The findings of the re-licensure survey, conducted 09/05/23 through 09/08/23 and 09/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following areas:

OAR 411-054-0036 (1), (2), & (4) Service plans;

OAR 411-057-0140 (1) Administration Responsibilities;

OAR 411-057-0155 (3) Staff Training Requirements; and

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

The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the revisit to the re-licensure survey of 09/11/23, conducted 04/09/24 through 04/11/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with H refer to the Home and Community Based Services Rules OARs 411 Division 004.

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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 09/11/23, conducted 07/23/24 through 07/24/24, 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure 1 of 1 sampled resident (#8) was treated with dignity and respect, and had a safe and homelike environment. Findings include, but are not limited to:

Resident 8 moved into the MCC in 04/2023 with diagnoses including dementia with unspecified psychotic disturbance.

Observations during the survey from 09/05/23 through 09/08/23, identified the following:

On 09/07/23 at approximately 4:30 pm, the surveyor overheard a staff member raising her voice and repeating, "get out" three times. When the staff member noticed the surveyor watching the interaction between her and Resident 8, her tone changed to calm and friendly. At that point she stated to the resident, "Come on, it's dinner time, let's get ready for dinner." The resident then walked out of the room with the staff member.

The need to ensure residents were treated with dignity and respect and had a safe and homelike environment was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23 at 10:30 am. They acknowledged the findings.

The outside consultant and the ED have reviewed the residents rights Document and made necessary changes.

Resident 8 service plan will be reviewed and updated by the RCC or designee for more person centered approaches for redirection when needed.

Staff member involved with resident 8 has been terminated .

ED or designee will hold an All-Staff meeting on abuse neglect, dignity and resident's rights.

Training meeting will be held annually and as needed by ED or designee on abuse and neglect, dignity and residents rights.

Based on observation, interview and record review, it was determined the facility failed to report injures of unknown cause to the local SPD office as suspected abuse unless an immediate facility investigation reasonably concluded the injury was not the result of abuse, failed to immediately notify the local SPD office of any incident of abuse or suspected abuse, and failed to promptly investigate incidents and take measures necessary to protect residents and prevent reoccurrence of abuse, for 4 of 4 sampled residents (#s 2, 4, 6, and 7) reviewed for incidents which required investigations or reporting. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia and epilepsy.  

a. The resident had a signed physician order for 100 mgs of lacosamide (a narcotic), one tablet by mouth two times a day for seizure disorder related to epilepsy. The medication was scheduled for administration at 8:00 am and 8:00 pm.

Resident 2's Controlled Substance Disposition logs and MARS, dated 06/01/23 through 09/05/23, were reviewed and revealed the following:

* On 07/28/23, the MAR reflected the resident refused the medication but the medication had been signed out on the disposition log; and

* On 08/22/23, the MAR reflected staff couldn't locate the medication but the medication had been signed out on the disposition log.

There was no evidence the disposition log count had been corrected when the medication was not administered, or documentation to show the medication had been disposed of.

On 09/06/23, Staff 1 (ED) confirmed she was unaware of the issue. The surveyor requested the facility to report the incident.

On 09/06/23 at 3:46 pm, the surveyor received verification the facility reported the missing narcotics to the local SPD office.  

b. Progress notes dated 06/13/23 through 09/04/23, Temporary Service Plans (TSPs) dated 07/01/23 through 07/25/23, and incident reports were reviewed. The following resident to resident altercations were documented:

* TSP dated 07/01/23 - "[Y]elling and grabbing peers hands. Pulling, pushing, and yelling;"

* Progress note on 07/14/23 - two documented attempts to hit another resident in which the MT was able to intervene, then documented, "this time [Resident 2] must have tried to hit [the other resident] because [the other resident] has a scratch to [his/her] right arm;"

* Progress note on 07/23/23 - "Resident on alert for an altercation with [another resident]," with no other information included to what occurred; and

* Progress note on 07/25/23 - "noticed [Resident 2] hitting/smacking [another resident] who is wheelchair bound."

On 09/07/23 at 8:30 am, Staff 1 (ED) confirmed none of the resident to resident altercations had been reported to the local SPD office.

The surveyor requested the incidents be reported to the local office. Verification the facility reported the resident to resident altercations was received on 09/07/23.

The need to ensure resident to resident altercations were immediately reported to the local SPD office was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 01/2023 with diagnoses including dementia.

Observations of the resident, interviews with staff, and the resident's 06/22/23 Individual Service Plan Report, temporary service plans, progress notes, and incident reports were reviewed.

The following facility investigations failed to document all required components, reasonably conclude the injuries of unknown cause were not a result of abuse, and/or report the incidents to the local SPD office:

* 06/10/23 - Unwitnessed fall without injury, found on floor;

* 06/11/23 - Unwitnessed fall without injury, found on floor;

* 06/25/23 - Skin tear left lower extremity; and

* 09/02/23 - Yellow lump by groin with fluid.

During an interview with Resident 6 on 09/05/23, s/he was unable to provide answers on what may have occurred on those dates.

The facility was directed to self-report the incidents to the local SPD office. Confirmation of the reporting was received on 09/11/23 at 8:29 am.

The need to investigate incidents of abuse or suspected abuse immediately, and report injuries of unknown cause if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

4. Resident 7 was admitted to the facility in 03/2023 with diagnoses including Alzheimer's disease, early onset.

Observations of the resident, interviews with staff, and the resident's 06/22/23 Individual Service Plan Report, temporary service plans, progress notes, and incident reports were reviewed.

The facility failed to immediately investigate the following incidents:  

* 06/10/23 - Unwitnessed fall with injury, skin tear;

* 06/14/23 - Unwitnessed fall without injury; and

* 08/13/23 - Unwitnessed fall with injury, carpet burn on right knee and bleeding from right eyebrow.

During an interview with Resident 7 on 09/06/23, s/he was unable to provide answers on what may have occurred on those dates.

The facility self reported the incidents to the local SPD office on 09/08/23.

The need to investigate incidents of abuse or suspected abuse immediately was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

2. Resident 4 moved into the facility in 05/2023 with diagnoses including dementia.

On 07/12/23 staff documented Resident 4 was found by a caregiver in another resident's room with his/her pants off, only wearing a t-shirt. On 07/23/23, Resident 4 was found in his/her room naked with another unsampled resident, who was clothed at the time. Alert charting records indicated that during both instances, Resident 4 had been on behavior monitoring for "sexual behaviors."

On 09/11/23, the surveyor requested documentation that the incidents had been investigated or reported. The facility was unable to provide documentation the incidents had been investigated and/or reported as suspected abuse.

In an interview on 09/11/23, Staff 1 (ED) and Staff 3 (RCC) were asked about the facility's policies and procedures for reviewing resident incidents. Staff 1 and Staff 3 confirmed incident reports should have been completed.

The need to ensure all incidents of abuse or suspected abuse were immediately reported and investigated was discussed with Staff 1, Staff 2 (RN), Staff 3, and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Resident 2 medication error was reported to APS by ED, Licensed Nurse will review medication error and make corrections as needed.

Resident 2 resident-to-resident altercation was reported by the ED.

ED or designee will complete incident reports for resident 4 for dates 7/12/23 and 7/23/23.

Resident 6 has passed away.

ED reported resident 7 incident of unwitnessed falls to APS.

ED or designee will hold a staff meeting with the interdisciplinary team on reporting and investigating abuse.

Outside consultant or desingee will review abuse reporting and invesgation Policies.

Outside consultant or designee will provide inservice to the interdisciplinary team regarding the above policies.

Incident reports will be reviewed, by the interdisciplinary team Monday through Friday during the 24hr follow through meeting.

Outside consultant or designee will perform a random audit every two weeks to ensure incidents requiring reporting has been completed through the 24hr follow through meeting.

Outside consultant or designee will bring results of this audit monthly for 3 months or until deficient practice has resolved

2. Resident 10 was moved into the facility in 12/2021 with diagnoses including dementia.

Observations of the resident from 04/09/24 to 04/11/24 revealed the resident required staff assistance with incontinence care and meal assistance.

Progress notes and incident reports dated 01/11/24 through 04/08/24 indicated the following:

* 01/17/24 staff documented the resident was involved a resident to resident altercation. There was no documented evidence the facility investigated the incident and immediately reported suspected abuse to SPD;

* 01/29/24 staff documented the resident was on alert charting due to bruising. There was no documented evidence the facility investigated the cause of injury and reasonably concluded the injury was not the result of suspected abuse and failed to report the incident to local SPD;

* On 03/02/24 staff documented the resident was on alert charting due to fall and had "a bump on [his/her] head". An incident report stated abuse and neglect "cannot be ruled out due to the SP [service plan] not being followed ...this incident had been self reported."; and

* On 03/10/24 the resident had a fall on 03/09/24. On the fall investigation staff noted abuse and neglect "cannot be ruled out. Staff were not following [his/her] service plan when they left [him/her] unattended."

During the survey, staff were requested to provide evidence the facility had reported these incidents to local SPD. On 04/11/24 at 2:40 pm, Witness 2 (Consultant LPN) confirmed there was no documented evidence the facility reported the incidents to local SPD. The facility was directed to self-report the incidents to the local SPD office. Confirmation of the report was received on 04/11/24 prior to the survey team exiting from facility.

During an interview on 04/11/24, the need to investigate incidents of suspected abuse or neglect of care and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 28 (ED) and Witness 2. They acknowledged the findings.

Based on observation, interview and record view, it was determined the facility failed to promptly investigate injuries of unknown cause, resident to resident altercations, and unwitnessed falls to rule out abuse/neglect, document all required areas of an investigation, and notify the local SPD office when abuse/neglect could not be ruled out for 3 of 4 sampled residents (#s 9, 10, and 11) reviewed with incidents. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 08/2022 with diagnoses including neurocognitive disorder with Lewy bodies and dementia.

Resident 9's most recent service plan identified him/her as at risk for falls related to cognitive impairment, weakness and history of falls. Service plan fall interventions included ensuring the resident always had on non-slip footwear when out of bed due to his/her tendency to "remove [his/her shoes] often throughout the day".

A review of the resident's record, including progress notes, dated 01/11/24 through 04/08/24, identified the following:

* A progress noted dated 03/29/24 at 6:07 pm indicated the resident was found on the floor in his/her bathroom with "no obvious injuries."

* An incident report dated 03/29/24 at 5:00 pm related to the same fall indicated in three separate sections: "no injuries observed at time of incident", "abrasion" to "back of head", and "back of neck".

The following required components were not included in the investigation:

* Time of incident; and

* Administrator review.

In an interview on 04/11/24, Staff 28 (Executive Director), acknowledged the investigation had not been promptly completed to rule out abuse.

Staff 28 was asked to report the incidents to the local SPD office. Confirmation of report was provided prior to survey exit.

The need to thoroughly investigate incidents of suspected abuse and/or neglect, including unwitnessed falls, and the need to report to SPD if unable to reasonably rule out abuse and neglect was discussed with Staff 28 on 04/11/24. He acknowledged the findings.

3. Resident 11 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's disease.

a. A review of the resident's record, including progress notes and investigations dated 01/11/24 through 04/08/24, identified the following:

* An incident report regarding a right toenail injury of unknown cause dated 02/02/24 determined abuse or neglect could not be ruled out;

* An incident report, dated 02/19/24, regarding a skin tear to the right shin that occurred while staff was assisting the resident with transferring on 02/17/24 determined abuse or neglect could not be ruled out; and

* An incident report, dated 04/08/24, regarding a skin tear to the right leg that occurred while staff was assisting the resident with transferring on 04/05/24 determined abuse or neglect could not be ruled out.

During an interview on 04/11/24, Staff 28 (ED) confirmed the above injuries were not reported to the local SPD office. Confirmation of reporting the three incidents was requested and received prior to survey exit.

b. The following required documentation was not included in any investigations in Resident 11's record:

* Administrator review.

The need to immediately report abuse and suspected abuse to the local SPD office and to include all required documentation on facility investigations was discussed with Staff 28 on 04/11/24. He acknowledged the findings.

1. Resident #9  - Time of incident and administrator has reviewed and signed. The incident was reported to SPD prior to survey exit.

Resident #10 - All incident reports reviewed during survey were reported to SPD prior to survey team exit.

Resident 11 - Administrator has reviewed and signed incident reports. All incident reports reviewed during survey were reported to SPD.

2. The consultant will provide training to all staff on how to enter an Incident report, including but not limited to the "who, what, when where, why, and how." The DHS Abuse Reporting and Investigation Guide for Providers will be given to all staff during training.

Incident reports are reviewed by ED, RCC, and/or LN during the clinical team meeting. ED and/or LN will review and report as appropriate during weekends and holidays.

An RN consultant or designee will perform audits weekly to ensure incidents requiring reporting have been completed and reported appropriatedly

3. Incident reports will be reviewed daily by ED, RCC, and/or LN and audited weekly by consultnat.

4. ED, LN, RCC

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the move-in evaluation, 30 day evaluations were used to develop the resident's service plan, and quarterly evaluations were reflective of the resident's current physical health status for 3 of 6 sampled residents (#s 2, 3, and 5) whose evaluations were reviewed. Findings include, but are not limited to:  

1. Resident 2 was admitted to the facility on 06/13/23 with diagnoses including dementia.

The "Admission" evaluation, dated 06/09/23 was reviewed and lacked the following required elements:

* Customary routines relating to eating and bathing;

* List of medications and PRN use;

* Vital signs if indicated by diagnosis, health problems, or medications;

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

* Nutrition habits, fluid preferences;

* List of treatments;

* Complex medication regimen; and

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

The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility on 07/06/23 with diagnoses including dementia.

The move-in evaluation lacked the following required elements:

* Customary routines relating to eating and bathing;

* List of medications and PRN use;

* Vital signs if indicated by diagnosis, health problems, or medications;

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

* Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Nutrition habits, fluid preferences;

* Recent losses;

* Elopement risk or history; and

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

The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

3. Resident 3 moved into the facility in 01/2021 with diagnoses including dementia.

A review Resident 3's most recent quarterly evaluation, dated 08/09/23, indicated the resident had no evidence of "dehydration or unexplained weight losses", and had not experienced any falls within the last 90 days.

Resident 3's weight record indicated the resident had lost 5.8 pounds (5.2 % of body weight) in one month, which was a significant loss. A review of progress notes indicated Resident 3 had experienced falls on 06/24/23, 06/30/23, and 08/08/23.

The need to ensure the quarterly evaluation was reflective of the resident's health status to develop a quarterly service plan was reviewed with Staff 1 (ED), Staff 3 (RCC) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

RCC or designee will review and update resident 2 evaluation and service plan to enusre all required elements are addressed to meet residents needs.

RCC or designee will review and update resident 3 evaluation and service plan to enusre all required elements are addressed to meet residents needs.

RN  will complete a change of condition and update the  service plan. Update resident 3 evaluation and service plan to enusre all required elements are addressed to meet resident's needs.

RCC or designee will review and update resident 5 evaluation and service plan to enusre all required elements are addressed to meet resident's needs.

RCC or designee will review and update evaluations and service plans to enure all requiered elements are  addressed for all residents with each scheduled service plan to assure it is up to date.

Outside consultant will complete an inservice with interdisciplinary team on evalutions, service plans and change of conditions.

Outside consultant or designee will do a 10% audit of evaluations and service plans monthly to ensure all required elements are present.

Outside consultant or designee will bring required audits to QAPI for three months or until the deficiency is corrected.

5. Resident 2 moved into the facility in 06/2023 with diagnoses including dementia.

The facility kept resident service plans in a binder at the staff work desk in each unit for staff to access and review. On 09/07/23 at 4:16 pm, the service plan binder on the "Sandy" unit was reviewed. There was a document located in the binder under the resident's tab entitled, "Nice to Meet You!" Although the document did provide some information that staff could use to get to know Resident 2, it was not reflective of the resident's care needs.

Observations of the resident, staff interviews, review of the service plan, and review of the Temporary Services Plans (TSPs) revealed the service plan did not provide clear direction regarding the delivery of services and lacked a description of who shall provide the services and what, when, how, and how often the services shall be provided in the following areas:

* Personal relationship with another resident on the Sandy unit;

* Pain management, including non-drug interventions and how the resident expressed pain;

* Behavior interventions;

* Fall interventions;

* Dressing assistance relating to pain and left lower extremity movement;

* Stand by assist with showers including the resident's modesty preferences;

* Set up assistance needed for oral hygiene;

* Interventions for the resident accepting treatments and medications;

* Wanting to be let out of the unit to go home; and

* Forgetfulness relating to the location of his/her room, needing the four wheeled walker at all times, and that s/he was the only resident with a key to his/her room.

The facility failed to ensure service plans were available to staff to provide clear direction in the provision of Resident 2's care.  

The need to ensure service plans were available to staff and provided clear direction for the delivery of services was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

6. Resident 5 moved into the facility in 07/2023 with diagnoses including dementia.

The facility kept resident service plans in a binder at the staff work desk in each unit for staff to access and review. On 09/07/23 at 4:16 pm, the service plan binder on the "Clackamas" unit was reviewed. There was no documentation under the resident's tab for staff to reference to direct care relating to Resident 5.  

Observations of the resident, staff interviews, review of the service plan, and review of the Temporary Service Plans (TSPs) revealed the service plan did not provide clear direction regarding the delivery of services and lacked a description of who shall provide the services and what, when, how, and how often the services shall be provided in the following areas:

* Resident's routine of going to bed after each meal to elevate legs;

* Ability to verbalize pain and dizziness;  

* Fall interventions;

* Desire to be in a favorite chair located in a common area on the Clackamas unit;

* Full assistance for dressing, grooming, hygiene, and showering;

* Assistance needed with some toileting tasks;

* Home health involvement and contact information;

* Oxygen usage, including liters per minute flow, while napping and when s/he goes to bed at night;

* Oxygen concentrator maintenance, including filter and tubing changes;

* Ability to use the call system; and

* Staff were unaware if the resident utilized hearing aides.

The facility failed to ensure service plans were available to staff to provide clear direction in the provision of Resident 5's care.  

The need to ensure service plans were available to staff and provided clear direction for the delivery of services was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

7. The survey team performed a service plan audit of all residents in the building, which revealed nine residents lacked documented evidence of a service plan, 33 resident records contained partial service plans, and 26 resident records contained service plans that were last updated greater than 90 days ago.

The need to ensure service plans were available to staff and provided clear direction for the delivery of services was discussed with Staff 1 (ED), Staff 5 (Contractor), Staff 6 (Consultant), and Staff 7 (RN Consultant) on 09/08/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, provided clear direction regarding the delivery of services, included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, and services were implemented for 6 of 7 sampled residents (#s 2, 3, 4, 5, 6, and 8) whose service plans were reviewed. Resident 3, who required meal assistance, had a significant weight loss. Resident 6's service plan was not followed, and s/he sustained a left hip fracture and a head laceration. Resident 8 required up to three staff assistance for ADLs. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 01/2023 with diagnoses including dementia, insomnia, abnormal weight loss and was identified in the acuity interview as having a history of falls.

a. On 08/25/23, the resident experienced a fall and sustained a left hip fracture and head laceration.

A review of the resident's record, including the most recent service plan and Temporary Service Plans (TSPs), interviews and observations with staff and the resident were conducted between 09/05/23 and 09/11/23 and revealed the following information:

The Individual Service Plan Report, dated 06/22/23, documented Resident 6 required one caregiver escort and assistance for toileting. A handwritten note under toileting indicated the resident was "full assist," but was not dated or initialed.

In an interview on 09/06/23 at 3:20 pm, Staff 8 (Staffing Coordinator/MT) confirmed the resident required one staff person to assist at all times with toileting, and not to be left alone. Staff 8 further stated the service plan was not being followed as the resident was left standing alone at the time the resident fell.

During an interview on 09/07/23 at 10:20 am, Staff 9 (MT/CG) reported that prior to the fall, Resident 6 was engaged with activities, and was using a wheelchair or a four wheeled walker for mobility. She reported since the left hip fracture, Resident 6 was bedbound, had fluctuating pain, and required one to two staff members for repositioning for comfort.

Observations from 09/05/23 through 09/11/23 of Resident 6 revealed s/he was confined to the bed and relied on staff for grooming, dressing, medications, meal assistance, and incontinence care.

The facility investigation, completed 08/25/23, indicated the resident was left standing alone in the bathroom for an unknown amount of time.

The facility's failure to ensure implementation of services resulted in Resident 6 experiencing a fall and sustaining a left hip fracture and head laceration.

On 09/08/23, the survey team requested an immediate plan of correction to address the lack of a reflective service plan with clear direction to the staff for Resident 6. The plan was provided by the facility and approved by the survey team on 09/08/23 at 6:23 pm, and the situation was abated.

b. Resident 6's service plan was not reflective or did not provide clear direction to staff following areas:

* Bathing;

* Skin condition, including wounds;

* Modified diet;

* Incontinent care;

* Assistive devices, including hospital bed and side rail;

* Evacuation assistance;

* Meal assistance, including 1:1 assistance;

* Outside providers;

* Falls;

* Activities and assistance required to participate; and

* Mobility and transfers, including repositioning.

The need to ensure service plans were reflective, available to staff, provided clear direction regarding the delivery of services, and was implemented was discussed with Staff 1 (ED), Staff 5 (Contractor), and Staff 7 (RN Consultant). They acknowledged the findings.

3. Resident 3 moved into the facility in 01/2021 with diagnoses including dementia.

a. On 09/06/23, Staff 1 (ED) stated the facility kept resident service plans in a binder at the staff work desk in each unit for staff to access and review. On 09/07/23 and 09/08/23, the service plan binder on the Columbia Unit was reviewed. There was no service plan for Resident 3 available for staff. A copy of the current service plan for Resident 3 was requested and Staff 1 provided a copy of a service plan, printed from the electronic system and last updated 08/26/23.

On 09/08/23, Staff 9 (MT/CG) and Staff 16 (MT/CG) were asked how care staff had access to the resident's service plans for review. Both confirmed the service plans were kept in the desk on Columbia Unit, stored in the binder.

b. Observations of the resident, staff interviews and review of the service plan, last updated 08/26/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff or was not implemented in multiple areas including:

* Pain management, availability of PRN pain medication;

* Providing two hour toileting;

* Fall interventions;

* Two-person transfer assistance;

* Mobility and ambulation status; and

* Use of medicated mouthwash.

c. The service plan was also not reflective of the resident's need for cueing and encouragement with eating.

Observations and interviews made on 09/06/23 through 09/08/23 showed the following:

* On 09/06/23 at 12:15 pm, a plate with a grilled cheese sandwich, french fries and a small bowl of cole slaw was delivered and placed on the table next to the resident's bed. Staff 23 (CG) was asked about the care provided to Resident 3. Staff 23 stated the resident liked to eat meals in the room and could feed him/herself. At 1:00 pm, Resident 3 was observed in bed with the plate of lunch still on the bedside table within reach. The surveyor asked Resident 3 if s/he was hungry. Resident 3 did not respond verbally, but took a french fry from the plate and ate it.

* On 09/07/23 at 9:55 am, Resident 3 was observed in bed. There were no fluids available within reach of the resident. Staff 23 reported the resident had not eaten much at breakfast. At 10:05 am, Staff 5 (Contractor) was observed assisting care staff transfer Resident 3 out of bed. The resident was unsteady on his/her feet and required two people to transfer safely. The need for staff to provide fluids within reach of the resident and cueing to eat his/her meals was discussed with Staff 5 who stated a Temporary Service Plan (TSP) would be created to instruct staff on nutrition and hydration care and interventions.

* On 09/08/23 at 8:20 am, Resident 3 was observed asleep in bed. There was a cup of water with a straw on the over-the-bed table next to the resident's bed, however it was out of reach of the resident. Staff 9 (MT) was interviewed regarding Resident 3's intake at breakfast. Staff 9 showed the surveyor the resident's plate with food on the dining room table. When asked if the resident ate any of the food, Staff 9 stated "not too much, just the bacon". Staff 9 was asked if there was a TSP available instructing staff on the resident's nutrition and hydration needs. Staff 9 said she was not aware of a TSP, but was told at "shift change report" that the resident would be getting a "shake" from the kitchen.

Resident 3 remained in bed for long periods of time. The resident did not have any fluids available within reach, while s/he was in bed. Meals were placed on the bedside table without encouragement, cueing to eat or offers to assist with eating provided by staff.

On 09/08/23 at 8:45 am, Staff 5 was informed the resident needed to have access to fluids and direction provided to care staff on all shifts to address the nutritional and care needs of the resident.

On 09/08/23 an immediate plan of correction to address the lack of service plans available to staff to follow and provide care to residents was requested. The plan was provided by the facility and approved by the survey team on 09/08/23 at 6:23 pm and the situation was abated.

The need to ensure service plans were available to staff, reflective of current care needs, provided clear direction to staff and were implemented was discussed with Staff 1 and Staff 5 on 09/08/23. They acknowledged the findings.

4. Resident 4 moved into the facility in 05/2023 with diagnoses including dementia.

a. The service plan available to staff, located in the service plan binder on the unit, was last updated 08/27/23. On 09/07/23, the most recent evaluation was requested and provided. The quarterly evaluation had been completed on 08/29/23. There was no documented evidence the 08/27/23 service plan had been updated to reflect the most recent evaluation in the following areas:

* Unexplained weight loss was marked as "yes" on the evaluation but not addressed in the service plan;

* Assistance needed with personal hygiene, grooming and oral care was marked "no" on the evaluation, however, the resident required staff assistance;

* Skin integrity service plan was marked as "no" on the evaluation, however the resident had multiple skin treatments; and

* The evaluation included the resident's use of a bed cane, however, there was no bed cane in use.

b. The 08/27/23 service plan failed to provide clear direction regarding interventions for behaviors of wandering into other resident's rooms and hyper-sexualized behaviors. The service plan did not include a written description of what, when, how, and how often the services should be provided when problematic behaviors occurred.

The need to ensure service plans reflected the resident's needs as identified in the evaluation and included clear interventions for staff to follow was discussed with Staff 1 (ED) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

2. Resident 8 moved into the facility in 04/2023 with diagnoses including dementia with unspecified psychotic disturbance.

a. The Individualized Service Plan Report (s) (ISP's), dated 06/22/23 and 07/14/23, were reviewed and identified the following:

* The resident required a two person assist with toileting for extensive redirection, assist with cleansing peri-area after incontinent episodes, wore incontinence briefs, "encourage and assist";

* The resident was independent with bed mobility, needed reminders to rise from bed with use of walker, independently repositioned in bed;

* One staff member to provide dressing, and provide simple instructions during dressing;

* Required staff assistance with oral hygiene. If s/he refused, re-attempt three times before noting the refusal; and

* Under the behavior/mood section - "Assess and anticipate [the resident's] needs, known needs for [resident] are listed in other areas of care plan."

There was no further service plan information available and no Temporary Service Plans (TSP's) available for Resident 8.

Progress notes dated 07/10/23 through 07/30/23 noted the following:

* "Resident refused all care on [night] shift. [R]esident spent night on sofa in common area. Resident is visible soiled through clothing, but 3 staff unable to get resident to agree to assist with changing to clean clothes."

* "Walked around with only a wet brief and sweatshirt when [Resident 8] woke up. Refused and screamed at care staff when they tried to help [the resident]."

* "Refusing to change, starts to scream and hit when trying to provide help."

* "Only thing is behavior wise, [the resident] did not let us change [him/her] for the morning and [the resident] was getting upset and trying to hit us."

On 09/08/23 at 9:30 am, Staff 18 (CG), reported Resident 8 needed two to three caregivers for bladder/bowel care, was resistive to accept care, would yell, cuss, and hit staff, and would yell at other residents.  Additionally, Staff 18 reported multiple times during the week, she would come into work and Resident 8's incontinence brief was saturated because the resident wouldn't let staff change him/her. "Sometimes it takes three people and when they don't have enough staff [during the nighttime], they wait until [staff] come in on day shift [at 6:00 am]."

On 09/11/23 at 9:08 am, Staff 20 (CG), reported Resident 8 usually slept in late and missed breakfast. The resident was resistive to accept personal care and needed two to three caregivers for bladder/bowel care, two caregivers for bathing and dressing, one person for grooming and oral care, and one caregiver for emergency evacuation. Resident 8 was aggressive with staff, yelled at other residents, wandered around and went into other residents' rooms. Additionally, Staff 20 reported, "sometimes when we are short staffed on night shift and [the resident] is fighting [the staff]," Staff 20 would come in to work in the morning and the resident would need to have his/her incontinent brief changed right away. "[The night shift] are supposed to make sure [the residents] are changed before we come in, but sometimes, it takes two people to hold [his/her] hands and one person to change [him/her]."

An observation of Resident 8 on 09/07/23 at approximately 4:30 pm, revealed the resident was walking independently and sat on another resident's bed in the Sandy Neighborhood. The resident lived in the Clackamas Neighborhood. The surveyor overheard a staff member raising her voice and repeated, "get out" three times.  

The ISP's dated 06/22/23 and 07/14/23 lacked the following information:

* The resident required three-person assistance for bowel/bladder management;

* The resident required two-person assistance for dressing and bathing;

* The resident exhibited physical and verbal aggression towards staff and residents, and the plans lacked interventions for staff;

* The resident was resistive to care including physical and verbal aggression towards staff during ADL care and interventions to assist with ADL care; and

* The resident exhibited wandering behavior(s) and the plans lacked interventions for staff.

The lack of complete and detailed service plans that provided clear direction to staff and interventions for Resident 8's behaviors resulted in neglect of care.  

On 09/08/23, an immediate plan of correction to address the lack of complete and detailed service plans that provided clear direction to staff and interventions for Resident 8's behaviors was requested. The plan was provided by the facility and approved by the survey team on 09/08/23 at 6:23 pm. The immediate situation was abated.

b. The ISPs, dated 06/22/23 and 07/14/23 were not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Customary routines including: sleeping and eating;

* Interests, hobbies, social and leisure activities;

* Mental health including behavioral or mood problems;

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

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

* Communication including: ability to understand and to be understood;

* Eating status;

* Ability to manage medications;

* Ability to use the call system;

* Assistance needed for housekeeping;

* Nutrition habits, food and fluid preferences;

* One person emergency evacuation status; and

* Environmental factors that impact the resident's behavior including: noise, lighting and room temperature.

The need to ensure service plans were available to staff, reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 5 (Contractor) and Staff 7 (RN Consultant) on 09/08/23. They acknowledged the findings.

Resident 6 has passed away.

Resident 2 had a TSP completed to reflect true ADL and residents needs and behavioral needs to include individulaized interventions.

Resident 3 had a TSP completed to reflect true ADL and resident needs and behavioral needs to include meal assistance and individualized interventions.

Resident 4 had a TSP completed to reflect true ADL and resident needs and behavioral needs to include individualized interventions.

Resident 5 had a TSP completed to reflect true ADL and resident needs and behavioral needs to include individualized interventions.

Resident 8 had a TSP completed to reflect true ADL and resident needs and behavioral needs to include individuallized interventions.

ED and outside consultant started immediate training with care staff on how to read the service plans and where they are being kept at all times, in the communities in the SP/TSP binders, and how to complete TSP's

RCC Audited all resident's in the house for comprehensive service plans to determine which service plans need to be completed and will place the updated service plans and TSP in the binders in the community daily as updated, sticking out in the binder to alert the staff to review as well as informing staff through change of shift

The IDT will work to complete all identified service plans needing to be complete and completed.  

A Supervisor was scheduled to provide monitoring and oversight and direction for each shift starting the evening of 9/8/23 through evening of 9/11/23.

The RCC or designee will create a tracking log to monitor and ensure that service plans are completed timely.

A 24 hour follow through meeting will be held each morning M-F to review clinical data from the previous day/days in which the IDT team will ensure that the TSP's are in place as needed and returned to each community to be accessible to the staff.

The Licensed Nurse or designee will complete a weekly audit on 10% of the residents to ensure all needed TSP's are in place.

ED or designee will complete a 10% audit of all service plans scheduled for review quarterly to ensure accurate and completed timely.

A quarterly Inservice will be held with all staff on how to read the service plans and where they are kept as well as how to complete TSP's starting by the RCC or designee.

Licensed Nurse or designee will bring results of the audit to QAPI quarterly.

ED or designee will bring results of the audit to QAPI quarterly

3. Resident 11 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's disease.

The resident's service plan dated 03/26/24 and temporary service plans were reviewed, observations of the resident were made, and interviews with staff were conducted. The resident's service plan was not reflective of his/her current needs and preferences and/or was not being followed in the following areas:

* Elopement risk;

* Bed repositioning;

* Ability to feed self;

* Mobility, including devices used;

* Oral care;

* Transfer assistance;

* Pain;

* Temperature preferences;

* Hearing, vision, and communication;

* Scoop mattress;

* Dining preferences;

* Fall interventions; and

* Nail care.

The need to ensure service plans were reflective of residents' current needs and preferences, and services were implemented was discussed with Staff 28 (ED), Witness 2 (Consultant LPN), and Witness 3 (Consultant RN) on 04/11/24. They acknowledged the findings.

2. Resident 9 was admitted to the facility in 08/2022 with diagnoses including neurocognitive disorder with Lewy bodies and dementia.

The resident's most recent service plan, dated 03/07/24, and temporary service plans dated 03/08/24 and 03/29/24 were reviewed, observations were made, and staff were interviewed. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Assistance with meals;

* Behaviors related to food and beverage intake; and

* Weight gain and weight loss.

In addition, the service plan directed team members to place a cup in Resident 9's hand to encourage hydration. During lunch on 04/09/24, the resident was observed sitting at the table for the duration of the meal with no attempts to place a cup in his/her hand. The resident's table service was cleared with no liquids consumed.

The need for service plans to be reflective of the resident's current care needs, provide clear instruction to staff, and for the facility to ensure the implementation of services was discussed with Staff 1 (Executive Director) and Witness 2 (Consultant LPN) on 04/11/24. They acknowledged the findings.

4.  Resident 12 was admitted to the facility in 2018 with diagnoses including dementia.

The resident's service plan dated 03/16/24 was reviewed, observations were made, and interviews with the staff were conducted. The resident's service plan was not reflective of his/her current needs and preferences in the following areas:

*One on one feeding assistance.

The need to ensure service plans were reflective of residents' current needs was discussed with Staff 28 (ED) and Witness 3 (Consultant RN) on 04/10/24. No additional information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction regarding the delivery of services, and were implemented for 4 of 4 sampled residents (#s 9, 10, 11, and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 was admitted to the facility in 12/2021 with diagnoses including dementia.

The current service plan, dated 02/23/24, and Temporary Service Plans from 01/11/24 to 04/08/24 were reviewed, and observations of Resident 10 and interviews with staff were completed during the survey.

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Use of an air mattress;

* Use of a two inch cushion while in wheelchair;

* Emergency evacuation status;

* Be in common areas with staff while awake;

* Dressing to bilateral lower extremities status;

* Conflicting directions for meal assistance;

* One-on-one care and supervision requirements;

* Transfer status;

* Three staff person requirement for incontinent care status;

* Mobility status including utilization of devices; and

* Use of partial snap in dentures status.

The need to ensure service plans were reflective of the resident's current needs and preferences and provided clear direction regarding the delivery of services was discussed with Staff 28 (ED) and Witness 2 (Consultant, LPN) on 04/11/24. They acknowledged the findings.

1. Resident 9, 10, 11, 12 service plans have been updated in all areas identified during survey:

#9 Use of an air mattress; Use of a two inch cushion while in wheelchair; Emergency evacuation status; Be in common areas with staff while

awake; Dressing to bilateral lower extremities

status; Conflicting directions for meal

assistance; One-on-one care and supervision

requirements; Transfer status; Three staff person requirement for incontinent care status; Mobility status including utilization of devices; and Use of partial snap in dentures status

#10 Assistance with meals; Behaviors related to food and beverage intake; and Weight gain and weight loss.

#11 Elopement risk; Bed repositioning; Ability to feed self; Mobility, including devices used; Oral care; Transfer assistance; Pain; Temperature preferences; Hearing, vision, and communication; Scoop mattress; Dining preferences; Fall interventions; and Nail care.

#12 One on one feeding assistance.

2. ED, LN RCC will review Service Plans quarterly, with significant changes of condition, during the first 30-days after moving in and prior to a resident moves in. Care team will also provide input into service plans prior to printing off and putting in service plan binders, which are available to all care staff. Review in clinical meetings which service plans are coming due.

3. At every clinical meeting and monthly to plan for reviews and updates.

4. ED, RCC, LN

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which 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 4 sampled residents (#s 3, 6, and 7) whose quarterly service plans were reviewed. Findings include, but are not limited to:

Residents 3, 6, and 7's most recent service plans lacked documented evidence that 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 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Reident 6 has passed away.

Resident 3 service plan will be reviewed and care conference held with service planning team.

Resident 7 service plan will be reviewed and care conference held with service planning team.

Outside consultant or designee will complete an Inservice with the service planning team.

The RCC or designee will invite outside members of the service planning team such as the residents legal representative, if applicable any person who is the residents choice, physician, or other health practitioner, as well as the facility staff as outlined in the rule to the care conference, and if they decline documents as such in the residents EMR.

Outside Consultant or designee will review 2 resident SP weekly to ensure that they were completed and care conference held with the service planning team.

Outside Consultant or designee will bring the results of these audits to QAPI monthly for 3 months or until deficient practice has resolved.

4. Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia.

A review of the resident's clinical records, including progress notes and Temporary Service Plans (TSPs), showed the resident experienced the following short-term changes of condition:

* Staff documented Resident 2 had behaviors and accused other residents of stealing his/her belongings on 06/22/23, 06/23/23, 06/27/23, and 07/03/23. The resident was observed during those times looking in other residents' rooms, yelling at other residents, and yelling at care staff.   

* A TSP dated 07/01/23 identified the resident, "[Y]elling and grabbing peers hands. Pulling, pushing, and yelling."

* A second resident to resident incident occurred on 07/03/23 during dinner time. The facility monitored the incident for additional behaviors exhibited by Resident 2 through 07/11/23. Staff documented Resident 2's "PCP [was] notified of behaviors and resident to be placed on behavior monitoring on MAR at this time."

* On 07/14/23, the resident was identified as having a resident to resident altercation.

* On 07/21/23, Resident 2 was identified as having a resident to resident altercation.

* On 07/25/23, the resident was put on alert charting for another resident to resident altercation. Staff documented, "Remove from alert charting at this time and add to behavior monitor each shift for tracking and documentation of resident behaviors."

* A progress note, dated 07/25/23, revealed, "Resident is on alert for starting a new medication. Resident showing no signs of adverse effects." There was no indication of what medication Resident 2 had started.  

* On 08/20/23 and 08/26/23, progress notes revealed the resident did not receive lacosamide (a narcotic used to treat epilepsy).

Staff 1 (ED) confirmed on 09/07/23 at 8:30 am, there was no documented evidence of behavior monitoring from the two above dates of 07/03/23 and 07/25/23.

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the actions or interventions to staff on each shift, and monitored the conditions with progress noted at least weekly through resolution for each of the resident's changes of condition.

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 with Staff 1, Staff 5 (Contractor), Staff 6 (Consultant), and Staff 7 (RN Consultant) on 09/08/23. They acknowledged the findings.

5. Resident 5 was admitted to the facility in 07/2023 with diagnoses including dementia and diabetes.

A review of the resident's clinical records, including progress notes and Temporary Service Plans (TSPs) showed the resident experienced the following short-term changes of condition:

* Falls on 07/09/23, 07/25/23, 08/04/23, 08/05/23, 08/09/23, and 08/24/23; and

* On 07/25/23 the resident was not administered his/her morning dose of insulin.

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident, communicated the actions or interventions to staff on each shift, and monitored the conditions with progress noted at least weekly through resolution for each of the changes of condition.

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 with Staff 1, Staff 5 (Contractor), Staff 6 (Consultant), and Staff 7 (RN Consultant) on 09/08/23. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 01/2023 with diagnoses including dementia and abnormal weight loss.

A review of the resident's record, including weight records dated between 01/24/23 and 08/01/23, the most recent service plan and evaluation, Temporary Service Plans (TSPs), 08/01/23 through 09/05/23 MARs, incident reports, and progress notes dated between 06/04/23 and 09/05/23, interviews and observations with staff and the resident were conducted between 09/05/23 and 09/11/23 were reviewed. The resident experienced multiple changes of condition.

a. Weight documentation reviewed between 01/13/23 and 09/01/23 noted the following:

* 01/13/23: 103 pounds;

* 01/24/23: 98.5 pounds;

* 02/01/23: No weight;

* 03/01/23: No weight;

* 04/01/23: No weight;

* 05/01/23: 90.4 pounds;

* 06/01/23: 91.2 pounds;

* 07/01/23: No weight, resident refused;

* 08/01/23: 82.6 pounds; and  

* 09/01/23: Unable to weigh.

From 01/13/23 to 06/01/23, Resident 6 sustained an 11.8 pound loss, which constituted an 11.5% loss in five months. On 06/20/23, a RN assessment for a significant change of condition for weight loss was completed and interventions were initiated. The Individual Service Plan Report, dated 06/22/23, provided the following weight loss interventions for staff to follow:

* "Alert the nurse if meal/food consumption is poor [less than 50% of meals], meal refusals, coughing or choking with meals, or pocketing food";

* "Encourage [the resident] to eat in an upright position, to eat slowly, and to chew each bite thoroughly before attempting to swallow";

* "Invite, encourage and assist [Resident 6] to attend activities that serve refreshments. Encourage and offer snacks daily"; and

* "Observe for and report to nurse any complaints of loss of appetite, refusal to eat, and weight loss."

There was no documented evidence the facility monitored the resident consistent with his/her evaluated needs for the severe weight loss.

A 07/01/23 progress note indicated Resident 6 was sleeping and refused to awaken to be weighed. There was no documented evidence that an additional attempt was made to weigh Resident 6 in 07/2023.

From 05/01/23 to 08/01/23, Resident 6 continued to lose weight, and sustained a 7.8 pound loss, which constituted a severe 8.6% loss in three months.

There was no documented evidence previous interventions were reviewed for effectiveness with each successive weight loss.

Resident 6 was unable to be weighed during the survey secondary to inability to stand due to a left hip fracture.

Observations of the resident between 09/05/23 and 09/11/23 showed the resident was unable to feed himself/herself. The resident's intake varied with multiple meals often less than 25%. The resident was provided a nutritional shake with meals during observations.

During an interview on 09/07/23 at 10:20 am, Staff 9 (MT/CG) stated Resident 6 received nutritional shakes with meals, a pureed diet, one to one assistance with meals, had difficulty swallowing, and his/her intake varied greatly from meal to meal.

There was no documented evidence of ongoing monitoring of the resident's weight, that additional weight loss was reported to the RN, or that interventions in place were evaluated for effectiveness and adjustments made to prevent additional weight loss.

During an interview on 09/11/23 at 9:35 am, Staff 2 (RN) confirmed no RN assessment or service plan update had been completed for the additional weight loss.

The facility's failure to evaluate Resident 6's ongoing severe weight loss, determine what actions or interventions were needed, communicate the actions or interventions to staff, and refer the additional weight loss to the RN for further assessment put Resident 6 at risk for further weight loss.   

b. The resident experienced multiple short term changes of condition without documented actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution for the following:

* Falls on 06/10/23, 06/11/23, and 08/25/23;

* Skin tear to left lower extremity on 06/25/23;

* Discontinuation of PRN risperidone on 07/23/23;

* New antibiotic, Keflex on 08/27/23;

* New sore on bottom on 08/28/23;

* Green/yellow leakage from head wound on 09/02/23;

* Lump on left thigh on 09/02/23; and

* New pain medication and antibiotic on 09/06/23.

During an interview on 09/07/23 at 10:20 am, Staff 9 (MT/CG) stated a hospice provider was involved and monitoring his/her wounds, and they were aware of the greenish-yellow leakage from the scalp. She reported the facility process for changes of condition was for the MT to place resident on alert charting in the progress notes.

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 with Staff 1 (ED), Staff 5 (Contractor), Staff 6 (Consultant), and Staff 7 (RN Consultant) on 09/08/23 and 09/11/23. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 03/2023 with diagnoses including Alzheimer's disease, early onset.

a. Review of the resident's clinical records, including progress notes and Temporary Service Plans (TSPs), showed the resident experienced the following short-term changes of condition:

* 06/11/23: Fall with skin tear;

* 06/14/23: Fall without injury;

* 08/05/23: Fall without injury; and

* 08/13/23: Fall with injury.

The record lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution.

b. Resident 7's weight records were reviewed and revealed the following:

03/14/23: 122.4 pounds;

04/13/23: 116.4 pounds;

05/11/23: 116 pounds;

06/14/23: 114 pounds;

07/13/23: 115.2 pounds;

08/03/23: 113 pounds; and

08/10/23: 111.6 pounds.

From 03/14/23 to 04/13/23, Resident 7 had a weight loss of 6 pounds or 5% of his/her body weight in one month. This change in weight was considered a significant weight loss which required an RN assessment. The facility failed to evaluate the resident and refer to the facility nurse.

The surveyor requested Resident 7 be weighed at time of survey. On 09/07/23, Staff 9 (MT/CG) reported Resident 7's weight was 117.8 pounds.

During lunch on 09/05/23 and 09/07/23 and breakfast on 09/08/23, staff were observed encouraging the resident to eat his/her meal. When the resident did not want to eat lunch on 09/07/23, staff brought him/her a nutritional shake.

During an interview on 09/6/23 at 10:35 am, Staff 15 (MT/CG) confirmed Resident 7 received nutritional shakes with meals and his/her appetite was improved with offering finger foods.

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, or conditions monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 5 (Contractor), Staff 6 (Consultant), and Staff 7 (RN Consultant) on 09/08/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, referred to the facility RN and service plans updated, failed to monitor and document what actions or interventions were needed for short-term changes of condition, including resident-specific instructions communicated to staff on each shift and made part of the resident's record with weekly progress noted through resolution for 5 of 5 sampled residents (#s 2, 3, 5, 6, and 7) who experienced changes of condition. Resident's 3 and 6 experienced severe weight loss. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2021 with diagnoses including dementia and a history of pubis fracture and pain.

Review of the resident's clinical records including progress notes, physician's orders, quarterly evaluations and weight records, showed the resident experienced the following significant change of condition:

a. Weight documentation reviewed between 03/03/23 and 08/03/23 noted the following:

* 03/03/23:  117 pounds;

* 04/03/23:  116 pounds;

* 05/03/23:  No weight;

* 06/03/23:  113.5 pounds;

* 07/03/23:  112 pounds; and

* 08/03/23:  106.2 pounds.  

Between 07/03/23 and 08/03/23, Resident 3 lost 5.8 pounds or 5.2% body weight in one month, representing significant weight loss and a significant change of condition.

There was no documented evidence the facility evaluated the weight loss, determined what actions or intervention was needed for the resident, and referred the weight loss to the RN.  

Observations of the resident between 09/06/23 and 09/08/23 showed the resident was able to feed him/herself but would use their fingers to select finger foods and needed encouragement and cueing to eat. The resident did not seek out or ask for food items during survey observations but would accept items from staff when offered. During room visits on 09/06/23 at 12:10 pm, 09/07/23 at 9:45 am and 11:15 am, and 09/08/23 at 8:20 am, the resident was in bed and did not have any fluids available within reach.

On 09/06/23, a request was made to obtain the resident's current weight. On 09/07/23, facility staff obtained the resident's weight and it was reported to be 92.4 pounds. Between 08/03/23 and 09/07/23, Resident 3 lost an additional 13.8 pounds or 12.21% body weight resulting in severe weight loss and a subsequent significant change of condition.

The facility's failure to evaluate Resident 3's significant weight loss, determine what actions or interventions were needed, communicate the actions or interventions to staff, and refer the weight loss to the RN, resulted in severe weight loss.    

During a discussion relating to the resident's weight loss on 09/07/23 at 10:05 am, Staff 5 (Contractor) stated "we will start providing [the resident] protein shakes from the kitchen three times a day and update the doctor."

b. Review of the resident's clinical records showed the resident experienced the following short term changes of condition:

Resident 3 experienced four falls during the review period on:

* On 06/30/23, the resident had complaints of back pain and was placed on alert monitoring;

* On 08/08/23, the resident was complaining of hip pain after a fall and was placed on alert to monitor;

* On 08/10/23, progress notes documented the resident had been found on the floor following another fall. The notes indicated the resident had been trying to walk to the bathroom when s/he fell; and

* On 08/11/23, the resident sustained another fall when s/he was found on the floor next to the bed.

There was no documented evidence the falls were evaluated to determine actions or interventions needed for the resident to prevent further falls. In addition, while the resident was placed on alert monitoring for pain related to falls, there was no evaluation to determine whether the resident's mobility had been affected.

c. Review of the resident's clinical records showed the resident experienced the following additional short term changes of condition:

* On 08/12/23 staff documented, "Resident is being placed on alert for pain in [his/her peri] area and not being able to turn with [his/her] left leg... unable to move [his/her] left leg to walk";

* Discontinuation of hydrocodone PRN pain medication on 08/22/23, which resident had been receiving at least weekly; and

* "Symptoms of a urinary tract infection" on 08/22/23.

The record lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution.

The need to determine and document what actions or interventions were needed for residents who experienced short term changes of condition and ensure residents who experienced significant changes of condition were evaluated and referred to the RN was discussed with Staff 1 (ED) and Staff 5 on 09/08/23. They acknowledged the findings.

Resident 2 will have a TSP completed to reflect true ADL and behavioral needs to include individualized interventions.

RCC or Designee will complete and evaluation and service plan with needed updates for resident 2

Resident 3 will have a TSP completed to reflect true ADL and behavioral needs to include individualized interventions.

RN will complete a change of condition evaluation with service plan review updates for resident 3.

Resident 5 will have a TSP completed to reflect true ADL and behavioral needs to include individualized interventions.

RCC or designee will complete an evauation on service plan with needed updates for resident 5.

Resident 6 will have a TSP completed to reflect true ADL and behavioral needs to include individualized interventions, she has since passed away.  

Resident 7 will have a TSP completed to reflect true ADL and behavioral needs to include individualized interventions.

The RCC or designee will create a tracking log to monitor and ensure that service plans are completed timely.

A 24 hour follow through meeting will be held each morning M-F to review clinical data from the previous day/days in which the IDT team will look for short or significant changes of condition. If short term changes of condition are noted, the residents will be placed on alert charting, with TSP's in place to direct staff while monitoring to determine if a significant change of condition occurs or has resolved. If a significant change of conditions occurs th RN will complete a significant change of condition assessment  with a comprehensive service plan update as directed by regulation.

The outside consultant or designee will audit the 24 hr flowthrough documents with each visit to ensure that both short team and significant changes have been identified and addressed according to regulation.

The outside consultant will provide the results of the audit to IDT team once completed for any needed corrections as well as bringing them to QAPI monthly for 3 months or until deficient practice has resolved.

2. Resident 6 was admitted to the facility in 01/2023 with diagnoses including dementia and "abnormal weight loss."

a. Weight documentation reviewed between 03/01/23 and 09/01/23 noted the following:

* 03/01/23:  No weight;

* 04/01/23:  No weight;

* 05/01/23:  90.4 pounds;

* 06/01/23:  91.2 pounds;

* 07/01/23:  No weight, resident refused;

* 08/01/23: 82.6 pounds; and  

* 09/01/23: Unable to weigh.

Between 05/01/23 and 08/01/23, Resident 6 lost 7.8 pounds or 8.6% body weight in three months, which represented a severe weight loss and a significant change of condition.

There was no documented evidence the facility RN conducted an assessment for the significant weight loss, which included findings, resident status and interventions made as a result.  

During an interview on 09/11/23 at 9:35 am, Staff 2 (RN) confirmed no RN assessment or service plan update had been completed for the severe weight loss.

Refer to C270, example 2a.

b. An 08/25/23 progress note indicated the resident had a fall, was sent to the hospital and subsequently diagnosed with a left hip fracture and a head laceration. Upon return from the hospital, subsequent progress notes indicated the resident required assistance with repositioning, one to one assistance with meals, had difficulty swallowing, and was bedbound.

The hip fracture and change in ADL assistance constituted a significant change of condition and required an RN assessment.

During an interview on 09/11/23 at 9:40 am, Staff 2 confirmed no assessment had been completed for the significant change of condition.

The need to ensure all significant changes of condition were assessed by an RN and the licensed nurse participated on the service planning team or reviewed the service plan with date and signature within 48 hours was discussed with Staff 1 (ED), Staff 2, Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23 . They acknowledged the findings, and no additional documentation was provided.

Refer to C260, example 1.

3. Resident 7 was admitted to the facility in 03/2023 with diagnoses including Alzheimer's disease with early onset.

Resident 7's weight records were reviewed and revealed the following:

03/14/23: 122.4 pounds;

04/13/23: 116.4 pounds;

05/11/23: 116 pounds;

06/14/23: 114 pounds;

07/13/23: 115.2 pounds;

08/03/23: 113 pounds; and

08/10/23: 111.6 pounds.

From 03/14/23 to 04/13/23, Resident 7 had a weight loss of 6 pounds or 5% of his/her body weight in one month. This change in weight was considered a significant weight loss which required an RN assessment.

During an interview on 09/11/23 at 9:40 am, Staff 2 (RN) confirmed no assessment had been completed for Resident 7's significant weight loss.

The need to ensure significant changes of condition were assessed by a RN and included findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2, Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings, and no additional documentation was provided.

Based on observation, interview and record review, it was determined the facility failed to conduct an RN assessment which included findings, resident status, and interventions made as a result of the assessment for 3 of 3 sampled residents (#s 3, 6 and 7) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2021 with diagnoses including dementia, hypertension and a history of pain.

Weight documentation reviewed between 03/03/23 and 08/03/23 noted the following:

* 03/03/23:  117 pounds;

* 04/03/23:  116 pounds;

* 05/03/23:  No weight;

* 06/03/23:  113.5 pounds;

* 07/03/23:  112 pounds; and

* 08/03/23:  106.2 pounds.  

Between 07/03/23 and 08/03/23, Resident 3 lost 5.8 pounds or 5.2% body weight in one month, representing significant weight loss and a significant change of condition.

A review Resident 3's most recent quarterly evaluation, dated 08/09/23, indicated the resident had no evidence of "dehydration or unexplained weight losses" within the last 90 days.

There was no documented evidence the facility RN conducted an assessment which included findings, resident status and interventions made as a result.  

The RN failed to assess Resident 3's significant weight loss, determine what actions or interventions were needed, communicate the actions or interventions to staff, which resulted in severe weight loss.    

Refer to C270, example 3a.

The need to ensure an RN assessment was conducted following significant changes of condition was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/08/23 and 09/11/23. They acknowledged the findings.

Resident 3 will have a TSP completed to reflect true ADL and behavioral needs to include individualized interventions.

RN will complete a change of condition evaluation with service plans review update for residents 3.

Resident 6 has passed away.

Resident 7 will have a TSP completed to reflect true ADL and behavioral needs to include individualized interventions.

The outside consultant or designee will hold an inservice on changes in condition with the IDT team.

RN will complete a change of condition evaluation with service plans review update for resident 7.

A 24 hour follow through meeting will be held each morning M-F to review clinical data from the previous day/days in which the IDT team will ensure the change of conditions are idenitifed and the RN completes a timley change of conidition.  

Outside consultant or designee will review the clinical review weekly and aduit to ensure that changes of condition are identified and completed.

The outside consultant or designee will bring the above reviewed document to QAPI monthly for 3 months or until deficient practice has resolved.

Based on observation, interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site and off-site outside providers were communicated to staff and service plans adjusted if necessary for 2 of 3 sampled residents (#s 3 and 5) who received outside services. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 07/2023 with diagnoses including dementia.

Progress notes, which had outside provider documentation transcribed within them, dated 07/06/23 through 09/04/23, revealed the following home health recommendations lacked evidence they were communicated to staff and the plan of care was updated when necessary:

* 07/06/23 - "loves puzzles, needs extra cues and encouragement to attend activities, is a social person, enjoys games, has a Nintendo Switch [hand held electronic gaming device], nicknames are Big Bear and Freddy Flinstone";  

* 07/07/23 - "call ElderPlace for any concerns or changes of condition";

* 07/10/23 - "may benefit from a perimeter mattress";

* 07/13/23 - RN left the number to call and documented, "call ElderPlace with any questions or concerns";

* 07/27/23 - "replace dressing on knee abrasions if it comes off, call ElderPlace for increased redness, drainage, fever, pain";

* 08/10/23 - "watch for left hand bruising or bleeding, notify for signs or symptoms of infection to left knee, monitor for latent injuries or changes in ADL's related to fall"; and

* 08/24/23 - "keep wounds covered, if dressing comes off or soiled, cleanse wound and cover with dressing."

The facility lacked documented evidence the information and interventions were communicated to direct care staff.

The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 01/2021 with diagnoses including dementia and a history of pubis fracture.

Resident 3 was identified during the acuity interview on 09/06/23 as receiving physical therapy.

Review of progress notes and "Outside Provider Forms" from 06/07/23 through 09/07/23 included the following recommendations made by the provider:

* 08/04/23: "please encourage out of bed and into wheelchair for more upright sitting"; and

* 08/23/23: "... have staff assist [him/her] up in WC [wheelchair] and to spend time outside..."

The facility lacked documented evidence the information and interventions were communicated to direct care staff.

Observations of resident care and interviews with Staff 23 (CG) on 09/06/23 through 09/08/23 showed the recommendations were not followed.

The need to ensure staff were informed of new interventions and the service plan adjusted, if necessary, when recommendations were made by outside providers was discussed with Staff 1 (ED) and Staff 5 (Contractor) on 09/08/23. They acknowledged the findings.

Resident 3 RCC or desginee will review the past quarter of outside provider's sheets and update the service plan with care coordination and interventions.

Resident 5 RCC or designee will review the past quarterly outside providers sheet and update the service plan with care coordination and interventions.

The ouside consultant scheduled a care coordination meeting with Providence Elderplace operations manager and supervisor.

Outside consultant or designee will review the outside provider review coordinator policy and update accordingly.

Outside Consultant or designee will hold an all staff meeting with the interdisciplinary team on how to process outside provider communication.

The ED or designee will audit 2 outside provider communication forms weekly through the 24hr follow through meeting.

The ED or designee will bring the commpleted documents to QAPI monthly for 3 months or until deficient practice has resolved.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols and have a designated "Infection Control Specialist". Findings include, but are not limited to:

1. In an interview on 09/07/23, Staff 1 (ED) reported the facility did not have a designated individual to be the facility's "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols, qualified by education, training and experience or certification, and who had completed specialized training in infection prevention and control protocols.

2. Observations made between 09/06/23 and 09/08/23 showed facility staff failed to adhere to universal precautions for infection control in the following areas:

a. On 09/06/23, Staff 23 (CG) was observed serving lunch in the dining room and clearing dirty dishes from tables. Staff 23 did not wash his/her hands between touching clean and dirty dishes and before touching multiple residents during the course of the lunch service.

b. On 09/07/23, Staff 24 (CG) was observed wearing gloves without performing hand washing before and after donning gloves and moving between providing care to multiple residents out in the common areas.

3. During breakfast and lunch observations throughout the survey, direct care staff serving food in the Columbia and Deschutes units of the facility were not wearing aprons or some other barrier to prevent contamination between clothing and food.

The need to ensure infection prevention protocols were followed and the facility had a qualified "Infection Control Specialist" was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Administrator has designated RCC to be the facilities identified Infection Control Specialist.

RCC will complete the required training for Infection Control Specialist in Community Based Care course through Oregon Care Partners.

Outside Consultant or designee will conduct an all staff meeting on Infection Control and Universal precautions.

RCC or Designee will perform weekly infection control audits to ensure universal precautions are carried out with care and meals.

RCC or designee will bring the results of these audits to QAPI for three months or until deficient practice resolves.

3. Resident 10 moved into the facility in 12/2021 with diagnoses including dementia.

Observations and interviews with staff during the survey identified the resident relied on staff for incontinence care needs.

On 04/10/24, at approximately 9:17 am, the surveyor observed Staff 18 and Staff 22 (Caregivers) provide incontinence care for Resident 10.

During the observation, Staff 22 wore single-use gloves and failed to change the gloves after wiping fecal matter from Resident 10's perineum. Staff 22 flushed the toilet and touched a clean brief, a shirt, and a pair of pants while wearing the same soiled gloves.

The above observation was discussed with Staff 28 (ED) and Witness 2 (Consultant, LPN) on 04/11/24 at 8:45 am. The staff acknowledged appropriate infection control practices were not followed.

Based on observation and interview, it was determined the facility failed to ensure establishment and maintenance of infection prevention control protocols for 2 of 3 sampled residents (#s 10 and 11) dependent on staff for ADL care and for multiple unsampled residents. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's disease, and was identified during the acuity interview as needing assistance with incontinence care.

Staff 20 (CG) and 29 (CG) were observed providing incontinence care for Resident 11 at 12:50 pm on 04/09/24. They both donned single-use gloves without first performing hand hygiene. Both staff assisted with removal of the wet brief. Staff 29 then performed perineal care without first removing soiled gloves, performing hand hygiene, and donning clean gloves, and Staff 20 assisted with applying a clean brief without first removing soiled gloves, performing hand hygiene, and donning clean gloves. Staff 20 then lowered the resident's bed using the controller, touched the resident's wheelchair, body lotion, and other personal items still wearing soiled gloves. Staff 20 removed the soiled gloves and deposited in the trash in Resident 11's room and entered the dining room. She grabbed the handles of an unsampled resident's wheelchair and moved it, then entered another unsampled resident's room to provide incontinence care without performing hand hygiene.

2. Observations of staff providing care to sampled and unsampled residents were made from 04/09/24 to 04/11/24. Multiple staff were observed to provide ADL assistance such as transfers and repositioning to sampled and unsampled residents without performing hand hygiene between tasks.

The need to ensure establishment and maintenance of infection prevention control protocols was discussed with Staff 28 (ED), Witness 2 (Consultant LPN), and Witness 3 (Consultant RN) on 04/11/24. They acknowledged the findings.

1. Education on hand hygeine, hand washing between residents and when going from dirty to clean completed during April all-staff meeting.

2. ED, LN, and/or RCC will conduct ongoing training to all direct care staff on hand hygiene and practicing standard precautions, and importance of hand washing/hygeine when going from dirty to clean.

New hires will demonstrate this skill priort to working independently. Current staff will redemonstrate how to do proper handwashing, donning/doffing gloves.

3. Once everyone has been evaluated ED, LN, RCC will do regular rounds throughout the week observing staff.

4. ED, LN, RCC

Based on observation, interview and record review, it was determined the facility failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:

Administrative oversight of the medication administration system was found to be ineffective based on deficiencies identified in the following areas:

C 302: Systems: Tracking Control Substances;

C 303: Systems: Treatment Orders;

C 310: Systems: Medication Administration;

C 330: Systems: Psychotropic Medication; and

Z 155: Staff Training Requirements as it related to MT documented competency of administering medications and treatments was demonstrated.

The requirement to ensure adequate professional oversight of the medication administration system was discussed with Staff 1 (ED) and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

The ED hired a new RN and new RCC, and is in the process of hiring a new LPN in order to ensure adequate professional oversight of the medication and treatment administration systems. The RN will be working a minumum 40 hrs a week.

The RN will  take the "Role of the RN in a Community Based Care Facility" class.

Medication and pharmacy audit will be conducted by the Licensed Nurse and pharmacy consultant.

The outside consultant or designee will review the pharmacy audit and provide a inservice to the interdisciplinary team of the findings and put a plan in place to make needed corrections.

The outside consultant or designee will complete a monthly audit of the medication and treatment systems.

The outside consultant or designee will bring the above results to QAPI monthly for 3 months or until deficient practice has resolved.

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 2 sampled residents (#2) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia and epilepsy.

The resident had a signed physician order for lacosamide (a narcotic) 100 mg, one tablet by mouth two times a day for seizure disorder related to epilepsy. The medication was scheduled for administration at 8:00 am and 8:00 pm.

Resident 2's Controlled Substance Disposition logs and MARs, reviewed from 06/01/23 through 09/05/23 revealed the following:

* On 06/30/23, there was a blank on the 8:00 pm MAR entry but it was signed as administered on the disposition log;

* On 07/02/23, there was a blank on the 8:00 pm MAR entry but it was signed as administered on the disposition log;

* On 07/28/23, the MAR reflected the resident refused the medication but it was signed as administered on the disposition log;

* On 08/13/23, the MAR reflected the medication was administered, but it wasn't signed on the disposition log; and

* On 08/22/23, the MAR reflected staff couldn't find the medication but was signed as administered on the disposition log.

There were two doses of lacosamide that the facility could not account for on 07/28/23 and 08/22/23 for the 8:00 pm administration.

The need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (ED) on 09/06/23. She acknowledged the findings.

Resident 2 the RCC or designee will review controlled substances MAR and narcotic records to ensure documentation correlates.

Medication and pharmacy audit wll be conducted by the Licensed Nurse and pharmacy consultant.

The outside consultant or designee will review the pharmacy audit and provide an inservice to the interdisciplinary team of the findings and put a plan in place to make needed corrections.

The outside consultant or desginee will provide an inservice to the interdisciplinary team and med tech on the importance of controlled subtances and medication treament administration.

The RN or designee will do a weekly narcotic audit monthly.

The RN or designee will bring the above results to QAPI monthly for 3 months or until deficient practice resolves.

4. Resident 7 was admitted to the facility in 03/2023 with diagnoses including Alzheimer's disease with early onset.

The resident's MAR, dated 06/01/23 through 09/05/23, and physician's orders were reviewed.

Resident 7 had a physician's order dated 07/03/23 to weigh resident weekly and to alert primary care physician if resident's weight fell below 120 pounds.

During an interview on 09/06/23, Staff 15 (MT/CG) confirmed the facility's process was to alert the primary care physician via a fax.

Between 07/13/23 and 09/01/23, Resident 7's weight was less than 120 pounds on ten occasions. There was no documented evidence the primary care physician was alerted on eight occasions.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1(ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings, and no additional information was provided.

3. Resident 3 was admitted to the facility in 01/2021 with diagnoses including hypertension.

The resident's MAR, dated 08/01/23 through 09/06/23, and physician's orders were reviewed and instructed staff to administer:

*Amlodipine 5mg daily. Hold for SBP (systolic blood pressure) </= 110 mm/hg and hold if HR (heart rate) of </= 60;

* Metoprolol Succinate ER 50 mg daily.  Hold for SBP </= 110 mm/hg and hold if HR of </= 60; and

* Losartan Potassium 100 mg daily for essential hypertension. Hold for SBP </= 110 mm/hg.  

a. The MAR showed Resident 3 was administered the medications when the resident's SBP was within the "hold" parameters and should have been held, as follows;

* 08/04/23: SBP was 100/53, amlodipine and metoprolol were administered;

* 08/09/23: SBP was 100/62, amlodipine, metoprolol and losartan were administered;

* 08/14/23: SBP was 105/56, amlodipine, metoprolol and losartan were administered;

* 08/15/23: SBP was 101/63, amlodipine, metoprolol and losartan were administered; and

* 08/25/23: SBP was 110/60, amlodipine, metoprolol and losartan were administered.

b. There was no record of staff obtaining the resident's heart rate to determine whether the heart rate was within the required parameters for administration.

In an interview on 09/06/23, Staff 13 (MT/CG) reviewed the electronic system and stated staff were not obtaining the heart rate prior to administering the medications and were recording the resident's heart rate once a month when obtaining monthly vital signs.

The need to ensure physician's orders were followed, as prescribed, was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 09/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and had signed physician orders for all medications and treatments the facility was responsible to administer for 4 of 6 sampled residents (#s 2, 3, 5, and 7) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 admitted to the facility in 06/2023 with diagnoses including dementia, epilepsy, and pain.  

The resident's MARs, dated 06/13/23 through 09/05/23, and physician's orders were reviewed and revealed the following:

a. It was unclear if the following medications were administered as the MARs had blanks on the entries:

* Levothyroxine (for hypothyroidism) on 06/19/23, 06/23/23, 06/25/23, 07/01/23, 07/08/23, 07/17/23, 08/29/23, and 08/31/23;

* The 9:00 pm doses of Melatonin (for insomnia) and prevastatin (for hyperlipidemia) on 06/30/23, 07/02/23, 07/14/23, and 08/16/23;

* The 8:00 pm doses of lacosamide (for seizures), memantine (for dementia), and acetaminophen (for pain) on 06/30/23 and 07/02/23;

* The 8:00 pm treatment of diclofenac gel (for pain) on 06/03/23, 07/02/23, and 07/07/23; and

* Multiple blanks on pain monitoring and weekly skin observations.

b. The following medications were not administered as staff were unable to locate them:

* Alendronate (for bone health) on 08/01/23; and

* Lacosamide on 08/14/23 and 08/22/23.

c. The following medications were not administered as prescribed due to the medication not being available at the facility:

* Alendronate on 08/08/23;

* Caltrate (for osteoporosis) on 07/13/23 and 07/14/23;

* Losartan (for hypertensive heart disease) on 07/13/23 and 07/14/23;

* PreserVision (for supplement) from 07/12/23 through 07/14/23; and

* Memantine on 08/13/23.  

The need to ensure the facility administered all medications per physician's order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 07/2023 with diagnoses including dementia and Type 2 diabetes.

The resident's progress notes, dated 07/06/23 through 09/04/23, MARs dated 08/01/23 through 09/05/23, and physician's orders were reviewed and revealed the following:

a. It was unclear if the following medications were administered as the MARs had blanks on the entries:

* Donepezil (for dementia) and Melatonin (for trouble sleeping) on 08/14/23 and 08/24/23; and

* Novolin (for Type 2 diabetes) on 08/15/23 and 08/16/23.

b. The following medications and treatments did not have current physician's orders:

* Famotidine (for heartburn); and

* Oxygen one liter per minute, to be used while sleeping.

c. The following medications and treatments were not administered per physician's orders:

* Trazodone (for dementia, trouble sleeping, anxiety) - the physician's order directed staff to administer one 50 mg tablet at bed time. The MAR directed staff to administer one and a half 50 mg tablets at bed time;

* Metformin (for Type 2 diabetes) - the physician's order directed staff to administer one 500 mg tablet daily with breakfast and two 500 mg tablets daily with dinner. The MAR directed staff to administer two 500 mg tablets with breakfast and with dinner; and

* Obtain CBGs at 8:00 am and at 5:00 pm prior to receiving insulin and eating a meal.

- There was no documented evidence the facility took Resident 5's CBGs from 08/17/23 through 08/28/23;

- There was no documented evidence the facility took the resident's CBGs at 8:00 am on 07/25/23, 08/31/23, 09/01/23, and 09/04/23;

- There was no documented evidence the facility took Resident 5's CBGs at 5:00 pm on 08/16/23, 08/29/23, 08/30/23, and 09/02/23.  

d. The following medications and treatments were not administered as prescribed due to the medication not being available at the facility:

* Bengay (for chronic knee pain) 07/20/23, 07/21/23, and 07/24/23;  

* Insulin (for Type 2 diabetes) on 07/24/23 as there were no syringes available; and

* Cyanocobalamin (for inadequate B12) on 09/02/23.

The need to ensure the facility administered all medications per physician's order was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

The Licensed Nurse or designee will print out active orders and current MARS for resident 2 and send to the PCP for review and updates.

The Licensed Nurse or designee will print out active orders and current MAR's for resident 3 and send to the PCC for review and updates.

The Licensed Nurse or designee will print out active orders and current MAR's for resident 5 and send to the PCC for review and updates.

The Licenseed Nurse or designee will print out active orders and current MAR's for resident 7 and send to the PCC for review and updates.

The RCC or designee will ensure that all residents orders will be sent to the PCP for review by prior to the compliance date and then thereafter quarterly or with any significant change of condition.

The RCC or the designee will hold an all staff meeting for the medtech on proper medication and adminstration triple-check system and what to do if the medicaiton is not available.

The RCC or designee will audit med adminstration daily through the 24 hr follow through meeting.  

The RN designee will complete a monthly med audit.

The RCC will bring the above audit to the QAPI meeting monthly for 3 months or until deficient practice resolves.

The RN will bring the above audit to the QAPI meeting monthly for 3 months or until deficient practice resolves

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 10 and 11) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 moved into the facility in 12/2021 with diagnoses including dementia and primary osteoarthritis.

Resident 10 had a physician's order to administer a suppository rectally as needed "on day 6 of" no bowel movement.

Resident 10's 03/01/24 through 04/08/24 MAR showed the resident had no bowel movement for six days from 03/16/24 through 03/21/24, and 03/26/24 through 03/31/24. The medication was not administered as prescribed.

On 04/11/24, the physician orders and the MARs were reviewed with Staff 28 (ED) and Witness 2 (Consultant, LPN). They acknowledged the findings.

2. Resident 11 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's disease and was identified in the acuity interview as experiencing a significant weight loss.

The resident's 03/01/24 to 04/09/24 MARs and physician orders were reviewed. The following was identified:

The resident had an order for Boost Plus (a nutritional supplement), 237 ml by mouth once daily. The Boost was not administered on 17 occasions between 03/21/24 and 04/09/24. During an interview at 11:35 am on 04/10/24, Witness 3 (Consultant RN) confirmed the resident's Boost supply was not in the facility and had not been administered. During an interview at 1:55 pm on 04/10/24, Staff 34 (MT) confirmed the Boost had not been administered on the noted occasions.

The need to ensure orders were carried out as prescribed was discussed with Staff 28 (ED), Witness 2 (Consultant LPN), and Witness 3 on 04/11/24. They acknowledged the findings.

1. Resident 10 - PRN parameters reviewed and updated as needed. Med techs will be educated on PRN medications and using the staff communication binder.

Resident 11 - Boosts were ordered immediately. MT coordinated with provider to ensure those supplements were ordered and delivered in a timely manner.

2. Med techs will be re-trained regarding PRN orders: reason for giving, timely follow-up documentation, and how to manage situations if result is not effective, the importance of following the directions for administration.

Clinical meeting will include review of prns given and medication variances.

3. Daily clinical meetings Monday-Friday. Weekly audits by consultant or designee.

4. ED, LN

Based on interview and record review, it was determined the facility failed to ensure an accurate Medication Administrator Record (MAR) was kept for all medications and treatments that were ordered by a legally recognized prescriber and were administered by the facility for 3 of 6 sampled residents (#s 2, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2023 with diagnoses including dementia and pain.

The resident's 06/01/23 through 09/05/23 MARs and physician orders were reviewed and identified the following:

Resident 2 had an order for staff to "evaluate/observe pain level each shift" and gave instructions for, "0 = no pain to 10 = worst pain." The "hours" listed on the MAR specified, "Day, Eveni[ng], and Night."

There was no numeric documentation of Resident 2's pain.

The need to ensure MARs were accurate with clear parameters for staff was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the the findings.

2. Resident 5 was admitted in 07/2023 with diagnoses including dementia and venous insufficiency.

The resident's 08/01/23 through 09/05/23 MARs were reviewed and identified the following:

* Ammonium lactate external lotion (for venous insufficiency/stasis) was marked as not administered as the "resident was out of the facility" at 8:00 am on 08/10/23. Resident 5 received all other medications and treatments at 8:00 am on 08/10/23.

* Circaid compression wraps (for venous insufficiency) was documented as the resident refused to have them taken off at 9:00 pm on 08/02/23. The compression wraps were signed as applied at 8:00 am on 08/03/23.

* Miconazole powder (for yeast) had a section where staff were to document which "site" at 8:00 am and at 8:00 pm. There were multiple entries where staff documented applying the powder, but not the site applied.

The need to ensure MARs were accurate was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

3. Resident 4 moved into the facility in 05/2023 with diagnoses including dementia and chronic atrial fibrillation.

Resident 4's 08/01/23 through 09/06/23 MARs were reviewed and the following was identified:

The MAR had multiple blank spaces and were missing the initials of staff that administered multiple medications including:

* On 08/15/23: Dutasteride for prostate health, Advair for asthma, Azelastine nasal spray for asthma and Refresh eye drops; and

* Melatonin for sleep on 08/15/23, 08/23/23 and 08/24/23.

Staff 3 (RCC) stated the medications "appeared to have been administered" but were not marked as "administered" on the MAR.

The need to ensure MARs were accurate and included the initials of the person who administered the medications was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3, and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

The Licensed Nurse or designee will print out active orders and current MAR's for resident 2 and send to the PCP for review and updates.

The Licensed Nurse or designee will print out active medicaion orders and current MAR for resident 4 and send to the PCC for review and updates.

The RN or desingee will review medication orders to ensure orders are being carried out on the MAR.

The Licensed Nurse or designee will print out active medication orders and current MAR for resident 5 and send to the PCC for review and updates.

The LN or designee will review all residents orders/EMAR to ensure that at minimum the following directives are in place as directed by regulations, including medication reason for use, specific instructions needed, resident specific parameters and/or instructions for PRN medications, and who to notify if not effective.

The RCC or the designee will hold an all staff meeting for the Med Techs on proper medication administration to include following parameters, noting numeric pain rating, and results, fluid consumption, ect, triple check system, and what to do if medications are not available.

The RCC or designee will audit med administration daily through the 24 hour follow through meeting.  

The RN or designee will complete a monthly med audit.

The RCC will bring the above audit to the QAPI meeting monthly for 3 months or until deficient practice resolves.

The RN will bring the above audit to the QAPI meeting monthly for 3 months or until deficient practice resolves.

2.  Resident 10 was admitted to the facility in 12/2021 with diagnoses including dementia.

Resident 10's 03/01/24 through 04/08/24 MARs and physician's orders, dated 04/04/24 were reviewed.

A physician's order for milk of magnesia as needed for constipation. There were no clear parameters when to administer the medication.

On 04/11/24 at 9:03 am, Staff 30 (MT) reported she was not sure when to administer the medication. She further stated she would communicate with nurses for the use of the medication.

The need to ensure accurate MARs were kept and included instructions for as needed medications was discussed with Staff 28 (ED) and Witness 2 (Consultant, LPN) on 04/11/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions for PRN medications were included on the MAR for 2 of 4 sampled residents (#s 10 and 12) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 2018 with diagnoses including dementia.

The resident's 03/01/24 through 04/08/24 MAR was reviewed and revealed the following:

a. Record bowel movements on each shift.

   There were no recorded bowel movements 03/01/24 through 03/09/24.

b. PRN polyethylene for constipation lacked parameters for administration.

The PRN medication lacked resident specific instructions related to administration of the PRN bowel medication.

The need to ensure PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 28 (ED) and Witness 3 (Consultant RN) on 04/10/24. No additional information was provided.

1. Resident 12 - PRN Bowel medications  were updated with clear instructions.

Resident 10 - PRN Bowel medications were updated with clear instructions.

2. Med techs will be re-trained regarding PRN orders: reason for giving, timely follow up documentation,and how to manage situations if result is note effective, importance of following the order for administration.

LN or designee will perform PRN monthly audits per section. RCC will be trained by LN on how to PRN monthly audits to provide assistance to the LN.

Clinical meeting will include review of prns given and medication variances. 3rd check of any PRNs will include reviewing the parameters.

3. Daily clinical meetings Monday-Friday. Weekly audits by consultant or designee.

4. ED, LN

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications were used only after documented non-pharmacological interventions to treat a resident's behavior were tried with ineffective results for 1 of 1 sampled resident (#7) who was prescribed a PRN medication to address anxiety. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 03/2023 with diagnoses including Alzheimer's disease with early onset and anxiety.

The resident's 06/01/23 through 09/05/23 MARs, physician's orders, and 06/04/23 through 09/05/23 progress notes were reviewed.

The resident was prescribed lorazepam 0.5 mg every eight hours as needed for severe anxiety.

There were three non-pharmacological interventions listed on the MARs to attempt prior to administering the PRN psychotropic medication. Resident 7 was administered lorazepam on four occasions. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administration on the following dates:

* 07/07/23;

* 07/11/23; and

* 09/04/23.

In an interview on 09/06/23, Staff 15 (MT/CG) confirmed there were non-pharmacological interventions to offer Resident 7, but they were not documented as attempted in the MARs or progress notes.

The need to ensure documented, non-pharmacological interventions had been tried with ineffective results prior to the administration of a PRN psychotropic medication was discussed with Staff 1(ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

The RCC or designee will ensure that there are non- pharmaceutical  interventions for resident 7 and they are service planned.

The RCC or designee will ensure that the psychotropic medication for resident 7 has a space provided to document prior to medication administration.

The RCC or the designee will audit all residents with PRN psychotrospic med and insure that non pharmaceutical interventions are in place.

The ouside consultant or the designee will hold a staff meeting with the med techs and interdisciplinary team on the management and administration of psychotropic medications.

The RCC or designee will complete a 10% audit of the residents receiving psychotropic meds monthly to ensure that nonpharmaceutical interventions are tried prior to administration.

The RCC will bring the above audit to QAPI meeting monthly for 3 months or until deficient practice resolves.

3. Resident 5 moved into the facility in 07/2023 with diagnoses including dementia.

On 09/11/23 at 9:14 am, the resident's room was observed and Staff 13 (MT/CG) was interviewed. Resident 5 had a quarter-length side rail attached to the left side of his/her bed. Staff 13 confirmed the bed was "brought in that way." The side rails were observed to be easily moved and loose. Staff 13 confirmed she did not monitor the side rails and didn't know she would need to report to another staff member if they were loose or in disrepair.

An assessment dated 08/10/23 was started, but it was not signed as being completed by an RN, PT, or OT.

There was no documentation related to the use of side rails in Resident 5's service plan.

The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT, staff were trained on the correct use and precautions related to the side rail, and were included in the resident's service plan was discussed with Staff 1(ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, failed to instruct caregivers on the correct use and precautions related to the use of the device, and failed to include the use of the supportive device in the service plan and evaluated on a quarterly basis for 3 of 3 sampled residents (#s 3, 5, and 6) who used a supportive device with restraining qualities. Findings include, but are not limited to:

1. Resident 6 moved into the facility in 01/2023 with diagnoses including dementia and insomnia.

Observations of the resident and interviews with staff indicated the resident had a quarter-length side rail on the left side of his/her bed. The side rail was in good repair and flush with the mattress.

The resident's Individual Service Plan Report, dated 06/22/23, contained no information regarding the side rail. Staff reported the resident was primarily bedbound and received the hospital bed with side rail from the hospice provider.

On 09/06/23, Staff 3 (RCC) confirmed an assessment of the side rail was not completed.

The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1(ED), Staff 2 (RN), Staff 3, and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

2. Resident 3 moved into the facility in 01/2021 with diagnoses including dementia and history of a pubis fracture.

Observations showed the resident had quarter-length side rails on the left and right sides of his/her bed. The resident required staff assistance to get out of bed. A review of the clinical record showed the resident had experienced falls out of bed during the previous quarter.

On 09/06/23, an "Oregon Safety Device Assessment", dated 04/26/23, was provided. A review of the document revealed the following:

* The evaluation had not been updated quarterly;

* The evaluation did not include documentation the resident had been informed of the risks and benefits of using the side rails; and

* Less restrictive alternatives had not been evaluated prior to use.

The need to ensure supportive devices with restraining qualities included the required documentation and were evaluated at least quarterly was discussed with Staff 1(ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Outside consultant or designee will complete supportive devices assessment for resident 3.

Outside consultant or designee will complete supportive devices assessment for resident 5.

Resident 6 has passed away.

Outside consultant completed a full audit for assistive devices and all idenified resident's service plans were completed.

Oustside consultant or designee will do a 10% audit of resident's with assistive devices quarterly to ensure the proper service plans are in place.

The outside consultant will bring the above audit to QAPI for 3 consecutive months or until the deficient practice is resolved.  

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) was reviewed before a resident moved in to the facility, updated with each significant change of condition, was updated no less than quarterly, and the entries were reflective of the resident's current care needs for 6 of 6 residents reviewed (#s 2, 3, 4, 5, 6, and 7). Findings include, but are not limited to:

1. A review of the facility's ABST on 09/08/23 revealed the facility failed to enter the newly admitted residents before move in, updated the residents identified as having significant changes of condition, and update all residents no less than quarterly.

2. Resident 2 was admitted to the facility on 06/13/23 with diagnoses including dementia.

a. Per the facility's ABST, the resident's information was inputted on 06/14/23.

b. Observations of Resident 2, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas:

* Personal hygiene;

* Bathing;

* Non-drug interventions for pain management;

* Providing treatments;

* Cueing or redirecting due to cognitive impairment or dementia;

* Non-drug interventions for behaviors; and

* Monitoring physical conditions.

3. Resident 5 was admitted to the facility on 07/06/23 with diagnoses including dementia.

a. Per the facility's ABST, the resident's information was inputted on 07/06/23.

b. Observations of Resident 5, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas:

* Dressing and undressing;

* Bowel and bladder management;

* Bathing;

* Medication administration;

* Providing treatments;

* Monitoring physical conditions or symptoms;

* Assisting with assistive devices for hearing and vision;

* Responding to call lights; and

* Safety checks and fall interventions.

The need to ensure residents were entered into the ABST system prior to moving into the facility, updated with each significant change of condition, updated no less than quarterly, and the entries were reflective of the resident's care needs was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

6. Resident 6 moved into the facility in 01/2023 with diagnoses including dementia.

Observations were conducted with Resident 6  from 09/05/23 through 09/11/23, and the resident's current service plan, evaluation, completed 06/20/23, progress notes dated 06/04/23 through 09/05/23, and ABST report, last edited 06/15/23, was reviewed and revealed the following:

The ABST report for Resident 6 was not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas:

* Bathing;

* Repositioning in bed or chair;

* Supervising, cueing or supporting while eating;

* Providing treatments; and

* Responding to call lights.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care to the resident was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

7. Resident 7 moved into the facility in 03/2023 with diagnoses including Alzheimer's disease with early onset.

Observations were conducted with Resident 7 on 09/05/23 through 09/11/23, and the resident's current service plan, evaluation, completed 06/09/23, progress notes dated 06/24/23 through 09/05/23, and ABST report, last edited 06/15/23, was reviewed and revealed the following:

The ABST report for Resident 7 was not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas:

* Bathing;

* Supervising, cueing, or supporting while eating;

* Providing treatments;

* Assisting with leisure activities; and

* Responding to call lights.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care to the resident was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

4. Resident 3 moved into the facility in 01/2021 with diagnoses including dementia.

Observations were conducted with Resident 3 on 09/06/23 and the resident's current service plan, evaluation, completed 08/09/23, progress notes dated 06/24/23 through 09/05/23, and ABST report, last edited 06/15/23, was reviewed and revealed the following:

The ABST report for Resident 3 was not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas:

* Grooming;

* Dressing;

* Bowel and bladder management;

* Ambulation, escorting to and from meals and activities; and

* Supervising, cueing or supporting while eating.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care to the resident was discussed with Staff 1 (ED) on 09/11/23. She acknowledged the findings.

5. Resident 4 moved into the facility in 05/2023 with diagnoses including dementia.

Observations were conducted with Resident 4 on 09/07/23 and the resident's current service plan, evaluation, completed 08/29/23, progress notes dated 06/24/23 through 09/05/23, and ABST report, last edited 08/21/23, was reviewed and revealed the following:

The ABST report for Resident 4 was not reflective of the resident's current care needs and had an inaccurate amount of minutes assigned in the following areas:

* Ambulation, escorting to and from meals and activities;

* Providing treatments;

* Cueing or redirecting due to cognitive impairment or dementia;

* Ensuring non-drug interventions for behaviors;

* Assisting with leisure activities;

* Monitoring behavioral conditions or symptoms; and

* Safety checks.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care to the resident was discussed with Staff 1 (ED) on 09/11/23. She acknowledged the findings.

The RCC or designee will review ABST for resident 2 to ensure it meets the individual service plan needs.

The RCC or designee will review ABST for resident 3 to ensure it meets the individual service plan needs.

The RCC or designee will review ABST for resident 4 to ensure it meets the individual service plan needs.

The RCC or designee will review ABST for resident 5 to ensure it meets the individual service plan needs.

Resident 6 has passed away.

The RCC or designee will review ABST for resident 7 to ensure it meets the individual service plan needs.

The RCC or designee will update the ABST with each subsequent resident service plan review.

ED or designee will review 2 service plans a week to ensure the ABST was updated accordingly.

The ED or designee will bring the above audit to the QAPI meeting for 3 months or until the deficient practice is resolved.    

Based on interview and record review, it was determined the facility failed to ensure 5 of 5 direct care staff (#s 8, 10, 11, 12, and 21) had documented evidence for completion of First Aid certification and training in abdominal thrust within 30 days of hire, and direct care staff had sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. Findings include, but are not limited to:

a. Staff training records were reviewed on 09/05/23 at 1:00 pm.

The following direct care staff lacked documented evidence First Aid and abdominal thrust training was completed within 30 days of hire:

Staff 08 (MT/Staffing Coordinator), hired on 07/27/23;

Staff 10 (MT/CG), hired on 03/27/23;

Staff 11 (MT), hired on 07/18/23;

Staff 12 (MT), hired on 07/27/23; and

Staff 21 (CG), hired on 02/25/23.

b. Multiple care staff lacked sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed.

On 09/05/23, at approximately 10:45 am, an interview with Staff 21 (CG) revealed she was unable to respond with sufficient communication and language skills to direct the survey team to the service plan binder on the unit.

On 09/06/23 and 09/07/23, Staff 23 (CG) was interviewed regarding care being provided to Resident 3. Staff 23 was unable to respond with sufficient communication and language skills to enable communication.

On 09/07/23 at 9:20 am, Staff 24 (CG) was interviewed regarding care being provided to Resident 6. Staff 24 was unable to respond with sufficient communication and language skills regarding diet orders for Resident 6.

The need to ensure newly hired direct care staff completed all required training in the specified time frames and staff had sufficient communication skills was discussed with Staff 1 (ED) on 09/05/23 and with Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided.

ED ensured that all med techs without proper training were removed from the cart until med tech training and competencies were verified.

ED ensured all untrained med techs training and competencies were complete.

Outside consultant completed a full staff audit of missing trainings and competencies to include first aid, abdominal thrust.

Outside Consultant alerted all staff to complete all trainings.

Outside consultant scheduled a first aid/abdominal thrust class in the facilty for staff to attend.

Outside consultant completed a training tracker and has placed all staff training on the tracker.

ED or designee will evaluate all staff to identify any that require interpretation or service plans in alternate languages to ensure staff are able to sufficiently communicate.

ED or designee will do a weekly 10% audit of all staff to ensure that their sufficient communication evaluation as well as abdominal thrust training is complete and placed in training binder.

ED or Designee will bring the above audit to QAPI for 3 months or until deficient practice is resolved.

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted and recorded every other month per Oregon Fire Code (OFC), fire and life safety training was conducted on alternate months of the fire drills, and a written fire drill record was kept. Findings include, but are not limited to:

Fire drill and fire and life safety records were requested on 09/05/23 at 12:00 pm.

a. The facility failed to keep a written fire drill record that included the following required components:

* Date and time of day;

* Location of simulated fire origin;

* The escape route used;

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

* Evacuation time period needed;

* Staff members on duty and participating;

* Number of occupants evacuated; and

* Alternate exit routes were used during fire drills to react to varying potential fire origin points.

b. There was no documented evidence fire and life safety training for staff was conducted and recorded on alternating months of fire drills.

On 09/05/23 at 12:30 pm, Staff 4 (Maintenance Director) reported he was unable to locate any fire drill or fire and life safety training records for staff.

The need to ensure fire drills were conducted and recorded every other month per Oregon Fire Code (OFC), and staff were instructed on fire and life safety training on alternating months of the fire drills was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided.

The ouside consultant or designee will review the fire life and safety policy and protocols with the Maintenace Director.

The Maintenance Director or designee will conduct fire drill and staff training as directed in the OAR monthly.

The ED or designee will audit for compliance monthly.

The ED or designee will bring the above audit to QAPI for 3 months or until the deficient practice is resolved.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed about the facility's fire and life safety procedures per Oregon Fire Code (OFC), within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and a written record of fire safety training, including content of the training sessions and the residents attending was kept. Findings include, but are not limited to:

Fire and life safety records for residents were requested on 09/05/23 at 12:00 pm.

On 09/05/23 at 12:30 pm, Staff 4 (Maintenance Director) reported he was unable to locate any fire drill records for the building or resident fire and life safety training records.

The need to ensure residents were instructed about the facility's fire and life safety procedures per Oregon Fire Code (OFC), within 24 hours of admission and re-instructed, at least annually was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings. No further information was provided.

The ouside consultant or designee will review the fire life and safety policy and protocols with the Maintenance Director.

The Maintenance Director or designee will instruct all residents about fire and life safty procedures with any new move in within 24 hrs.Aall residents will be reinstructed annually.  

The Maintenance Director or designee will conduct fire drills and staff training to meet the requirement.

The ED or desginee will audit new admits to ensure they have fire and life safety training as required.

The ED or designee will bring the above audit to QAPI for 3 months or until the deficient practice is resolved.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed with Staff 33 (Maintenance) on 04/09/24 and 04/10/24 and the following deficiencies were identified:

* There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire and life safety training provided at least annually.

The need to ensure residents received fire and life safety training at least annually was discussed with Staff 28 (ED), Staff 33 and Witness 2 (Consultant, LPN) on 04/10/24. They acknowledged the findings.

1. Maintenance Director has begun Fire Safety training to all to residents.

2. Maintenance Director will conduct a fire and safety with the resident upon Admissions and perform annual re-education.

3. ED will audit the fire training log to ensure the training was conducted and properly documented after each training. ED will audit quarterly to ensure annual and new admissions are being completed and documented.

4. ED, Maintenance Director.

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

Refer to C231, C260, C295, C303, C310, C422, C510 and Z155.  

Refer to C231, C260, C295, C303, C310, C422, C510, Z155

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit. Findings include, but are not limited to:

The interior of the building was toured on 09/05/23 at 9:14 am. The following issues were noted:

a. On 09/05/23, toxic disinfectant in a spray bottle was in an unlocked kitchenette cabinet in the Clackamas Neighborhood and in the Columbia Neighborhood.

The kitchenettes were open for residents to enter without staff assistance or supervision.

During a tour of the facility on 09/05/23, with Staff 1 (ED), the disinfectant spray bottles were removed.

b. On 09/08/23 at 9:40 am, in the Clackamas Neighborhood, a disinfectant spray bottle was observed on top of a table in the dining room.

c. On 09/08/23 at 9:45 am, in the Deschutes Neighborhood, a disinfectant spray bottle was observed on top of a side table within reach of multiple residents.

The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 1, Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

The ED and Maintenane Director idenifted 4 cupboards in each community where locks will be installled and chemicals and toxic material will be stored.

ED or designee will hold an all staff meeting to ensure that chemical and toxic materials are locked and stored at all times.

Maintance Director or designee will do a weekly audit to ensure all chemical and toxic materials are locked in storage cabinets.

Maintance Director or designee will bring the above audits to QAPI for 3 months or until the deficient practice is resolved.  

Based on observation and interview, it was determined the facility failed to ensure toxic materials were secured in locked storage. This is a repeat citation. Findings include, but are not limited to:

The facility was toured on 04/09/24 at 9:45 am. The following toxic materials were found in unlocked cupboards in each of the four neighborhood kitchenettes:

* A 1.25 gallon of Lysol disinfectant was in the Deschutes, Columbia, Clackamas, and Sandy neighborhoods.

* Two spray bottles of 730 HP disinfectant cleaner were in the Columbia and Clackamas neighborhoods, and one spray bottle of 730 HP disinfectant cleaner was in the Sandy neighborhood.

* A spray bottle of ZEP air and fabric odor eliminator was in the Deschutes neighborhood.

The kitchenettes were accessible to residents and throughout the survey residents were observed entering the kitchenettes.

On 04/09/24 at 10:20 the facility was directed to removed these chemicals to secured locked storage, which was confirmed as completed.

The need to ensure all toxic materials were maintained in locked storage was discussed with Staff 28 (Executive Director) and Staff 33 (Maintenance) on 04/10/24. They acknowledged the findings.

1. All chemicals were locked up.

2. Care staff task sheet will include checking to ensure chemicals are locked up at the beginning and end of shift and after each meal.

Also, Med Tech in each community will perform an audit on each kitchenette and its cupboards and cabinets to ensure cleaning supplies are locked up.

3. Leadership team will audit the kitchette cupboards and cabinets daily at different times of day.

4. ED, Maintenance Director

Based on observation and interview, the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to:

The facility laundry area was toured on 09/05/23 at 11:15 am with Staff 4 (Maintenance Director).

Staff 4 reported the facility hot water system was designed on a "loop system" which meant all areas of the facility were on a continuous hot water system. The hot water system had to be maintained at 120 degrees F. or lower because the hot water also served resident units.

Staff 4 reported when he started approximately a month ago the facility had a chemical disinfectant that was on an automatic dispense into the washers that were dedicated for soiled clothing and linen however, they were disconnected and stored in a garage in the back perimeter of the property.

Staff 4 confirmed the care staff were currently not using a chemical disinfectant when washing soiled clothing.

The need to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Outside consultant will review the minimum rinse temperatures with the owner of the property and Maintenance Director.

Outside consultant will  reach out to Eco Lab to have the chemical system reinstalled.

Maintenance Director will ensure chemical disinfectant is functional with weekly rounds.

Maintenance Director will bring audits to QAPI monthly for 3 months or until deficient practice has resolved.  

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

Observations on 09/05/23 at 11:40 am, identified exit doors to the "Garden" interior courtyard in the Clackamas and Sandy Neighborhoods did not have an operable alarm or other acceptable system to alert staff when residents exited the building.

On 09/05/23, Staff (CG), stated "usually I hear an alarm when they go outside, but I don't hear it today."

The failure to ensure exit doors were equipped with an alarming device or other acceptable system and were operable was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Outside consultant performed a full facility walk through identifying all exit doors that were not alarming.

Maintenance Director or designee will ensure all exit doors have a fully functioinal alarming device in place.

Maintenance Director or designee will complete a weekly audit insuring all alarms are fully functional.

Maintenance Director or desgine will bring the results of the above  audits to QAPI monthly for 3 months or until the deficient practice is resolved.  

Concerns were identified and the facility was provided with technical assistance in the following areas:

(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Concerns were identified and the facility was provided with technical assistance in the following areas:

(d) Each individual has privacy in his or her own unit.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:

The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence, and comfort. This included the supervision and training of the staff.

During the re-licensure survey, conducted 09/05/23 through 09/08/23, and 09/11/23, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations.

1.  A situation was identified which constituted an immediate plan of correction to residents' health and safety in the following areas:

OAR 411-054-0036 (1), (2), & (4) Service plans;

OAR 411-057-0140 (1) Administration Responsibilities;

OAR 411-057-0155 (3) Staff Training Requirements; and

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

The facility put an immediate plan of correction in place during the survey and the situation was abated.

2.  Refer to deficiencies in the report.

ED ensured that all med techs that do not have proper training were removed from the cart until med tech training and competency were verified.

ED ensured all untrained medtechs training and competencies were complete.

Refer to C 260, Z 155, Z 162, for POC

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 200, C 231, C 295, C 361, C 372, C 420, C 422, C 510, C 530, and C 555.

Refer to POC for C200, C231, C295, C361, C372, C420, C422, C510, C530 and C555.

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 not limited to:

Refer to C231, C295, C422, and C510.

Refer to C231, C295, C422, C510

Based on observation, interview, and record review, it was determined the facility failed to have documented evidence of required pre-service orientation, pre-service dementia training and demonstrated competency within 30 days of hire for 5 of 5 newly hired staff (#s 8, 10, 11, 12, and 21), completion of annual infectious disease prevention for 2 of 2 non direct care staff, and a total of 16 hours of annual in-service training which included 6 hours of dementia care topics for 3 of 4 (#s 9,18, and 22). Additionally, the facility failed to ensure 6 of 10 MT's (#s 8,10,11,12, 17, and 27) had documented evidence of completion of medication administration competency. This constituted a situation which put resident care needs at risk related to a lack of medication training. Findings include, but are not limited to:

Staff training records were reviewed on 09/05/23 and 09/08/23 and the following was identified.

1. On 09/08/23, the survey team asked to review all MT competency training. The facility failed to ensure 6 of 10 MT's (#s 8,10,11,12, 17, and 27), completed required competency training in medication and treatment administration.

On 09/08/23 Staff 17 (MT/CG) was observed passing medications to residents without having completed medication competency, at which time survey requested an immediate plan of correction which included removing all untrained MT's from the task of passing medications and treatments until training was completed and competency was demonstrated. The survey team received the immediate plan of correction on 09/08/23 at 6:23 pm.

On 09/11/23 at 11:06 am, Staff 17 was observed passing medication to residents.

On 09/11/23 at 11:23 am, the surveyor discussed the observation with Staff 1 (ED) and requested Staff 17's documented medication competency. Staff 1 stated, "we are aware, [Staff 9 (MT)] was supposed to train her [Staff 17] last week [on 09/08/23], but the training didn't happen. She [Staff 9], is coming in right now and will train and shadow her until the medication competency is completed."

Later in the day on 09/11/23, observations confirmed Staff 9 was training and working with Staff 17. The situation was abated.

2. Training records for Staff 8 (MT/Staffing Coordinator), Staff 10 (MT/CG), Staff 11 (MT), Staff 12 (MT), Staff 17 (MT), Staff 21 (CG), and Staff 27 (MT), hired on 07/27/23, 03/27/23, 07/18/23, 04/10/23, 07/27/23, 02/25/23, and 03/10/23, respectively, identified the following:

a. Staff 8, 10, 11, 12, and 21 lacked documented evidence pre-service orientation training was completed prior to beginning job responsibilities in all or some of the following areas:

* Resident rights and values of community based care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures; and

* Written job description.

b. Staff 8, 10, 11, 12, and 21 lacked documented evidence pre-service dementia training including how to provide personal care to residents with dementia, an orientation to the resident's service plan and the use of supportive devices with restraining qualities was completed prior to independently providing care and services to residents.

3. Staff 8, 10, 11, 12, 17, 21, and 27, lacked documented evidence of knowledge and performance demonstrated within 30 days of hire in one or more of the following required areas:

* Role of the service plan in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting changes of condition;

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving, and sanitation; and

* Other duties as applicable, which included competency in medication and treatment administration.

4. Staff 25 (Dietary) and Staff 26 (Housekeeping), hired 04/13/21 and 08/15/18, respectively, lacked documented evidence for completion of annual infectious disease prevention training.

5. Staff 09 (MT/CG), Staff 18 (CG) and Staff 22 (CG), hired 07/20/17, 09/14/17, and 05/13/19 respectively, lacked documented evidence of completion of 16 hours of annual in-service training which included annual infection control training and at least six hours of dementia care training.

The need to ensure all required training was completed in the specified time frames was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

ED ensured that all med techs without proper training were removed from the cart until med tech training and competencies were verified.

ED ensured all untrained med techs training and competencies were complete.

Outside consultant completed a full staff audit of all missing trainings and competencies to include first aid, abdominal thrust, food handlers cards, pre-service orientation training, infection control training for non-direct care staff and the 16 hours of annual training (including the six hours of dementia care training).

Outside Consultant alerted all staff to complete all trainings.

Outside consultant scheduled a first aid/abdominal thrust class in the facilty for staff to attend.

Outside consultant completed a training tracker and has placed all staff training on the tracker.

ED or designee will do a weekly 10% audit of all staff to ensure that there training is complete and placed in training binder.

All med techs have been reviewed by ED to determine if required training has been completed. All identified med techs that do not have sufficient training have been removed from the schedule and will not be passing medications until training completed by ED. Trained med techs or outside agancy staff will be passing medications for any open med tech shifts to be managed by ED or designee.  

All untrained med techs will be trained by qualified med tech or Licensed Nurse.

ED or designee will complete a full staff audit of pre service training and training within 30 days of hire and assign staff any delinquent training for completion.

Med techs and caregivers will not be placed on the floor until their required training is completed and tracked in the training log. This will be managed by the RCC or designee.

A training log will be created and maintained by the ED or designee.

The ED or designee will complete a weekly audit times four weeks to ensure all required training is in place and that the training log is being used correctly and then monthly thereafter.

Ads will be placed by ED or designee to hire more med techs and care staff

If there is not sufficient med tech and care staff coverage the staffing coordinator or designee will notify the ED and come up with a plan to fill with qualified trained staff up to and including agency use.

ED or Designee will bring the above audit to QAPI for 3 months or until deficient practice is resolved.

Based on interview and record review, it was determined the facility failed to have documented evidence of demonstrated competency in any job duty within 30 days of hire pursuant to OAR 411-054-0070(5) for 2 of 2 newly hired staff (#s 35 and 36) and of a system in place to ensure all direct care staff completed a minimum of 16 hours of inservice training annually. This is a repeat citation. Findings include, but are not limited to:

a. Staff training records were reviewed with Staff 37 (Business Office Manager) at 3:14 pm on 04/10/24. There was no documented evidence appropriate facility staff documented they observed and evaluated Staff 35's (MT), hired 02/09/24, and Staff 36's (MT), hired 03/19/24, ability to perform safe medication and treatment administration unsupervised. During an interview at 11:06 am on 04/11/24, Staff 28 (ED) confirmed the two staff members would not administer medications to residents until their competency was evaluated by appropriate facility staff.

b. During an interview at 10:45 am on 04/11/24, Staff 37 was asked to explain the facility's process for providing annual in-service training to staff. Staff 37 stated the facility's goal was to assign courses through an online training program as well as complete training via monthly all staff meetings, and the facility would monitor the courses and hours of training completed by staff. Staff 37 stated this had not been initiated yet.

The need to ensure documented evidence of competency in any job duty pursuant to OAR 411-054-0070(5) and a system in place to ensure all direct care staff completed a minimum of 16 hours of inservice training annually was discussed with Staff 28 on 04/11/24. He acknowledged the findings, and no further documentation was provided.

1. Business Office Manager to audit and assign all training to meet annual training of 16 hours. Competency checklists will be completed for all med techs and evaluated by LN.

2. All staff will be required to attend all staff meetings as they will include continuing education hours. They will also be assigned online training modules to ensure the annual six hours of dementia and a total of sixteen hours of annual training.

3. Business office manager will audit weekly until all training is up to date, then monthly to ensure ongoing compliance.

4. ED, Business Office Manager

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 252, C 260, C 262, C 270, C 280, C 290, C 300, C 302, C 303, C 310, C 330, and C 340.

Refer to POC to C252, C260, C262, C280, C290, C300, C302, C303, C310, C330, and C340.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C260, C303, and C310.

Refer to C260, C303, and C310

4. Resident 3 moved into the memory care community in 01/2021 with diagnoses including dementia.

Review of the resident's service plan, last updated 08/26/23, revealed the following:

The service plan did not include any information related to the resident's nutritional needs or an individualized nutritional plan.

The need to ensure an individualized nutrition and hydration plan was included in the service plan was discussed with Staff 1 (ED) and Staff 5 (Contractor) on 09/08/23 and 09/11/23. They acknowledged the findings.

5. Resident 4 moved into the memory care community in 05/2023 with diagnoses including dementia.

The resident's current service plan, last updated 08/29/23, lacked documentation of an individualized nutrition and hydration plan.

The need to ensure the resident had an individualized nutrition and hydration plan documented in the service plan was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

2. Resident 2 admitted to the facility in 06/2023 with diagnoses including dementia.

The resident's current service plan, updated 06/20/23, was not available to staff.

Resident 2's daughter provided some information to the facility relating to food and beverage preferences. The resident's electronic service plan was not reflecitive of the information provided.

The need to ensure residents had an individualized nutrition and hydration plan was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

3. Resident 5 admitted to the facility in 07/2023 with diagnoses including dementia.

Although there was information the resident's spouse provided to the facility relating to food and beverage preferences, staff didn't have access to the information.

The resident's current electronic service plan, updated 07/16/23, lacked documentation of an individualized nutrition and hydration plan. The information the facility listed as food preferences ("meat and potatoes") was not reflective of the information Resident 5's spouse provided.

The need to ensure residents had an individualized nutrition and hydration plan was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 5 of 7 sampled residents (#s 2, 3, 4, 5, and 8), whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 8 moved into the memory care community in April 2023.

On 09/11/23, Resident 8 was observed to sleep in later in the morning and missed breakfast.

On 09/11/23 at 9:08 am, Staff 20 (CG) reported Resident 8 often sleeps in. "We save a plate in the warmer cart for awhile until we need to send it back. We can give [the resident] a snack." An alternative meal option was not offered.

Resident 8's "individualized service plan report" (s) dated 06/22/23 and 07/14/23 were reviewed.

There was no documented evidence the facility developed and implemented an individualized nutrition and hydration plan which included information regarding missed meals, alternative meal options, or food and fluid preferences.

The need to ensure the facility developed individualized nutrition and hydration plans for Resident 8 was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Resident 2 service plan  will be updated to include an individualized nutrition and hydration plan.

Resident 3 service plan will be updated to include an individualized nutrition and hydration plan.

Resident 4 service plan will be updated to include an individualized nutrition and hydration plan.

Resident 5 service plan will be updated to include an individualized nutrition and hydration plan.

Resident 8 service plan will be updated to include an individualized nutrition and hydration plan.

RCC or designee will complete a full house audit to identify any other residents requiring an individualized nutrition and hydration plan and update the service plan accordingly.

ED or  designee will complete a weekly audit of 2 service plans ensuring that the nutrition and hydration plan is person-centerd for the individual resident.

ED or designee will bring the results of the audit to QAPI for 3 months or until the deficient practice is resolved.  

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations addressed all required components, and individualized activity plans were developed for 7 of 7 sampled residents (#s 2, 3, 4, 5, 6, 7, and 8) whose activity plans were reviewed. Findings include, but are not limited to:

Resident's 2, 3, 4, 5, 6, 7, and 8's records were reviewed and observations were made during the survey. There was no documented evidence activity evaluations were completed and included the following:

* Past and current interests;

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitation;

* Adaptations needed to participate;

* Identification of activities for behavioral interventions; and

* There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.

The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. The findings were acknowledged.

Outside consultant or designee will provide training to Activities staff on how to complete evlauations and service plans.

Activities Director or designee will complete resident 2 evaluation and make TSP/SP updates.

Activities Director or designee will complete resident 3 evaluation and make TSP/SP updates.

Activities Director or designee will complete resident 4 evaluation and make TSP/SP updates.

Activities Director or designee will complete resident 5 evaluation and make TSP/SP updates.

Resident 6 has passed away.

Activities Director or designee will complete resident 7 evaluation and make TSP/SP updates.

Activities Director or designee will complete resident 8 evaluation and make TSP/SP updates.

Activities Director or designee will complete a full house audit identifying all residents who need an updated evaluation and SP.

Activities Director or Designee will complete the identified evaluations and SP/TSP.

Activities Director attended a Life Enrichement Webinar  9/23/23 through Oregon Care partners for further training and education.

ED or designee will do a weekly audit reviewing two SP to ensure that they have person-centered, meaningful activites present.

ED or designee will bring the results of the above audit to QAPI for 3 consecutive months or until deficient practice resolves.    

2. Resident 2 admitted in 06/2023 with diagnoses including dementia.

A review of the resident's clinical records, including progress notes, dated 06/13/23 through 09/04/23, and Temporary Service Plans (TSPs), revealed the resident thought other residents were stealing his/her personal items. Resident 2 had four instances of yelling and physical altercations with other residents. Resident 2 displayed signs of agitation and aggression when staff would explained to him/her that no one had stolen the items in question.  

A service plan, last updated on 06/20/23, was printed and reviewed. The service plan lacked information relating to any behaviors. TSPs dated 07/01/23, 07/14/23, and 07/25/23 only identified Resident 2 had been in resident to resident altercations. There was no behavior evaluation nor were the behaviors included on the service plan.  

The need to ensure behavioral symptoms which negatively impacted the resident and others were evaluated and included on the service plan was reviewed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident behaviors which negatively impacted themselves or others were evaluated and included in the service plan for 2 of 3 sampled residents (#s 2 and 8). Resident 8 repeatedly exhibited verbal and physically aggressive behaviors that negatively impacted him/herself and others in the community. Findings include, but are not limited to:

1. Resident 8 moved into the facility in April 2023 with diagnoses including dementia with unspecified psychotic disturbance.

Resident 8's most recent "individualized service plan report"(s), which provided a summary of services for the resident, dated 06/22/23 and 07/14/23, and progress notes dated 07/01/23 through 09/08/23 were reviewed. Staff documented daily and on each shift if a behavior was observed. The following behaviors were documented:

* Physical aggression such as grabbing, slapping, hitting, and punching staff;

* Verbal aggression which included yelling and cussing toward staff and residents;

* Resistive to care when providing bathing, personal hygiene, oral care, incontinent care, and wound care;

* Wandering into other resident rooms; and

* Urinating on other residents' property.

The 06/22/23 "Service Plan Report" had nothing documented under behaviors. The 07/14/23 "Service Plan Report" noted "assess and anticipate [residents name] needs, under the section "behavior/mood".  The service plan reports failed to include the following:

* A description of the resident's behaviors (as noted above); and

* Resident specific interventions or approaches for staff to utilize for each type of behavior.

There were no temporary service plans available.

The facility failed to evaluate the resident's behaviors and updated the service plan.

Resident 8 continued to have behaviors that negatively impacted him/herself and others in the community.

On 09/11/23, the need to ensure behaviors were evaluated and the service plan to address behaviors which negatively impacted the resident and others in the community was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant). The findings were acknowledged.

Service plan will be reviewed for by RCC or designee for resident 2 to insure behavior that impacted themselves and others is managed on service plan with behavioral interventions.

Service plan will be reviewed by RCC or designee for resident 8 to insure behavoir that impacted themselves and others is managed on service plan with behavialor interventions.

RCC or designee will complete a full house audit identifing any resident with behaviors and insure they are service planned with interventions.

ED or designee will compete a weekly audit of 2 service plans ensuring if the resident has behaviors they are service planned with behavioral intervention.

ED or designee will bring the results of the above audlt to QAPI for 3 months or until the deficient practice is resolved.

Based on observation and interview, it was determined the facility failed to ensure doors to the secure outdoor recreation area were unlocked unless it was during the nighttime or during severe weather, and failed to have a written policy. Findings include, but are not limited to:

During an environmental tour of the facility on 09/05/23 at 9:52 am, the interior "Park" courtyard door in the Columbia Neighborhood was locked. The weather was currently sunny with no precipitation.

During an interview and tour of the facility on 09/05/23 at 1:00 pm, with Staff 1 (ED), the interior "Park" courtyard door was observed to be locked. The surveyor requested a copy of the facility's written policy for when the interior courtyard doors would be locked.

On 09/08/23 at 11:06 am, the interior "Park" courtyard door in the Sandy Neighborhood was observed to be locked.

On 09/08/23 at 11:23 am, the surveyor reported to Staff 1 that the interior "Park" courtyard door continued to be locked. The surveyor requested the facility's written policy. Staff 1 acknowledged and stated she would provide a policy. As of the survey, no policy was given to the survey team.

The need to ensure the facility had a written policy for when the secured courtyard doors would be locked was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. No further information was provided.  

Outside consultant will create a policy for managing out door coutyard doors.

Outside consultant or designee will do a weekly random audit at random time to ensure the policy is being followed.

Outside consultant or designee will bring the results of the audit to QAPI for 3 months or until the deficient practice is resolved.

Based on observation and interview, it was determined the facility failed to ensure the outside perimeter fence gate allowed for egress in the event of an emergency. Findings include, but are not limited to:

The facility's outdoor areas were toured on 09/05/23. A perimeter fence gate between the outer "Garden" patio and surrounding property at the back of the building was observed to have a keypad locking device.

On 09/05/23 at 12:00 pm, Staff 4 (Maintenance Director) reported, "all egress doors should disengage, but I haven't done a fire drill yet, so I can't say for sure that they do."

On 09/05/23 at 12:30 pm, Staff 18 (CG) and Staff 24 (CG) reported they were not aware if the gate unlocked during an emergency or if they needed to enter a code on the keypad. Additionally, Staff 18 and 24 were unable to recall what the keypad code was.

The need to ensure the outside perimeter fence gate allowed for egress in the event of an emergency was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC), and Staff 6 (Consultant) on 09/11/23. They acknowledged the findings.

The code to the key pad of the outside egress gate was posted by the front desk staff.

The Maintance Director or the designee will complete a fire drill to ensure that the Egress door disenages properly.

Maintance Director or designee will complete a walk- through audit weely to ensure all posted codes are in place to exit doors or gates.

MaintenaDce director or designee will bring the audits to QAPI for 3 months or until the deficient practice is resolved.