given on "good pan stewardship". Deep groves have been sanded from cutting boards.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observations and interviews, 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 C240.

Refer to C240.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

Based on observation, interview and record review, conducted during a site visit on 08/28/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: A review of the facility's ABST and resident roster indicated the following: · All 38 residents were listed on the tool (26 MC and 12 SNC). · Resident 3 moved into the MC on 08/22/24 and did not have any care needs entered. · Resident 4 moved into the MC on 08/24/24 and did not have any care needs entered. · Resident 5 moved into the MC on 08/13/24 and did not have all care needs entered. A review of the staffing schedules for 08/13/24-08/27/24 indicated the following: · SNC indicated a one to four staffing ratio needed for day/swing shifts and one to six on Noc shift. · Facility was staffing per the SNC and ABST for the SNC side. · MC ABST indicated 4.14 staff needed for day shift, 3.9 needed for swing shift, and 1.12 for Noc shift. · Facility was not exceeding staffing per the ABST for the MC on dayshift on two separate days. Compliance Specialist observed the MC was staffed with three caregivers and one MT for day shift on 08/28/24. The SNC was staffed with four direct care staff for day shift. In an interview on 08/28/24, Staff 1 (Executive Director) and Staff 2 (Staffing Coordinator) stated the following: · They were not aware of any staffing concerns or needs missed. · They did not know they needed to look at the day with the highest staffing need and round up for the ABST, or that they needed to exceed the ABST to account for unscheduled needs. ·  If there was a call out in the SNC, we would send staff from the other side, however, would still be staffed at the minimum. On 08/28/24, findings were reviewed with and acknowledged by Staff 1. It was confirmed the facility failed to fully implement and update an ABST.

Based on interview and record review, it was determined the facility failed to ensure a move-in evaluation addressed all required elements for 1 of 1 sampled resident (#3) who was recently admitted to the facility.  Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2022.  Review of the resident's records indicated the move-in evaluation lacked the following elements: * Visits to health practitioner(s), ER, hospital, or nursing facility in the past year; * Personality, including how the person copes with change or challenging situations; * Recent losses; and * Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature. On 05/04/22 the need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (RN).  They acknowledged the findings.

1.Team will review with resident #3 past er/hospital/doctor visits in the last year, personality, recent losses and environmental factors that effect behaviors, and include in his service plan. 2.Management team has been inserviced on new PCC evaluation tool and will also include personality and environmental factors. 3.ED/DHS/RCC will review all preadmission evaluations to ensure they include past er/hospital/doctor vists in the last year, personality, recent losses and environmental factors that effect behaviors. 4.Person doing the evaluation and service plan team. (Ed/DHS/RCC or designee)

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident, for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed.  Findings include, but are not limited to: Resident 1, 2 and 3's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (RN) on 05/03/22. They acknowledged the findings.

1.Residents #1,#2,#3 care conference will be conducted with resident/family and management team. 2.Inservice management team on care conferences to be conducted quarterly and as needed. Designee will send out invites and current service plan to family, for date to review all together quarterly and as needed for change of condition. 3.Audit 2 random residents weekly to ensure service plan conference summary has been completed. Findings will be brought to monthly Qaulity assurance meeting for 2 months. 4.ED/DHS/RCC designee

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#1) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2021 with a diagnosis of dementia with behaviors. During the acuity interview on 05/02/22, the resident was identified as having recently fracture his/her hip and having it repaired and as being on hospice. The resident had a signed physician order for tramadol (a narcotic pain reliever) 50 mg one tablet every six hours as needed for severe pain. Review of the resident's 04/01/22 through 05/02/22 MARs and the Controlled Substances Log revealed the following: * On 04/09/22 there were two doses of tramadol signed as having been administered on the MAR, but only one dose signed out on the disposition log; * On 04/10/22 there was one dose of tramadol signed as having been given on the MAR, but two doses signed out on the disposition log; * On 04/13/22 there were no doses of tramadol signed as having been administered on the MAR, but one dose was signed out on the disposition log; * On 04/14/22 there was one dose of tramadol signed as having been given on the MAR, but two doses signed out on the disposition log; and * On 04/15/22 there were no doses of tramadol signed as having been administered on the MAR, but there was one dose of tramadol signed out on the disposition log. The number of tablets remaining on the medication card matched the number of tablets indicated in the disposition log. The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (RN), and Staff 7 (Resident Care Manager) on 05/04/22. They acknowledged the findings.

1.RN will fix medication administration record against Narcotic book for Tramadol in April for Resident #1 if possible, Or Progress note correct administration. 2.Inservice Medication technicians on proper narcotic administration on 6/2/2022. Implement Medication administration record against Narcotic book audits monthly. Request pharmacy training for narcotic record. Daily review of PRN narcotics given by, and missing medications. 3.Daily review of PRN narcotics given by, and missing medications, including narcotic against Medication administration record audit included in 24 hour review. 4.ED/DHS/RCC/Designee

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 1 of 3 sampled residents (# 2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in 08/2018 with diagnoses including diabetes and received insulin injections multiple times daily. Resident 2's MAR, physician orders, and progress notes, reviewed from 04/01/22 through 05/02/22, revealed the following: * Physician orders instructed staff to check Resident 2's blood glucose levels (CBG) four times daily, before each meal and at bedtime, and record the result.  On 04/16/22 Resident 2's CBGs were not checked as ordered. * Insulin Lispro orders instructed staff to inject two units subcutaneously three times a day before meals.  There were seven occasions in April when staff documented administration of three units of insulin instead of the two units that were ordered.  On 04/16/22 no Insulin Lispro was administered. * Lantus Solostar insulin orders instructed staff to inject 11 units subcutaneous daily at 5 p.m.  On 04/16/22 there was no scheduled Lantus Solostar insulin administered as ordered. * Insulin Lispro was ordered to be administered subcutaneously 10 minutes before each meal based on a sliding scale, determined by the resident's CBG.  On 04/11/22 at 5:00 p.m. Resident 2's CBG was 238.  According to the orders, a CBG of 201 to 300 would require six units of insulin to be administered.  No sliding scale insulin was administered at that time. There was no negative outcome identified related to the lack of following physician orders related to insulin administration and CBG monitoring. Resident 2's MARs and orders were reviewed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), and Staff 3 (RN) on 05/03/22. They acknowledged staff failed to ensure orders were carried out as prescribed.

1.Resident #2 insulin orders have been updated/rewritten to include clear instructions on how much/how often and when to administer. Team now has house stock supply of testing strips in the event resident #2 runs out. Sliding scale insulin was discontinued. 2.All Medication technicians have been inserviced on how to read MAR instructions, review importance of insuline administration and CBG checks. House stock testing strips available when needed. 3.DHS or designee will do a weekly review of insulin/CBG checks/administration per instructions and dosing is accurate. 4.DHS/ED/Designee

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications, including over-the-counter medications that were ordered by a legally recognized prescriber and were administered by the facility for 2 of 3 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 02/2022 with diagnoses including Alzheimer's, chronic pain, and prostate cancer. Review of Resident 3's MAR, dated 04/01/22 through 05/02/22 identified the following deficiencies: The MAR lacked accurate parameters for use of multiple PRN pain medications. These were acetaminophen (for "mild to moderate" pain), lidocaine patch ("as needed for pain") and hydrocodone (for "moderate to severe" pain). There were no instructions for the sequential order of administration, or for determining Resident 3's pain scale rating. On 05/04/22 the need to keep an accurate MAR of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (RN). They acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2021 with a diagnosis of dementia with behaviors. A review of the resident's 04/01/22 through 05/02/22 MARs revealed the following: * The resident had two physician orders for Risperidone (an antipsychotic). One ordered 2 mg every day at 8:00 p.m.; the MAR indicated this was to be administered at 8:00 a.m. The second order was for 1 mg at 8:00 a.m. and 1 mg at 1:00 p.m.; the MAR indicated it was to be administered at 8:00 a.m. and 8:00 p.m. * Administration documentation on the MAR was inaccurate. Staff initialed the MAR multiple times indicating the medication had been administered. Staff 3 (RN) reported the medication was never received from the pharmacy, because the resident's insurance would not cover the cost. The need to ensure the MAR was accurate was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (RN) and Staff 7 (Resident Care Manager) on 05/04/22. They acknowledged the findings.

1.Resident #3 PRN's have parameteres and instructions included for administration. Pain scale has been added to PRN pain medications. Order of administration for PRN pain medications was clarified and added the medication administration record. DHS/ED/RCC/Designee will enter all new orders. Resident 1 PCP was notified of medication errors. Implemented running daily report including medication administration record review. 2.New Triple check/order entry system implemented for only DHS/ED/RCC to add new orders. DHS to be contacted for all new PRN's. Comprehensive review of all residents orders reviewed and audit will be completed by 7/3/2022. Medication tech training for Medication pass/EMAR understanding on 6/2/2022 3. Quarterly service plan/med review. Daily 24 hour review of PRNs given and all new order entry. 4.DHS/ED/RCC/Designee

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medication for 1 of 2 sampled residents (#1) who were prescribed as-needed psychotropic medications. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/2021 a with diagnosis of dementia with behaviors. A review of the resident's 04/01/22 through 05/02/22 MAR revealed the following: * Resident 1 had physician orders for haloperidol (an antipsychotic) 2mg/ml take 0.5ml by mouth every hour as needed for delirium, nausea, and/or vomiting and lorazepam (for anxiety) 1 mg one tablet by mouth every six hours as needed for anxiety (agitation). The lorazepam order was changed to 0.5mg one tablet by mouth every hour as needed for anxiety or dyspnea on 04/24/22. * Haloperidol was administered on 04/27/22 and 04/29/22. Staff documented non-pharmaceutical interventions were attempted without success prior to administration of the PRN psychotropic medication; they did not, however, document which interventions were attempted. * Lorazepam was administered multiple times between 04/01/22 and 05/02/22. Staff documented non-drug interventions were attempted without success prior to the administration of the lorazepam on eight occasions without noting which interventions were attempted. On the other occasions lorazepam was administered, staff did not documented having attempted any non-pharmaceutical interventions prior to administration of the medication. On 05/04/22 the need to document which non-pharmaceutical interventions were attempted without success prior to administering a PRN psychotropic medication was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (RN) and Staff 7 (Resident Care Manager). They acknowledged the findings.

1.Update Medication administration record for resident #1  to add additional directions when documenting Psychotropic medications. Resident #1 medication admnistration record has been updated to include interventions to use prior to administering medications. 2.Inservice Medication Technicians on recent comprehension of med administration, including reading parameters/instructions- using alternate interventions prior to administration. Choose 1 random resident weekly to audit PRN's interventions and ensure interventions were attempted prior to administration and documented DHS/RCC and or Designee

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 C252 and C262.

Referral tag

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#9) completed all required pre-service orientation, 2 of 3 staff (#s 9 and 11) demonstrated competency in their assigned job duties within 30 days of hire, and 1 of 1 long-term staff completed the required number of annual in-service training hours. Findings include, but are not limited to: Staff training records were reviewed on 05/04/22. 1. There was no documented evidence Staff 9 (MA), hired 12/19/21, completed pre-service orientation prior to performing any job duties. 2. There was no documented evidence Staff 9 (MA) or Staff 11 (MA), hired 12/19/21 and 06/21/21, respectively, demonstrated competency in their caregiver job duties within 30 days of hire. 3. There was no documented evidence Staff 8 (MA), hired 11/15/19, completed the required number of annual in-service training hours. The facility's failure to ensure staff completed all required trainings within the allotted time was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) on 05/04/22. They acknowledged the findings.

1.Staff #9 will complete preservice orientation. Staff #9 will have competency checklist completed. Staff #8 will receive revised annual service hours. 2.Staff will not be scheduled to work floor until preservice orientation is completed. Competency check list will be done within 30 days of hire. All staff will be assigned annual required training via relias and will be taken off schedule if not up to date. Audit of every new hire prior to being scheduled on floor to verify traiing is completed. Within 30 days of hire, ED will verify competency has been done. BOM will aduit 2 staff a month to verify annual training. BOM/ED/Designee

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 C302, C303, C310 and C330.

Referral tag

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and included in the service plan for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: Current service plans for Residents 1 and 3 were reviewed during the survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. On 05/04/22 the need to develop individualized service plans which addressed each resident's nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), and Staff 3 (RN). They acknowledged the findings.

1.Individualized Nutrition and hydration plan needs more information and staff instructions. This will be collected after reviewing physician orders and speaking with resident and advocates and added to resident #1 and #3 service plan. 2. Will start using Point Click Care Evaluation form that included Hydration/Nutrtion and will be fully completed at the time of evaluation by resident and advocates input. All residents will be audited and have a current nutrition/hydration plan by 7/3/2022. 3.Prior to move in during Evaluation, 30 days after move in, then quarterly and as needed for change of condition or change in preference. Community will perform 2 random service plan audits a week for 8 weeks for nutrtion/hydration review. DHS/RCC/ED/Designee

Based on observation, interview and record review, it was determined the facility failed to evaluate all required elements for activities and to develop an individualized activity plan from the evaluation for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to: A review of the activity evaluation and service plan for Residents 1 and 3 revealed the following: 1. The activity evaluation did not adequately address the following required elements: * Past and current interests; * Current abilities and skills; * Physical abilities; and * Adaptations necessary for the resident to participate. 2. Individualized activity plans, which addressed what, when, how, and how often staff should offer and assist the resident with activities, were not developed from the activity evaluation and documented. The need to ensure the facility completed a thorough activity evaluation and developed an individualized activity plan based on the evaluation for each resident was discussed with Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (RN) and Staff 7 (Resident Care Manager) on 05/04/22. They acknowledged the findings.

1.Resident #1 and Resident #3 will have past and current interests reviewed as well as current abilities and skills, physical abilities and adaptations necessary. These findings will be added to current service plan. 2.Inserviced Activity Director and went over activity evaluations and to add past and current interests, current abilities and skills, physical abilities and adaptations necessary. 3. 2 random residents activity service plan will be audited weekly to ensure past/current ability and skills and physical abilities and adaptations have been adressed. 4.Activity Director or Designee

The findings of the change of ownership survey, conducted 05/02/22 through 05/04/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. 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  re-visit to the initial survey of 05/04/22, conducted 08/15/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations. The facility was found to be in substantial compliance with the regulations.