The findings of the re-licensure survey, conducted 02/27/23 through 03/03/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/03/23, conducted 07/17/23 through 07/19/23, 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, and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 03/03/23, conducted 10/24/23 through 10/26/23, 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, and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the third revisit to the re-licensure survey of 03/03/23, conducted 12/19/20 through 12/20/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

During the re-licensure survey, conducted 02/27/23 through 03/03/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to the deficiencies identified in the report.

OAR 411-054-0025 Facility Administration:  Operation3   

1.  All citations in this report have been reviewed and plan of correction implemented. See all specific details in the plans outlined below. Plan of Correction date 5/2/2023

2.  Administrator will enforce monthly quality control audits to be completed by each department as designated.  

3.  Any concerns identified through quality control audits will corrected.

Based on interview and record review, it was determined the facility failed to have effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

A group interview was conducted on 02/28/23 with multiple residents who expressed concerns including the following:

* Floors and surfaces in common areas were in need of cleaning;

* Responses from care staff to calls for assistance consistently took longer than 30 minutes on night shift;

* Medications were often administered "late";

* Meals lacked variety, were often served cold, the menu changed without notice and food items were not available; and

* The facility "Garden Club" property had been damaged and removed without investigation.

The monthly Resident Council meeting notes from 10/2022, 11/2022, 12/2022 and 01/2023 were reviewed and included the resident concerns. Residents confirmed the meeting notes were provided to administration and concerns had been expressed by use of a "grievance form" and direct conversations with administrative staff. Efforts had not been made to address and resolve resident concerns.

During an interview on 03/02/23, a non-sampled resident stated they were not aware of the facility's process for reporting concerns and stated they "just tell caregiving staff" when they have a concern and "hopefully it gets to the nurse or the person in charge". The resident stated s/he had concerns related to billing that were not being addressed and the resident stated s/he "had to get my daughter to help me work with the business office".

In an interview on 02/28/23, Staff 1 (Executive Director) acknowledged the facility did not have a system in place to document how the facility attempted to resolve complaints that residents shared with them.

The need to ensure the facility had effective methods of responding to and resolving resident complaints was discussed with Staff 1 on 03/01/23. She acknowledged the findings.

OAR 411-054-0025 Facility Administration:  Policy and Procedure

1.  Grievance Policy & Procedure has been reimplemented to ensure documentation of grievance and how it is responded. A digital grievance log will be maintained online by the Administrator with RDO oversight.

2. Grievances will be taken by the Administrator at resident's request.

3.  Administrator will take necessary arrangements to correct the issue.

4.  Administrator will meet with the resident at the conclusion of the issue to explain how it was handled, if appropriate.  

5.  The Administrator will document alll relevant information regarding a resident grievance.  

6.  The digital grievance log will be maintained to ensure history and resolution.

7.  Residents will be educated on this process by the Administrator upon move in and in monthly resident council meetings. Residents will have access to the forms for filing a grievance.

8.  The Administrator will review Resident Council meeting notes for grievances and discuss individually or as a group with residents.  Which ever is more appropriate for the particular grievance.

9.  Staff members will be trained on the grievance process so that they can assist residents with making sure Administration is aware of concerns.

Based on interview and record review, it was determined the facility failed to have effective methods of responding to and resolving resident complaints. This is a repeat citation.  Findings include, but are not limited to:

A group interview was conducted on 07/17/23 with multiple residents who expressed concerns regarding lack of resolution to grievances.

During group, a non-sampled resident stated, "They always say 'we'll get on to it, we're doing the best we can.' They try to get you not to complain by telling us they're working on it" but there was no resolution.

In an interview on 07/19/23, Staff 18 (Reception) indicated that the grievance forms were in the binder sitting on her desk. Residents could ask for them, fill them out and return the form to her. Then she gives the form to Staff 22 (Executive Director).

In an interview with Staff 22 on 07/19/23, she acknowledged the grievance forms were received from Staff 22, then the grievances were typed up. Staff 22 acknowledged there was not a system in place for resolving the grievances and following up with the residents about resolution.

The need to ensure the facility had effective methods of responding to and resolving resident complaints was discussed with Staff 22 on 07/19/23. She acknowledged the findings.

{C 154} OAR 411-054-0025 (7) Facility Administration:  Policy and Procedure

1.  Grievance Policy & Procedure has been reimplemented to ensure documentation of grievance and how it is responded to. A digital grievance log will be maintained online by the Administrator.

2. Grievances will be taken by the Administrator at resident's request. Otherwise, they will be given in writing to the Receptionist at the front desk.

3.  Administrator will take necessary steps to correct any issue.

4.  Administrator will meet with the resident at the conclusion of the issue to explain how it was handled, if appropriate.  

5.  The Administrator will document all relevant information regarding a resident grievance on the digital grievance log.  

6.  The digital grievance log will be maintained to ensure history and resolution.

7.  Residents will be educated on this process by the Administrator upon move in and in monthly Community Town Hall meetings. Residents will have access to the forms for filing a grievance.

8.  The Administrator will review Resident Council meeting notes for grievances monthly and respond in writing accordingly. A copy will be provided to residents upon request.

9.  Staff members will be trained on the grievance process so that they can assist residents with making sure Administration is aware of concerns.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

Resident 8 was admitted to the facility 02/2017 with diagnoses including Asperger's and a hoarding disorder.

On 02/28/23, an unsampled resident reported a concern regarding the condition of Resident 8's apartment. The resident reported "hoarding" conditions and was concerned regarding the potential for "mold" and other health concerns.

Observations and interviews with staff indicated Resident 8 was not allowing staff or housekeeping into his/her apartment. Staff reported, during  the warmer weather, flies and pervasive odors come from the resident's apartment. Staff stated, the last time they were able to get into Resident 8's apartment was four months ago when the resident had gone out of town. Staff reported the resident's apartment was filled with garbage, boxes, papers, and rotting food.

The concerns regarding Resident 8's living conditions were discussed with Staff 1 (Executive Director) who reported she was unaware of these concerns. Resident 8's living conditions posed a health and safety risk to him/her self and to the other residents living in the community.

On 03/01/23 at 4:00 pm, it was reported that Resident 8 was currently out of the facility. The surveyor, Staff 1, and Staff 21 (Housekeeper) made observations of  Resident 8's apartment from the hallway. The following were identified:

* Empty food containers scattered and piled in multiple areas;

* Boxes and buckets stacked against the walls;

* Wrappers, papers, and garbage throughout; and

* There were no clear pathways observed in the apartment.

Staff 1 stated she would be contacting Resident 8's caseworker along with creating a plan to address Resident 8's apartment.  

The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety and welfare of residents was discussed with Staff 1, Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC) on 03/03/23. They acknowledged the findings.

OAR 411-054-0025 (4) Reasonable Precautions

Resident with hoarding behaviors

1.  Administrator has reached out to Medicaid case manager to possibly add mental health services for resident.

2.  Resident has agreed to allow the Office Manager to enter his room once weekly with a large black trash bag. Resident gets to choose what to throw away but must fill the bag each week.  

3.  Twice weekly will occur during the summer months to ensure no odors or flies.  

4.  Office manager will work with resident to allow housekeeping to enter as well.

5.  Administrator will conduct monthly visits to resident's room to ensure cleanliness is being maintained.   

Based on observation, interview and record review it was determined the facility failed to ensure residents received services in a manner that protected privacy and dignity in a homelike environment and were free from neglect for 2 of 8 Residents (#s 4 and 5). Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 01/2020 with diagnoses including diverticulitis, diabetes and osteoarthritis.

During an interview on 02/28/23 at 10:20 am Resident 5 reported that a few weeks prior, while out of the facility, staff had entered his/her apartment without the resident's knowledge or consent and removed all personal medications from the apartment, to include over the counter pain and bowel care medications that Resident 5 reported s/he was self administering as needed.

On 03/01/23 at 10:00 am Staff 2 (RN) reported that sometime between Thanksgiving and Christmas of last year she began to have concerns regarding the resident's safety with self administering medications. The RN stated that while Resident 5 was out of the facility shopping, she entered the apartment and removed all medications without the resident's knowledge or consent.

The facility failed to provide Resident 5 services in a manner that protected privacy and dignity when they entered, searched and removed medications from the apartment without the resident's knowledge or consent.

The need to ensure residents receive services that protects privacy and dignity was discussed with Staff 1 (Executive Director), Staff 2, Staff 3 (Regional Support Nurse) on 03/01/23.  Staff 2 stated she now knew that she needed consent prior to entering, searching and removing personal belongings from a resident's room.

2. Resident 4 was admitted to the facility in 05/2019 with diagnoses including dementia.

Resident 4's record and interviews with staff indicated the resident was receiving hospice services since 12/30/22. The current service plan, dated 01/29/23, instructed staff to "cut up all meats and any large food items", "assist with setting up meals on tray over the bed" and to "open any utensils and help direct where things are on the plate." Progress notes on 01/30/23 documented trying finger foods to help with eating.

Observations on 02/28/23 at 4:50 pm in Resident 4's room revealed plastic utensils sealed in packaging and a Styrofoam container with the lunch meal of pot roast on the table next to the kitchenette. The pot roast had not been cut into bite sized pieces and the meal was not within reach of the resident on his/her bedside table. The location of the un-eaten lunch was reported to Staff 6 (RCC).

On 03/01/23 hospice staff was observed moving an unopened Styrofoam container with scrambled eggs, three whole pieces of bacon and a whole biscuit to the kitchenette sink and unopened plastic utensils. The hospice staff stated the meal was cold upon his/her arrival and "s/he can't eat this."

At 9:39 am, Staff 6 (RCC) arrived at Resident 4's room and reported she would request a new breakfast on a "scoop plate." During observations from 9:30 am to 12:25 pm on 03/01/23, no food was delivered. Lunch was served to Resident 4 at 12:25 pm.

In an interview on 03/01/23, Witness 1 reported they frequently visited Resident 4 and observed meals were not being delivered to the bedside table. Plates of food were, instead, left on the kitchenette counter and meal set-up and cuing were not being provided by staff. Witness 1 stated when meals were reheated, set up properly and cuing provided to initiate the meal, the resident would eat "quite well". Witness 1 stated they communicated these concerns to facility staff, hospice staff and the Ombudsman on multiple occasions.

Based on observations and interviews, the facility failed to provide Resident 4 with needed assistance and service planned care to ensure s/he remained free from neglect.

The need to ensure residents received services and remained free from neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/01/23. They acknowledged the findings.

OAR 411-054-0027 (1) Resident Rights and Protection

1.  Training regarding resident 5 was given immediately to Staff 2 (RN).

2.  Training regarding resident 4 was given immediately to care staff and dietary aides.

3.  R4 - Meals will be placed on the table over her bed and be set up appropriately with silverware opened and resident receiving encouragment to eat at the start of the meal.  Administrator/designee will review that procedure is being done weekly and spot checked to ensure compliance.    

4.  The community will review resident rights during orientation and staff meetings at least annually.

5.  All staff in-serviced on resident rights between 3/28/2023 and 5/2/2023.

Based on interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were promptly investigated and immediately reported to the local Seniors and People with Disabilities (SPD) office and failed to ensure injuries of unknown cause were promptly investigated and immediately reported to the local SPD office if the facility's investigation did not reasonably conclude the injury of unknown cause was not the result of abuse for 3 of 5 sampled residents (#s 1, 3 and 7) whose records were reviewed. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 12/2022 with diagnoses including repeated falls.

Interviews with staff and Resident 7 and review of Resident 7's clinical records including progress notes, evaluations, service plans, incident reports and hospital after visit summaries dated 12/22/22 through 02/28/23 revealed the following:

a. In a progress note dated 02/22/23, staff documented Resident 7 was "found on the floor in front of [his/her] heater. [Resident 7] stated [s/he] did not know how this happened. Did complain of pain in [his/her] head". The resident was sent to the hospital and returned to the facility with diagnoses of transient unconsciousness, contusion of occipital region of the scalp and contusion of the right hip.

There was no documented evidence the facility promptly investigated the incident involving the unwitnessed fall with injury on 02/22/23, as the facility's investigation was dated 02/28/23, six days after the incident occurred.

b. During an interview on 02/28/23, Resident 7 reported concerns related to allegations of verbal abuse from an unknown staff member following his/her falls which occurred the previous week. Resident 7 stated unknown staff members told him/her that another staff member called the resident profane names and told the other staff members not to provide care to him/her. Resident 7 stated s/he had not reported this to the facility and s/he was concerned about possible retaliation by the staff member, but s/he did give the surveyor permission to report the incident to the facility.

The facility was notified of the resident's statement alleging verbal abuse and completed an internal investigation on 02/28/23. The investigation noted the facility determined abuse was ruled out and noted a staff member involved stated they told Resident 7 "if [s/he] was on the call pendant every 5 minutes [his/her]service plan would go up." The surveyor reported the incident to the local SPD office prior to survey exit.

The need to ensure incidents of abuse, suspected abuse or injuries of unknown cause were promptly investigated and immediately reported to the local SPD office was discussed with Staff 1 (Executive Director) on 03/02/23 and Staff 2 (RN) on 03/03/23. They acknowledged the findings and reported the incident involving the unwitnessed fall with injury to the local SPD office per the survey team's request. Confirmation of the report was provided prior to the survey team's exit.

3. Resident 1 was admitted to the facility in 04/2016 and was dependent on staff for all ADL care needs and bedbound.

The resident's record, including progress notes and incident investigations from 11/29/22 through 02/27/23 were reviewed and identified the following:

A facility progress note dated 01/31/23 reported "[Resident 1] being placed on alert for skin tear to [his/her] upper arm, resident does not know how [s/he] got it." "[Resident 1] is also nonverbal." "Staff do not know how this happened." It was further noted the "wound was cleaned and wrapped."

There was no documented evidence the facility ruled out abuse/neglect and reported the injury of unknown cause to the local SPD.

The need to ensure injuries of unknown cause were investigated in a timely manner to rule out abuse and/or neglect, and reported to the local SPD if abuse and/or neglect could not reasonably be ruled out, was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC) on 03/02/23. They acknowledged the findings.

The facility was asked to report the above injury of unknown cause to the local SPD office. Confirmation of the report was provided prior to survey exit.

2. Resident 3 resided at the facility since 04/2021.

On 02/28/23 during a group interview, multiple residents reported an incident that had occurred in January, 2023. Residents reported a female resident was "choking during lunch in the dining room" and another resident "had to perform the Heimlich" because there were no staff around. During an interview on 03/02/23, Resident 3 confirmed s/he had performed the Heimlich thrust after s/he observed the resident choking. Resident 3 stated s/he called out for staff to help, however staff arrived just after the abdominal thrust was performed and the food dislodged from the resident's throat. Resident 3 stated s/he believed the abdominal thrust caused a fracture to the choking resident's ribs.

Incident reports were requested on 03/02/23. There was no incident report, however the alert charting notes, dated 01/07/23 through 01/13/23 documented an unsampled resident experienced a choking episode and received abdominal thrust from another resident before staff had been able to respond. The alert note, dated 01/10/23 and completed by Staff 2 (RN) stated the resident later went to the emergency department, related to complaints of chest pain, and was diagnosed with "several cracked ribs".

In an interview on 03/02/23, Staff 1 (Executive Director), and Staff 2 (RN) stated the incident had not been reported to APD as staff believed abuse or neglect had been ruled out. Staff 1 and 2 confirmed there had been no additional investigation conducted of the incident that included time, date, place and individuals present; response of staff at the time of the event; follow-up action; and Administrator's review.

The need to investigate the incident of suspected abuse and neglect related to the injury and to report the incident to the local APD was discussed with Staff 1, and Staff 2 on 03/02/23. Documentation that APD was notified of the incident was requested and provided before the end of the survey.

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

1.  Entire staff will be taking an approved online class regarding Abuse Reporting and Investigating.  This will be done by 4/30/2023.

2.  Health Services Leadership has been in-serviced on state required reporting and investigating abuse and company policy in regard to timely incident and investigation documentation.  Incident reports and investigations routinely reviewed by Administrator/Health Services Leadership.

3.  Abuse reporting and investigating will be part of new hire orientation, annual in-service trainings and as needed.

4.  Administrator/Department Head will review training compliance monthly.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and falls with injury were promptly investigated to rule out abuse, and reported to the local Seniors and People with Disabilities Office (SPD) if abuse or suspected abuse could not be ruled out for 1 of 3 sampled residents (#10) whose record was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 04/2022, with diagnoses including congestive heart failure, atrial fibrillation and was blind.

Interviews with staff and review of Resident 10's clinical record, including incident reports, progress notes dated 05/02/23 through 07/17/23, service plans, temporary service plans (SPA) and physician communication forms revealed the following:

* A progress note dated 05/29/23 indicated Resident 10 was found on the floor with his/her head under the bed, and complained of severe pain (level "10") to the back and right hip.  The resident was unable to tell staff what had occurred and was sent to the emergency room for further evaluation of the pain resulting from the fall.  There was no documented evidence an investigation was completed to rule out abuse, or that the facility reported the incident to the local SPD office.

* On 07/01/23, a faxed communication to the physician reported a bruise to Resident 10's right wrist with cause unknown. There was no documented evidence the bruise was investigated  to rule out abuse, or that the facility reported the incident to the local SPD office.

On 07/18/23 Staff 23 (Regional Health Services Support, RN) reported that there were no investigations completed related to the fall with injury or the bruising to the right wrist, and the incidents had not been reported to the local SPD.

The need to ensure unwitnessed falls with injury and injuries of unknown cause were promptly investigated, and incidents were immediately reported to the local SPD if abuse or suspected abuse could not be ruled out was discussed with Staff 22 (Executive Director) and Staff 23 on 07/19/23. They acknowledged the findings and reported the required incidents to the local SPD office per the survey team's request; confirmation was provided.

{C 231} OAR 411-054-0028 (1-3) Reporting & Investigating Abuse - Other Action

1.  Care team leadership and Admin will be retaking an approved online class regarding Abuse Reporting and Investigations.  This will be done by 08/31/2023.

2.  Health Services Leadership has been in-serviced on state required reporting and investigating abuse and company policy in regard to timely incident and investigation documentation.  Incident reports and investigations routinely reviewed by Administrator/Health Services Leadership.

3.  Abuse reporting and investigating will be part of new hire orientation, annual in-service trainings and as needed.

Based on interview and record review, it was determined the facility failed to ensure falls with injury were promptly investigated to rule out abuse and reported to the local Seniors and People with Disabilities Office (SPD) if abuse or suspected abuse could not be ruled out for 1 of 1 sampled resident (#6) whose record was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis, diabetes, dementia and history of hallucinations.

Interviews with staff and review of Resident 6's clinical record including incident reports, progress notes dated 09/02/23 through 10/24/23, service plans and service plan addendums (SPAs) revealed the following:

* An incident report dated 10/07/23 indicated Resident 6 was found lying on the floor in front of the bedroom door on his/her back asleep. The resident had no animals in the apartment but told staff s/he was playing with "kitties" when s/he fell, and that one was on the wheelchair footrest and had run away. Resident 6 later complained of neck pain. The resident was sent to the emergency room for further evaluation of the pain resulting from the fall and was admitted for a urinary tract infection, returning to the facility on 10/12/23. There was no documented evidence an investigation was completed to reasonably rule out abuse or neglect, or that the facility reported the incident to the local SPD office.

* On 10/19/23 a progress note indicated the resident was placed on alert for a fall with a right shoulder contusion. The incident report indicated Resident 6 was found on the bedroom floor next to the bed with legs tangled up in blankets. When asked what happened the resident stated "I don't know but the floor is way more comfortable than my bed." The resident reported s/he was hallucinating about "my big fat kitty" and was seeing "blue balls rolling around under her dresser." The resident was sent to the emergency room and returned with diagnosis of right shoulder contusion. There was no documented evidence an investigation was completed to reasonably rule out abuse or neglect, or that the facility reported the incident to the local SPD office.

On 10/25/23 and 10/26/23 Staff 22 (Executive Director) reported that there were investigations completed related to the falls with injury and that the incidents had not been reported to the local SPD. The surveyor discussed with Staff 22 the incident report investigations for the falls with injury were incomplete and failed to reasonably rule out abuse/neglect.

The need to ensure unwitnessed falls with injury were investigated to rule out abuse/neglect, and incidents were immediately reported to the local SPD if abuse or suspected abuse could not be ruled out was discussed with Staff 22, Staff 25 (Regional Health Service Support)  and Staff 36 (Health Service Director) on 10/26/23. They acknowledged the findings and reported the required incidents to the local SPD office per the survey team's request. Confirmation was provided during the survey.

{C 231} OAR 411-054-0028 (1-3) Reporting and Investigating Abuse- Other Action

1) HSD/RN will take an approved online class regarding Abuse Reporting and Investigations. This will be completed by November 25, 2023.

2) Abuse reporting is part of the new hire process, annual in-service training and as needed. Health Services Leadership has since been in-serviced on state required reporting and investigating alleged abuse/ neglect including company policy in regards to timely incident follow up and investigation documentation. Incident reports and root cause analysis investigations are being routinely reviewed by the HSD and Administrator.

3. Every Incident will be investigated, with root cause, and will be reported per reporting and ivestigation policy.

4. HSD/RN

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 2 of 5 sampled residents (#s 1 and 6). Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis and a history of falls.

Resident 6's clinical records included evaluations dated 08/25/22 and 02/09/23. There was no documented evidence an evaluation was completed between 08/25/22 and 02/09/23.

During an interview on 03/01/23, Staff 2 (RN) confirmed Resident 6's evaluation had not been completed quarterly.

On 03/02/23, the need to ensure the facility completed evaluations at least quarterly was discussed with Staff 1 (Executive Director), Staff 2, Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC). They acknowledged the findings.

2. Resident 1 was admitted to the facility in 04/2016 with diagnoses including osteoarthritis and dementia.

Resident 1's clinical record contained an evaluation dated 08/07/22. The next quarterly evaluation would have been due on 11/05/22. There was no documented evidence an evaluation had been completed after 08/07/22.

On 03/02/23, Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC) confirmed Resident 1's evaluation had not been completed quarterly.

The need to ensure the facility completed evaluations at least quarterly was discussed with Staff 1, Staff 2, Staff 3, Staff 6 and Staff 7 on 03/02/23. They acknowledged the findings.

OAR 411-054-0034 (1-6) Resident Move-In and Eval: Res Evaluation

1.  Health Services Leadership has been in-serviced on state requirements and company policy regarding quarterly evaluations.  

2.  Past due service plans are currently being updated  by several member of Prestige's regional support team.

3.  Service plans coming due will be discussed at each routine morning meeting and assigned accordingly to ensure timeliness.  

4.  ED will review routinely during clinical meeting to ensure care conferences and service plans are agreed with and signed.  

3. Resident 6 was admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis and a history of falls.

Observations, interviews with staff and Resident 6 and review of Resident 6's clinical records including progress notes, service plans, incident reports and hospital after visit summaries dated 11/27/22 through 02/27/23 and evaluations dated 08/25/23 through 02/28/23 revealed the following:

During an interview with Resident 6 on 03/01/23, the resident's bed was observed to have quarter length side rails on both sides of the bed along with a scoop mattress. Additionally, a transfer pole was located on the right side of the resident's bed.

The sides rails, scoop mattress and transfer pole were not reflected in Resident 6's most recent service plan dated 02/09/23.

The need to ensure service plans were reflective of residents' current needs and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC) on 03/01/23. They acknowledged the findings.

4. Resident 7 was admitted to the facility in 12/2022 with diagnoses including "repeated falls".

Observations, interviews with staff and Resident 7 and review of Resident 7's clinical records revealed Resident 7's current service plan dated 01/28/23, was not reflective and/or did not provide clear direction to staff in the following care areas:

* Transfer ability and assistance needed;

* Mobility, toileting and dressing assistance needed;

* Private caregiver schedule and duties;

* Use of wheelchair for transfers and mobility; and

* Frequency of staff safety checks related to Resident 7's fall risk.

During an interview on 02/28/23, Resident 7 was observed requiring assistance with transferring from the toilet to a wheelchair.  The resident stated s/he was no longer able to use the walker for mobility and was using a wheelchair instead and required staff to help with all transfers.

During an interview on 02/28/23, Staff 16 (CG) stated after recent falls, Resident 7 required staff to assist with all transfers and s/he was no longer was able to use his/her walker and used a wheelchair for all transfers.

The need to ensure service plans were reflective of residents' current needs and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC) on 03/01/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 04/2016 with diagnoses including osteoarthritis and dementia.

Observations of the resident, interviews with staff, review of the clinical record and the most recent service plan dated 08/07/22 indicated the service plan failed to reflect the resident's current care needs and lacked clear directions to staff in the following areas:

* Assistive devices, including a hospital bed and an adjustable overbed table;

* Eating and drinking ability, including the level of assistance needed;

* Hospice services and schedule;

* Use of private caregiver; and

* How frequently did the staff need to check on the resident who could not use the call light to ask for assistance.

There was no documented evidence the facility had completed a quarterly service plan for the resident, which would have been due on or around 11/05/22.

The need to ensure service plans were reflective and provided clear directions to staff was discussed on 03/02/23 with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed quarterly, were reflective of residents' needs, provided clear direction regarding the delivery of services and were followed for 4 of 6 sampled residents (#s 1, 4, 6 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to facility in 05/2019 with diagnoses including dementia.

The current service plan, dated 01/29/23, was reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Level of assistance required for eating;

* Use of manual wheelchair for evacuation and transfers out of bed; and

* Use of an assistive device for eating (using a scoop plate).

Observations on 02/28/23 through 03/02/23 revealed the service plan was not followed in the following areas:

* Two person assistance with toileting, incontinence care and transfers;

* Set up and assistance for meals (cut up meats and large food items, setting up tray on over the bed table, open any utensils; and

* Providing nutritional supplement daily.

During an interview with the hospice RN on 03/01/23, s/he reported Resident 4 does not have a manual wheelchair in her apartment. During observations on 02/28/23 and 03/01/23, Resident 4 was not offered toileting assistance with two caregivers routinely and was not provided set up assistance for two of three meals observed.

The need to ensure service plans were reflective of residents' current needs and were followed was discussed with Staff 1 (Executive Director) on 03/01/23. She acknowledged the findings.

OAR 411-054-0036 Service Plan:  General

1.  Resident 1 deceased

2.  Service plans for resident 4, 6 and 7 were reviewed and updated. Health Services Team is auditing all remaining service plans.

3. Person centered care plans will include all elements as laid out in OAR 411-054-0036(1-4).

4. Service plans will reflect the needs as identified in evaluations and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.

5.  Care plans will have clear direction regarding delivery of services and will be updated within the appropriate time frame and will be made available to all staff by compliance date.

6.  Administrator/Health Services Team to review routinely during clinical meeting.

5. Resident 13 was admitted to the facility 05/2023 with diagnoses including liver cancer.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/12/23, temporary service plans (SPA) and progress notes dated 05/02/32 to 07/18/23 were completed. Staff reported resident spends all day and night in the recliner with the exception of toileting. For mobility, staff reported the resident needed to be followed closely with the wheelchair and use a gait belt while ambulating to/from the bathroom with the walker.  Several staff reported that over a week ago s/he had needed one to two person staff assist with transfers and toileting. The resident's service plan was not reflective and did not provide instruction to staff in the following areas:

* Evacuation assistance needed;

* Hearing aid assist;

* Barrier cream after toileting;

* Toileting assistance of one to two persons and frequency;

* Transfer assistance of one to two persons, gait belt and wheelchair use;

* Falls and safety intervention;

* Bathing assist with specific needs on days hospice does not provide;

* Changing linens on her recliner; and

* Food preferences for morning and afternoon shake supplements.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 6 (RCC), Staff 22 (ED) and Staff 25 (Regional Health Services Support/RN) on 07/18/23. They acknowledged the findings.

4. Resident 12 was admitted to the facility in 04/2019 with diagnoses including acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity, major depressive disorder, blindness in left eye, and heart failure.  

Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/01/23, temporary service plans (SPA), and progress notes dated 05/02/23 to 07/17/23 were completed.

The resident's service plan was not reflective, did not provide instruction to staff and/or was not followed in the following areas:

* Ability to use call system;

* Bedside activities;

* Hearing and vision impairment;

* Dietary needs including level of assist when eating, food cut up or finger foods, use of straw cup, and use of adaptive plate;

* Provision of supplemental shakes;

* Incontinence care; and

* Side rails.

The need to ensure resident service plans were reflective of current care needs, provided clear instruction to staff and/or were followed was discussed with Staff 22 (ED) on 07/19/23. They acknowledged the findings.

3. Resident 10 was admitted to the facility in 04/2022 with diagnoses including congestive heart failure, atrial fibrillation and was blind.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/10/23, temporary service plans (SPA) and progress notes dated 05/02/23 to 07/17/23 were completed. Staff indicated the resident required one to two person assistance with transfers, was full assistance with ADL cares and was blind. The resident's service plan was not reflective, did not provide instruction to staff and/or was not followed in the following areas:

* Barrier cream after toileting;

* Diagnosis of Dementia and behaviors with interventions;

* Transfers, requiring one to two person assist with a gait belt with instructions;

* Mobility, including use of a wheel chair with full assist;

* Pressure reducing cushion in the wheelchair;

* Loss of vision, with instruction for staff related to care and services;

* Toileting assistance of one to two persons with gait belt and grab bar;

* Raised toilet seat;

* Transfer pole next to recliner chair with instructions;

* Bed cane;

* Hygiene cares including instructions for set up, cueing and when to provide full assist;

* Fall history and interventions;

* Evacuation assistance needed;

* History of dehydration and significant weight loss with intervention instructions;

* High side plate and/or bowl for meals and no spill cup with straw for liquids; and

* Meal assistance instructions to ensure optimal consumption.

The need to ensure resident service plans were reflective of current care needs, provided clear instruction to staff and/or were followed was discussed with Staff 22 (ED) and Staff 25 (Regional Health Services Support/RN) on 07/19/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff and was consistently followed by staff for 5 of 6 sampled residents (#s 9, 10, 11, 12 and 13) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 03/2021 with diagnoses including diabetes and chronic kidney disease.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/02/23 and progress notes dated 05/03/23 to 07/13/23 were completed. Staff indicated the resident went to dialysis three times a week. The resident was very tired when s/he returned and was typically gone from the facility most of the day. The resident required one staff assistance for ADL care and could make his/her needs known. The resident's service plan was not reflective and was not followed by staff in the following areas:

* Falls and safety interventions;

* Recliner use vs. bed;

* Dialysis days, times and port/catheter site care and restrictions;

* Home health nursing services and physical therapy;

* Gait belt use and specifics on transfer needs;

* Scaley and discolored arms and other skin needs;

* Pain locations and interventions; and

* Glucose monitor kept in resident room.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 22 (ED) and Staff 25 (Regional Health Service Support/RN) on 07/19/23. They acknowledged the findings.

2. Resident 11 was admitted to the facility in 10/2018 with diagnoses including hemiplegia and chronic head wound.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/17/23 and progress notes dated 05/02/23 to 07/13/23 were completed. Staff indicated the resident required two staff assistance with transfers and was full assistance with all care. The resident was able to direct his/her own care and liked care done in a specific way. The resident required a sit to stand lift for all transfers. The resident's service plan was not reflective and was not followed by staff in the following areas:

* Hoyer lift vs. sit to stand;

* Head wound, non-stick pad use and placement;

* Barrier cream after toileting;

* Hand contracture;

* Brace on right leg and fracture status;

* Bathing and hair care related to head wound;

* Supervision while toileting; and

* Self administration of over-the-counter medications.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 22 (ED) and Staff 25 (Regional Health Services Support/RN) on 07/19/23. They acknowledged the findings.

{C 260} OAR 411-054-0036 Service Plan:  General

1.  Resident 10 moved to Prestige Orchard Heights Memory Care 08.03.23.

2.  Service plans for residents 9, 11, 12, and 13 were reviewed and updated. Health Services Team is continuing to audit/update all remaining service plans as scheduled and as needed.

3. Person centered care plans will include all elements as laid out in OAR 411-054-0036(1,2,4, and 5).

4. Service plans will reflect the needs as identified in evaluations and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.

5.  Care plans will have clear direction regarding services received, will be updated within the appropriate time frame as needed and will be made available to all staff by compliance date.

6.  Administrator/Health Services Team to review routinely during daily clinical meeting.

2. Resident 6 was admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis, osteoarthritis, diabetes, dementia and history of hallucinations.

Observations of the resident, interviews with staff, review of the resident's service plan dated 10/13/23 and progress notes dated 09/02/23 to 10/24/23 were completed. Staff indicated the resident required one to two staff assistance with transfers, was full assistance with all care, and had multiple falls since return from the hospital on 10/12/23. The resident's service plan was not reflective and did not provide clear director to staff in the following areas:

* Full assist for all ADL care;

* One to two person assist with transfers;

* Wheelchair assistance for mobility;

* Bed mobility assistance;

* Cueing needed for meal initiation;

* Assistance with CPAP machine needed;

* Hallucinations, including symptoms and interventions;

* Right shoulder pain and non-pharmacological interventions used;

* How often staff were to complete safety checks;

* Two quarter length padded side rails on bed with safety instruction for monitoring;

* A transfer pole next to the bed and one next to the recliner with instructions;

* Non-slip material in seat of wheelchair and recliner; and

* Non-slip tape strips in bathroom and in front of recliner.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 22 (Executive Director),Staff 25 (Regional Health Services Support), Staff 6 (RCC) and Staff 36 (RN) on 10/26/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' care needs and/or provided clear direction to staff for 2 of 2 sampled residents (#s 6 and 15). This is a repeat citation. Findings include, but are not limited to:

1. Resident 15 was admitted to the facility in 05/2019 with diagnoses including dementia and mood disturbance.

The resident's current service plan dated 10/13/23 was reviewed, observations were made, and interviews with staff and the resident's family were conducted. Resident 15's service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Frequency of safety checks;

* Food preferences;

* Level of meal assist;

* Showers; and

* Fall interventions.

The need to ensure service plans reflected the resident's needs and provided clear direction to staff was discussed with Staff 22 (Executive Director) on 10/25/23. She acknowledged the findings.

{C 260} OAR 411-054-0036 Service Plan: General

1) Resident 6 was discharged from the hospital to an ICF for permanent stay on 11/01/23.

1a) Service plan for Resident 15 has been reviewed and updated to reflect current care needs and any interventions previously put in place for incidents.

2) Health Services team is auditing and updating all resident care plans to ensure they accurately reflect needs and personal desires of the resident with emphasis that supports the principles of individuality, dignity, privacy, choice and maintaining independence. Overall edit to be completed and in compliance by 11/25/23, and then will be updated every 90 days and or earlier if a change in condition is warranted.

3) Correction will be completed by 11/25/23 and then every 90 days unless a change in condition is warranted.

4) Administrator and Health Services Leadership will review routinely during our clinical meeting.

5. Resident 2 was admitted to the facility in 03/2021 with diagnoses including chronic obstructive pulmonary disease and acute and chronic respiratory failure.

Observations of the resident, interviews with staff and review of the resident's 12/04/22 service plan, outside provider visit notes and 10/27/22 through 02/27/23 progress notes were completed.

Resident 2 experienced multiple short-term changes related to skin issues, without an evaluation and/or documented weekly monitoring of progress until resolution related to the following:

* 10/27/22 through 02/27/23 Bilateral leg edema with weeping and recurrent open wounds;

* 10/27/22 Head laceration with staples;

* 01/13/23 Bleeding scratch to left ankle; and

* 02/08/23 Two pressure "injuries" to the right buttock lacked monitoring of progress for each wound weekly through resolution.

On 03/01/23 Staff 2 (RN) verified the lack of evaluation and/or weekly monitoring of progress related to the skin conditions through resolution.

The need to ensure there was documentation for short-term changes of condition which reflected an evaluation and monitoring of progress to resolution at least weekly was discussed with Staff 1 (Executive Director),  Staff 2, Staff 3 (Regional Support Nurse) and Staff 7 (RCC) on 03/01/23. They acknowledged the findings. No further documentation was provided.

2. Resident 6 was admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis and a history of falls.

Observations, interviews with staff and Resident 6 and review of Resident 6's clinical records including progress notes, service plans, incident reports and hospital after visit summaries dated 11/27/22 through 02/27/23 and evaluations revealed the following:

a. On 12/20/22, Resident 6 returned to the facility following a hospitalization related to a planned surgical procedure of the left shoulder. The hospital "After Visit Summary" noted the resident was non-weight bearing for the upper left extremity, was able to get up with assistance, and required the use of a specialized walker (hemi-walker).

The evaluation prior to Resident 6's hospitalization was dated 08/25/22 and noted Resident 6 was independent with transfers, ambulation, dressing and toileting, the resident used a 4-wheel-walker for mobility and was considered a low fall risk.

There was no documented evidence the facility evaluated the resident, referred the resident to the facility nurse, updated the service plan as needed or developed resident specific interventions upon Resident 6's return to the facility.

b. In an incident report dated 12/22/22,  staff documented Resident 6 was found on the floor on his/her left shoulder near his/her bed and the resident stated "it felt like [his/her] right hip was broken and it was sore to the touch." The resident was sent to the hospital for further evaluation.

The hospital "After Visit Summary" documented Resident 6 was diagnosed with "fall from bed", acute pain of left shoulder due to trauma and contusion of the right hip. The hospital provided the resident a sling for his/her left arm and the resident returned to the facility on 12/22/22.

There was no documented evidence the facility evaluated the residents fall risk, developed resident specific fall interventions, or provided instruction to staff on the use of the sling for his/her left arm. There was no documented evidence the right hip contusion had been monitored to resolution.  

c. An incident report dated 12/26/22 documented Resident 6 was found on the floor near his/her bed. No injury was noted. There was no documented evidence the facility evaluated the residents fall risk, or developed resident specific interventions.

d. On 12/28/22, staff documented Resident 6 was found on the floor in his/her apartment and noted it "appeared [s/he] had tried to clean [his/herself]" after attempting to toilet independently. No injury was noted.

The following interventions and staff instruction were added to Resident 6's service plan on 01/01/23:

* Staff to provide physical assistance with toileting, bathing and dressing;

* Staff to provide standby assist with a gait belt for all transfers;

* Staff to provide stand by assist with "mobility with use of a wheelchair"; and

* Resident 6 "has a sling that [s/he] is supposed to wear."

e. An incident report dated 01/08/23 documented Resident 6 was found on the floor near his/her bed. No injury was noted. There was no documented evidence the facility developed resident specific interventions related to the resident's ongoing fall risk.

f. An incident report dated 01/12/23 documented staff found Resident 6 on the floor near his/her bed. The resident reported complaints of pain and was sent to the hospital for further evaluation. The hospital "After Visit Summary" dated 01/12/23, documented Resident 6 was diagnosed with a "fall from bed", contusion of right hip and left shoulder strain.

On 01/13/23 Staff 2 (RN) documented resident Resident 6's family was in the facility to measure the resident's bed for a scoop mattress. During an interview on 02/28/23, Staff 16 (CG) stated the mattress was not implemented until after Resident 6 returned to the facility following a stay in a skilled nursing facility 01/20/23 through 02/09/23. No further documentation was provided.

g. An incident report dated 01/16/23 documented staff found Resident 6 on the floor near his/her bed. No injury was noted.

Resident 6 experienced multiple changes of condition between 12/20/22 and 01/16/23 which effected multiple areas of functioning. The facility failed to evaluate the resident, develop resident specific actions or interventions, update the service plan with specific care instructions, and/or refer to the the facility RN. The residents decline lead to multiple falls, two with injury, and placed the resident at harm for further injury.  

The need to ensure the facility evaluated residents who experienced changes of condition, referred to the facility RN for significant changes, updated the service plan and determined resident specific interventions with weekly progress documented and monitored until the condition resolved was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse),  Staff 6 (RCC) and Staff 7 (RCC) on 03/02/23. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 12/2022 with diagnoses including "repeated falls."

Interviews with staff and Resident 7 and review of Resident 7's clinical records including progress notes, evaluations, service plans, incident reports and hospital after visit summaries dated 12/22/22 through 02/27/23 revealed the following:

Resident 7's most recent service plan dated 01/28/23, noted the resident was not at risk for dehydration and was able to manage dietary needs independently. The service plan noted the resident was at risk for falls and was usually independent with mobility and transfers with use of a walker. Staff were to provide stand by assist if Resident 7 reported feeling weak and staff "will be checking in on [him/her] on a regular basis."

* In a progress note dated 02/14/23, staff documented Resident 7 "came back from the hospital early this morning from being sent out. [Diagnoses] were dehydration, meningioma and TIA." A hospital after visit summary dated 02/13/23, noted weakness, and provided diagnoses of transient cerebral ischemic attack, meningioma (brain tumor) and dehydration.

Staff initiated a Service Plan Addendum (SPA) alert charting related to "return from higher level of care." The SPA did not include resident specific interventions or monitoring instructions related to dehydration or potential for worsening of residents condition due to newly diagnosed brain tumor.

* On 02/15/23, staff documented Resident 7 was "staying in [his/her] room. [s/he] has not really come out in 2 days. [S/he] is needing more help than usual. But not by much." In a separate progress note dated 02/15/23, staff documented Resident 7 "did still seem to need more help than usual."

* On 2/22/23, staff documented Resident 7 was "found on the floor in front of [his/her] heater. [Resident 7] stated [s/he] did not know how this happened. Did complain of pain in [his/her] head." The resident was sent to the hospital and returned to the facility with diagnoses of transient unconsciousness, contusion of occipital (eye) region of the scalp and contusion of the right hip.

* On 2/23/23, staff documented Resident 7 was found on the floor in his/her bathroom, no injury was noted, and resident was using a wheelchair instead of a walker for mobility.

* On 02/24/23, staff documented Resident 7 "was repositioned and toileted frequently throughout the night" and s/he requested help from staff for toileting and dressing. The resident was placed on SPA alert charting for "an injury fall and non-injury fall" and instructed staff to monitor for signs and symptoms of injury or change in functioning and provide "checks at routine intervals."

There was no documented evidence the facility evaluated the resident related to a decline in functional abilities, diagnoses of a brain tumor, TIA's and dehydration, referred the resident to the facility nurse, updated the service plan as needed or developed resident specific interventions. There was no documented evidence the facility monitored the resident consistent with previous service planned fall interventions.

The need to ensure, when residents experienced changes of condition, the the facility evaluated the resident, referred the resident to the facility nurse, updated the service plan as needed, determined resident specific interventions with weekly progress documented and monitored residents consistent with the resident's evaluation and service plan was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse),  Staff 6 (RCC) and Staff 7 (RCC) on 03/01/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to document what actions or interventions were needed for changes of condition, including resident specific instructions communicated to staff on each shift, weekly progress documented until the condition resolved and/or the facility failed to refer significant changes of condition to the facility RN for 4 of 6 sampled residents (#s 1, 2, 4, 6 and 7) who had changes of condition. Resident 1 experienced a significant and ongoing decline in his/her ability to eat independently, and Resident 6 experienced a decline in functional status and repeated falls with injury upon return to the facility following a hospitalization for a planned surgery. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2016 with diagnoses including osteoarthritis and dementia.

During the acuity interview on 02/27/23, Resident 1 was identified as receiving hospice services, was bedbound and needed full assistance with ADL's including meal set-up.

The resident's hospice outside service notes, progress notes, current service plan, and service plan addendums were reviewed from 11/29/22 through 02/28/23 and identified the following change of condition:

* 12/22/22, hospice wrote, "[Resident 1] is really needing more help with eating, especially if it is not finger food, this will help with dignity and comfort, [s/he] ate 75% of this meal with help of hospice."

* 12/29/22, hospice wrote, "Please ensure when delivering meals, utensils opened, straws are in drink, and overbed table is over the resident, sitting up, so [s/he] can eat."

* 12/29/22, coordination of care note, "[Resident 1] had a visit from hospice this morning, breakfast was cut up and fed to resident by LPN, [s/he] ate and drank, staff does not appear to be setting up meals for hospice residents."

* 01/30/23, staff documented in progress "[Resident 1] has been confused and not eating very much or understanding how to eat."

* 01/31/23, hospice wrote, "[ Resident 1] needs help eating, not just tray set up." "Often spilled all over when staff arrives."

* 02/07/23, coordination of care note, RN documented "Only change noted is that [Resident 1] needs assist for eating."

There was no evidence the facility determined and documented what action or intervention was needed for the change of condition related to the decline in the resident's ability to self-feed.  

Multiple interviews with staff conducted on 02/27/23 and 02/28/23, indicated staff were setting up the resident for meals, but were not providing feeding assistance.  

Observations conducted during the survey revealed the following:

* At 11:26 am on 02/28/23, Resident 1 was observed asleep in his/her bed. A pancake from the resident's breakfast was found on top of the resident's chest. On the bedside table a food container was tipped over and the contents had spilled onto the resident's bed.

* At 9:30 am on 03/01/2023, Resident 1 was  asleep in his/her bed. The resident's breakfast was observed untouched and was not in reach of the resident and access to the food could not occur without staff assistance. An interview with Resident 1's private caregiver indicated the facility was not providing feeding assistance and when she visits she finds untouched food containers from the previous day.

There was no documented evidence the facility had evaluated Resident 1, developed interventions with resident specific instructions and communicated to staff, and consistently monitored the interventions related to the resident's declining ability to self-feed as first noted by hospice on 12/22/22.

Observations made during survey and interviews with staff confirmed the resident was not able to feed his/herself and had limited communication abilities and staff were not providing assistance with feeding which placed the resident at risk for further decline and poor nutrition.

The need to ensure when residents experienced changes of condition, the facility evaluated the resident, updated the service plan as needed, determined resident specific interventions with weekly progress documented, and monitored residents consistent with his/her evaluated needs was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC) on 03/02/23. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 05/2019 with diagnoses including dementia.

Review of Resident 4's clinical record revealed the resident experienced multiple falls and emergency department visits between 12/21/22 and 02/09/23. These represented short term changes of condition. The clinical record was reviewed and showed the following:

* 12/21/22 resident experienced a fall. The incident report was completed on 12/21/22. An investigation note was completed on 01/20/23 (one month later). The record lacked evidence that interventions were identified following the short term change of condition.

* 12/24/22 resident experienced a fall and was sent to the emergency department for evaluation. Upon return to the facility, the resident was placed on "alert" monitoring and interventions were communicated to staff though a "Service Plan Addendum" that included: "staff to check on resident at routine intervals" and "observe for increased confusion or injury." The "alert" monitoring was discontinued on 12/27/22. The record lacked evidence the interventions were monitored for effectiveness.

*12/29/22 resident was sent to the emergency department and returned with diagnoses including "failure to thrive" and dehydration. A "service plan addendum" was completed and informed staff the resident would be receiving hospice services and to review the service plan for updates. A progress note dated 12/31/22 stated thickened liquids were being given. The record lacked evidence of interventions being identified and monitored to address the dehydration and any other areas that required intervention as a result of the emergency department visit.

* 02/09/23 resident experienced a fall. A progress note, dated 02/08/23, documented finding the resident walking in his/her room and encouraged staff to complete safety checks every hour. Following the fall on 02/09/23, a "Service Plan Addendum" was completed and identified the intervention "staff checks at routine intervals." The record lacked evidence of any additional interventions or monitoring of the effectiveness of the current intervention.

Observation of Resident 4's room on 02/27/23 through 03/01/23 showed a fall mat on the floor next to the resident's bed on one side. Resident 4 was wearing a call pendant around her neck and there was a bedside commode placed next to the wall in the room. The door to the resident's apartment remained closed. Direct care staff who were interviewed on 02/28/23 about fall interventions stated they would check on the resident when they did "rounds."

On 03/02/23, the need to determine and document what actions or interventions were needed when a resident experienced changes of condition and monitor the interventions for effectiveness was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 6 (RCC). They acknowledged the findings.

OAR 411-054-0040 Change of Condition and Monitoring

1.  Resident 1 is deceased

2.  Residents 4, 6 and 7 have had assessments and service plans updated

3.  Resident 2 to be updated after readmit from hospital.  

4.  We have reviewed our system for identification of changes and our RN's role for ensuring assessments for significant change of condition.

5.  Updates in process and will be completed by compliance date.

6. Care staff are being educated on the system and their responsibilities prior to compliance date.

7.  Changes in residents' condition will be evaluated, assessed and monitored according to the community "Change of Resident Condition" policy and procedure and OAR 411-054-0040. Changes in condition will have documentation of resident's status until the issue is resolved. This will be monitored by Administrator/Health Services Leadership.

Based on observation, interview and record review it was determined the facility failed to determine and document what action or intervention was needed, monitor resident's based on evaluated needs and service plan, note weekly progress through resolution and/or report a significant change of condition to the RN for 3 of 4 sampled residents (#s 9, 10 and 11) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 03/2021 with diagnoses including diabetes and chronic kidney disease.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/02/23 and progress notes dated 05/03/23 to 07/13/23 were completed.

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

* Hospital admit and return;

* Medication changes and missed medications;

* Skin injuries and breakdown;

* Weakness and increased care needs; and

* Arm pain.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 22 (ED) and Staff 25 (Regional Health Services Support/RN) on 07/19/23. They acknowledged the findings.

2. Resident 11 was admitted to the facility in 10/2018 with diagnoses including hemiplegia and chronic head wound.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/17/23 and progress notes dated 05/02/23 to 07/13/23 were completed.

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

* Medication changes;

* Seizure activity;

* Bleeding from chronic head wound;

* Gauze pad stuck to chronic head wound; and

* Change in mechanical lift type for transfers.

b. The resident was noted to be alert and oriented, required extensive assistance with all ADL care, currently utilized a sit to stand lift for transfers and an electric wheelchair for mobility. The resident had a large chronic head wound and paralysis on the right side of his/her body.

* An incident report dated 05/20/23, indicated during a Hoyer transfer the front of the resident's head was grazed by a hook. The resident's head began to bleed later in the day on the left side. There was no information to indicate if the bleeding occurred in an area bumped with the lift or if more than one area had been involved.

The resident was able to indicate his/her head was hit during transfer. The resident was evaluated by paramedics but was not transported.

* An incident report dated 06/06/23, indicated the resident was bumped on the top of his/her head with the bar of the Hoyer lift. The resident was noted to react with pain at the time of the incident but was fine soon after.

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

In interview on 07/17/23, the resident indicated s/he had no concerns with his/her care. The resident denied any mistreatment by staff and two staff assisted him/her with the Hoyer lift and the sit to stand lift. The resident stated s/he was uncomfortable with the Hoyer lift and preferred the sit to stand lift s/he used currently.

In interview on 07/19/23, Staff 22 (ED) and Staff 25 (Regional Health Services Support/RN) acknowledged the investigation of the incidents was not complete.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 22 and Staff 25 on 07/19/23. They acknowledged the findings.

3. Resident 10 was admitted to the facility in 04/2019 with diagnoses including congestive heart failure, atrial fibrillation and was blind.

a. Staff were interviewed and the resident's record was reviewed, to include progress notes dated 05/02/23 through 07/17/23, service plan dated 05/10/23, temporary service plans (SPA), most recent evaluation, incident reports and investigations, and staff were interviewed. The following changes of condition were identified:

* 05/09/23 - Unwitnessed fall with back and hip pain;

* 05/16/23 - Non injury fall;

* 07/01/23 - Bruise to right wrist; and

* 07/09/23 - Non-injury fall.

There was no documented evidence the facility evaluated the effectiveness of interventions in place at the time of the falls, or determined additional interventions indicated related to the falls, and no documented progress monitoring of the bruise to the wrist weekly through resolution.

b. Resident 10 was identified through observations, interviews and record review to have had a significant change of condition. The resident experienced a decline in ADL functioning and mobility and required a significant increase in staff assistance during the previous weeks. On 07/17/23, Staff 25 (Regional Health Service Support/RN) reported that she had not been notified of the resident's significant decline and increased care needs. Refer to C 280.

The need to evaluate changes of condition related to falls for effectiveness of interventions and determine additional interventions as indicated, monitor progress for short term changes of condition weekly through resolution and ensure the RN was notified of significant changes of condition was discussed with Staff 22 (Executive Director) and Staff 25 (Regional Health Service Support/RN) on 07/19/23. They acknowledged the findings.

{C 270} OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1.  Resident 10 was completed before 07/19/23 and has since moved to higher level of care.

2.  Residents 9 and 11 have had assessments and service plans updated

3.  We have reviewed our system for identification of changes of condition and our HSD/RN's role for ensuring completion of assessments for significant changes of condition.

4.  Updates are in process and will be completed by compliance date.

5. Care staff are being educated on the system and their responsibilities prior to compliance date.

6.  Changes in residents' condition will be evaluated, assessed and monitored according to the community "Change of Resident Condition" policy and procedure and OAR 411-054-0040. Changes in condition will have documentation of resident's status until the issue is resolved. This will be monitored by Administrator/Health Services Leadership.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes of condition were evaluated, and resident specific interventions were developed, communicated to staff on each shift and reviewed for effectiveness related to falls and skin condition for 2 of 2 sampled residents (#s 6 and 15) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 15 was admitted to the facility in 05/2019 with diagnoses including dementia and mood disorder.

Resident 15's 09/02/23 through 10/21/23 facility progress notes, an incident report dated 10/21/23, and a SPA resolution dated 10/25/23 identified the following:

* Fall on 08/25/23 with abrasion to left ankle was monitored and resolved on 9/11/23; and

* Fall on 10/21/23 with abrasion to right knee was monitored and resolved on 10/25/23.

In an interview with Staff 22 (Executive Director) on 10/26/23, she reported the interventions being monitored were "standard fall precautions."

There was no evidence the facility determined and documented resident specific interventions for these short term changes of condition.

The need to ensure resident specific actions or interventions were determined and implemented for residents with short term changes of condition, including falls, was discussed with Staff 22 (Executive Director), Staff 25 (Regional Health Service Support),  Staff 36 (RN) and Staff 6 (RCC) on 10/26/23. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis, osteoarthritis, diabetes, dementia and history of hallucinations.

Staff were interviewed and the resident's record was reviewed, to include progress notes dated 05/02/23 through 07/17/23, service plan dated 10/13/23, temporary service plans (SPA), skin monitoring records, incident reports and investigations. The following changes of condition were identified:

* 09/28/23 - Unwitnessed fall with right hip and shoulder pain;

* 10/03/23 - Increased confusion, rash in abdominal fold and fall with bruising;

* 10/04/23 - Large dark purple skin discoloration to lower back and dark purple discoloration to right thigh/hip;

* 10/07/23 - Unwitnessed fall with neck pain;

* 10/15/23 - Unwitnessed fall;

* 10/19/23 - Unwitnessed fall with right shoulder contusion; and

* 10/20/23 - Unwitnessed fall.

There was no documented evidence the facility evaluated the effectiveness of interventions in place at the time of the falls, or determined additional interventions indicated related to the falls, and/or no documented progress monitoring of the short term changes of condition weekly through resolution.

The need to evaluate changes of condition related to falls for effectiveness of interventions and determine additional interventions as indicated, monitor progress for short term changes of condition weekly through resolution was discussed with Staff 22 (Executive Director) and Staff 25 (Regional Health Service Support), Staff 6 (RCC) and Staff 36 (RN) on 10/26/23. They acknowledged the findings.

{C 270} OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1) a) HSD/RN is new and is being trained by a Health Services Support RN on changes of condition and monitoring per state regulations and company policy. b) Resident 15 has had a change of condition completed by the nursing team and the service plan will be updated by compliance date, 11/25/23.

2) Updates are in process and will be completed by compliance date.

3) Care staff are being re-educated on the system and their responsibilities in getting accurate and timely information for changes to resident's needs to Health Services Leadership prior to compliance date. Changes in any resident's condition will be evaluated, assessed, and monitored according the community "Change of Resident Condition" policy and OAR 411-054-0040. Changes in condition will have documentation of resident's status until any issues are resolved. This will be monitored by the Health Services Leadership and Administrator.

4) HSD/RN and Administrator to oversee

3. Resident 4 returned to the facility on 12/29/22 following a decline in her condition including decreased meal intake, increased confusion and the resident was admitted to hospice services on 12/30/22.

A review of the clinical record showed the following:

a. Staff 2 (RN) documented an assessment of Resident 4 on 01/09/23. While the assessment included a review of recent events, it lacked some of the required elements including interventions made as a result of the assessment, including those to address fall risk, weight loss and level of meal assistance needed.

b. Staff 2 completed the assessment on 01/09/23 (more than nine days after Resident 4 returned to the facility and started receiving hospice services). The assessment was not completed timely.

The need to ensure the RN conducts a timely and complete assessment of residents with significant changes of condition was discussed with Staff 1 (Executive Director) and Staff 2 on 03/02/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced significant changes of condition were assessed by the RN, and/or the assessments were completed in a timely manner and included findings made, resident status, and interventions made as a result of the assessment, for 4 of 4 sampled residents (#s 1, 4, 6 and 7) who experienced significant changes in condition. Resident 6 experienced a decline in functional status and repeated falls with injury upon return to the facility following a hospitalization for a planned surgery. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis and had a history of falls.

Interviews with staff and Resident 6 and review of Resident 6's clinical records including progress notes, service plans, incident reports, hospital after visit summaries dated 11/27/22 through 02/27/23 and evaluations revealed the following:

On 12/20/22, Resident 6 returned to the facility following a hospitalization after a surgical procedure on his/her left shoulder. The hospital "After Visit Summary" noted the resident was non-weight bearing on the upper left extremity, was able to get up with assistance, and required the use of a specialized walker (hemi-walker).

Prior to the surgery, Resident 6's 08/25/22 evaluation indicated Resident 6 was independent with transfers, ambulation, dressing and toileting, the resident used a 4-wheel-walker for mobility and was considered a low fall risk.

After the surgery on 12/20/22, Resident 6 experienced multiple unwitnessed falls on 12/22/22, 12/26/22, 12/28/22, 01/08/23, 01/12/23, and 01/16/23. The falls on 12/22/22 and 01/12/23 resulted in injuries, including a contusion to the right hip and "left shoulder strain" with acute pain. Five of the six falls indicated the resident had fallen out of bed.

On 12/27/22 Staff 2 (RN) documented a "significant change note" which summarized Resident 6 had returned to the facility following left shoulder surgery on 12/20/22, experienced a fall on 12/22/22 which resulted in "no brakes", and the resident experienced a non-injury fall on 12/26/22. She further documented the the resident was reminded to use the call pendant for assistance and staff were to assist with upper body dressing.

The assessment failed to include findings, resident status, and interventions made as a result of this assessment related to Resident 6's right hip contusion, non-weight bearing status of the upper left extremity, use of a sling on the left arm, use of a hemi-walker and the resident requiring staff to assist with all transfers. There was no further documented evidence the RN assessed the resident after the resident continued to fall. On 01/20/22 Resident 6 was admitted to a skilled nursing facility related to shoulder surgery and repeated falls.

The facilities failure to ensure the RN completed an assessment, which included residents status, documentation of findings, and interventions when Resident 6 experienced a significant change in condition, placed the resident at risk for further decline and injury.  

On 03/02/23, the need to ensure an RN assessment was completed and included documentation of findings made, resident status, and interventions when residents experienced significant changes in condition was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse),  Staff 6 (RCC) and Staff 7 (RCC). They acknowledged the findings.  

Refer to C270 example 2.

2. Resident 7 was admitted to the facility in 12/2022 with diagnoses including "repeated falls."

Interviews with staff and Resident 7 and review of Resident 7's clinical records including progress notes, evaluations, service plans, incident reports and hospital after visit summaries dated 12/22/22 through 02/27/23 revealed the following:

* In a progress note dated 02/14/23, staff documented Resident 7 "came back from the hospital early this morning from being sent out. Diagnosis were dehydration, meningioma and TIA." A hospital after visit summary dated 02/13/23, noted weakness as the reason for Resident 7's hospital visit and documented diagnoses of transient cerebral ischemic attack, meningioma and dehydration. This indicated a significant change of condition.

* On 02/22/23, staff documented Resident 7 was "found on the floor in front of [his/her] heater. [Resident 7] stated [s/he] did not know how this happened. Did complain of pain in [his/her] head". The resident was sent to the hospital and returned to the facility with diagnoses of transient unconsciousness, contusion of occipital region of the scalp and contusion of the right hip.

* On 02/23/23, staff documented Resident 7 experienced an unwitnessed fall without injury.

* On 02/15/23, 02/23/24 and 02/24/23 staff documented Resident 7 experienced a decline in functional abilities and required increased assistance from staff with ADLs.

* During interviews on 02/28/23 staff and Resident 7 stated the resident had experienced a decline in his/her functional abilities and required increased assistance from staff with ADLs.

There was no documented evidence an RN assessment was completed after the resident was diagnosed with a brain tumor, TIA, dehydration and subsequent decline in functional status.

Refer to C 270 example 3.

On 03/01/23, the need to ensure an RN assessment was completed and included documentation of findings made, resident status, and interventions when residents experienced significant changes in condition was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC). They acknowledged the findings.

4. Resident 1 was admitted to the facility in 04/2016 with diagnoses including osteoarthritis and dementia.

A review of Resident 1's clinical records, including hospice outside service notes and progress notes from 12/22/22 through 02/07/23, revealed Resident 1 experienced a significant change condition related to the resident's decline in his/her ability to eat independently, for which an RN assessment was required. There was no documented evidence the RN assessed the status of the resident, documented findings as a result of the assessment, or developed interventions related to the resident's significant change of condition.

The need to ensure significant changes of condition were assessed by an RN was discussed with  Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse),  Staff 6 (RCC) and Staff 7 (RCC) on 03/02/23. They acknowledged the findings.

Refer to C270 example 1.

OAR 411-054-0045 (1) (a-f) (A) (C-F) Resident Health Service

1.  Resident 1 is deceased.

2.  Residents 4 and 7 have had assessments and service plans updated by our regional support team RNs.

3.  Resident 6 has been updated by our community RN.

4.  The Health Services Director (RN) will follow-up on staff reported resident changes according to the community "Change of Resident Condition" policy and procedure.

5.  The Health Service Director (RN) will assess any resident identified to have a significant change of condition and document findings per policy. Updates to service notes, evaluations and service plans will be made as indicated.

6.  Short-term health monitoring and staff direction will be implemented as indicated by the RN assessment.

7.  Progress notes will be audited for changes routinely at our health services meeting by Administrator/Health Services Leadership.  

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 1 of 3 sampled residents (# 10) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 10 was admitted to the facility in 04/2019 with diagnoses including congestive heart failure and atrial fibrillation.

a. During the acuity interview conducted 07/17/23, Staff 6 (RCC) reported Resident 10 had dementia, required one to two person assist with transfers, was blind, had frequent falls and required meal assistance.

Progress notes, service plan dated 05/10/23, temporary service plans (SPAs) and evaluations dated 05/02/23 through 07/19/23 were reviewed.  The service plan indicated the resident was able to ambulate using a four wheel walker with stand by assist (SBA), needed SBA for grooming and personal hygiene, dressing, and needed set up, encouragement and guidance with meals. Staff were instructed to help with placement of food to allow Resident 10 to eat independently.

Multiple observations of the resident between 07/17/23 and 07/19/23 showed the resident required orientation and instruction related to the loss of vision with all interactions, one to two person assist with transfers using a gait belt, used a wheel chair for mobility with full assist, full assist of one to two staff for toileting, and full assist with grooming, hygiene and dressing. The resident was observed in the dining room eating during multiple breakfast and lunch meals. Staff oriented him/her to the food and fluids provided, placed the utensil in his/her hand and provided encouragement to eat. The resident was able to drink from a no spill cup with a straw and was at times able to attempt to scoop food onto the fork, although on multiple occasions was observed to put an empty fork in his/her mouth. On 07/18/23 and 07/19/23 staff were observed providing feeding assistance at meals.

In interview on 07/17/23, Staff 29 (CG)  indicated Resident 10 was able to transfer with one person assistance, ambulate with a walker and was able to participate in dressing, grooming and hygiene tasks until approximately a month ago. Staff reported the resident to be much weaker now and needed one to two staff to assist with transfers, all cares and some feeding assistance at meals.

In interview on 07/17/23, Staff 25 (Regional Health Service Support, RN) reported she was not aware of the resident's decline in functioning and mobility and therefore had not completed an assessment of the changes. On 07/17/23 Staff 25 completed a significant change of condition assessment and updated the service plan.

b. On 07/03/23 a progress note indicated the resident had an open wound to the coccyx area.

A significant change of condition RN assessment of the stage two pressure wound was not completed until 7 days later on 07/10/23.

The need to ensure RN assessments were completed timely for significant changes of condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 22 (Executive Director) and Staff 25 (Regional Health Service Support, RN) on 07/19/23. The staff acknowledged the findings.

{C 280} OAR 411-054-0045 (1) (a-f)(A)(C-F) Resident Health Services

1. Resident #10 required higher level of care. She moved to Prestige Orchard Heights memory care on 08/03/2023.

2.We have reviewed our system for Resident Health Services and our HSD/RN's role for ensuring items of change are being documented and followed up on.

3.Care staff are being educated on this system and their responsibilities prior to the compliance date. HSD/AHSD/ED will work together to evaluate the communication weekly utilizing the clinical meeting.

4. ED in partnership with Health Services leadership will ensure weekly monitoring.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled resident (#6) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis, osteoarthritis, diabetes, dementia and history of hallucinations.

During the acuity interview conducted 10/24/23, staff reported Resident 6 had a recent hospitalization and decline in condition since return to the facility.

Progress notes, service plan dated 08/13/23 and temporary service plans (SPA's) were reviewed.  The service plan indicated the resident was independent with transfers, ambulation using walker, grooming, hygiene and toileting. Assistance was needed for showers and dressing. The service plan directed staff to assist with ADL cares PRN or as requested. The service plan referenced Resident 6's pain as join pain, stiffness and back pain, as well as aching all over body due to arthritis.  

Observations and interview with Resident 6 on 10/25/23 were completed.  The resident was observed sitting in a wheelchair, unable to functionally use his/her right arm due to observed and verbalized severe pain.  

In interview on 10/25/23, Staff 33 (CG) indicated Resident 6 was able to transfer independently using the transfer pole, ambulate with a walker and was able to participate in dressing, independent with grooming and hygiene tasks until s/he returned from the hospital a few weeks prior. Staff 33 reported the resident was much weaker now, in a lot of pain, more confused, had increased hallucinations and needed assist with bed mobility, one to two staff to assist with transfers and full assist with all ADL care. Staff 33 reported the resident was unable to use his/her right arm due to pain, was no longer ambulating, but used a wheelchair for mobility with assistance.

In interview on 10/26/23, Staff 22 (Executive Director) reported she was aware of the resident's decline and had reported it to an RN.

There was no RN assessment completed for the significant change of condition decline in ADL functioning, increased confusion and increase in hallucinations.

The need to ensure RN assessments were completed for significant changes of condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 22, Staff 25 (Regional Health Service Support) and Staff 36 (RN) on 10/26/23. The staff acknowledged the findings.

{C 280} Resident Health Services

1) a) HSD/RN is new and is being fully trained on significant changes of condition and RN Assessments in regards to significant changes of condition. Training will be completed before compliance date.

b) Resident 6 has been moved to an ICF due to her significant change of condition.She was admitted to the hospital on 10/25 and did not return to us.

2) We have reviewed our system for Resident Health Services and our HSD/RN's role for ensuring items of change are being documented and followed up on.

3) HSD/ED/AHSD will work together to evaluate care staff's communications on possible significant changes of condition needing assessment and will be monitored in clinical meetings.

4) ED in partnership with Health Services leadership will ensure at minimum weekly moitoring.  

2. Resident was 6 admitted to the facility in 04/2022 with diagnoses including rheumatoid arthritis and had a history of falls.

Observations, interviews with staff and Resident 6 and review of Resident 6's clinical records including progress notes, service plans, outside provider notes, incident reports and hospital after visit summaries dated 11/27/22 through 02/28/23 and evaluations revealed the following:

On 12/20/22, Resident 6 returned to the facility following a hospitalization related to a planned surgical procedure of the left shoulder. The hospital "After Visit Summary" noted orders for Resident 6 to receive home health physical therapy services. A home health note stated physical therapy services (twice a week) started on 12/28/22. There was no documented evidence the facility ensured the physical therapy provider left written information related to the services provided 12/29/22 through 01/20/23.

The need to ensure the facility coordinated on-site health services with outside providers was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse),  Staff 6 (RCC) and Staff 7 (RCC) on 03/01/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented, communicated to staff, and the service plan updated for 2 of 5 sampled residents (#1 and 6) who was receiving services from outside providers. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2016 with diagnoses including osteoarthritis and dementia.

During the acuity interview on 02/27/23, Resident 1 was identified as receiving hospice services.

The resident's hospice outside service notes, progress notes, current service plan, and service plan addendums were reviewed from 11/29/22 through 02/28/23 and revealed the following:

* On 12/22/22, hospice wrote, "[Resident 1] is really needing more help with eating, especially if it is not finger food, this will help with dignity and comfort, [s/he] ate 75% of this meal with help of hospice."

* On 12/29/22, hospice wrote, "Please ensure when delivering meals, utensils opened, straws are in drink, and overbed table is over the resident, sitting up, so [s/he] can eat."

* On 12/29/22, coordination of care note, "[Resident 1] had a visit from hospice this morning, breakfast was cut up and fed to resident by LPN, [s/he] ate and drank, staff does not appear to be setting up meals for hospice residents."

* On 01/31/23, hospice wrote, "[ Resident 1] needs help eating, not just tray set up." "Often spilled all over when staff arrives."

Observations from 02/27/23 through 03/02/23 revealed the facility was not providing feeding assistance.

There was no evidence the above hospice instructions for the facility to provide feeding assistance to the resident had been incorporated into the resident's service plan, communicated with staff, or implemented.

The need to ensure outside provider recommendations and instructions were added to the resident's service plan, communicated with staff, and implemented was discussed on 03/02/23 with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Support Nurse), Staff 6 (RCC) and Staff 7 (RCC). They acknowledged the findings.

OAR 411-054-0045 (2) Res Hlth Srvc: On- and Off-Site Hlth Srvc

1.  Community has a system for sign-in of all outside resources and a process for documentation by the provider that is to be reviewed by the Health Services Team with service plan updates needed. We are not making changes to this system but reinforcing with education of our Health Services Team, the RN and the Executive Director. As we are currently reevaluating all residents and updating service plans, we are reviewing all provider documentation for past quarter to ensure recommendations are implemented. The RN is responsible for reviewing all service plan updates made as a result of the providers recommendations.

2.  Community will meet with outside providers to ensure they understand our policies/requirements for documentation to be left with health services.

3.   Review and/or monitoring of provider documentation will occur within 24 hours after the visit. If updates need to occur immediately, the service providers have been educated to meet with the Health Services Team prior to leaving the facility. The Executive Director, RN and Health Services Team are responsible to review routinely at clinical meeting.

2. Resident 9 was admitted to the facility in 03/2021 with diagnoses including diabetes and chronic kidney disease.

During the acuity interview on 07/17/23, Resident 9 was identified as receiving outside provider services related to nursing and physical therapy.  

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/02/23 and progress notes dated 05/03/23 to 07/13/23 were completed. The resident had varying levels of edema to his/her lower extremities with chronic sores.

* A nursing visit note dated 05/19/23, indicated the resident had no open wounds and staff were to continue edema management and apply Vaseline to the right lower extremity daily. Next visit was noted for 05/23/23.

There were no additional home health nursing notes documented in the resident's record.

In interview on 07/19/23, Staff 22 (ED) and Staff 25 (Regional Health Services Support/RN) indicated they were unsure if the resident still received nursing visits from home health. In a follow up interview the same day, Staff 25 indicated she spoke to the home health agency and the resident was currently being seen every two weeks for nursing services. The resident had no break in his/her treatment plan with the home health agency.  In an interview on 07/19/23, Staff 25 indicated she requested additional notes and documentation for the resident's outside provider visits.

The need to ensure on-going coordination of care visit documentation was received by the facility and reviewed for recommendations was discussed with Staff 22 and Staff 25 on 07/19/23. The staff acknowledged the findings.

3. Resident 11 was admitted to the facility in 10/2018 with diagnoses including a chronic head wound.

During the acuity interview on 07/17/23, Resident 11 was not identified to have any outside provider services.   

Observations of the resident, interviews with staff, and review of the resident's service plan dated 05/17/23 and progress notes dated 05/02/23 to 07/13/23 were completed. The resident had a large, partially open, chronic head wound, near the top of his/her head.

The resident started palliative care services on 03/28/23. Multiple visit notes were in the resident's record from 05/02/23 through 05/26/23.

The last documented visit on 05/26/23 indicated it was a PRN palliative care visit, no new recommendations were listed for staff.

There were no additional home health nursing notes documented in the resident's record.

In interview on 07/19/23, Staff 22 (ED) and Staff 25 (Regional Health Services Support/RN) indicated they were unsure if the resident still received palliative care visits from home health. In a follow up interview the same day, Staff 25 indicated she spoke to the home health agency and the resident was currently being seen every two weeks and she requested documentation for the visits from the home health agency.  

The need to ensure on-going coordination of care visit documentation was received by the facility and reviewed for recommendations was discussed with Staff 22 and Staff 25 on 07/19/23. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented, communicated to staff, and the service plan updated for 4 of 5 sampled residents (#s 9, 11, 12 and 13) who were receiving services from outside providers. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 04/2019 with diagnoses including acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity, major depressive disorder, and heart failure.  

During the acuity interview on 07/17/23, Resident 12 was identified as receiving hospice services.

The resident's hospice outside service notes, progress notes, current service plan, and service plan addendums were reviewed from 05/03/23 through 07/17/23 and revealed the following:

* On 05/24/23, hospice wrote "abrasion to L clavicle. Skin prep 1x daily to clean skin, until resolved. Order to follow."

During an interview with Staff 6 (RCC) on 07/18/23, she indicated there was no additional documentation showing the above hospice instructions were implemented.

The need to ensure outside provider recommendations and instructions were added to the resident's service plan, communicated with staff, and implemented was discussed on 07/19/23 with Staff 22 (Executive Director). She acknowledged the findings.

4. Resident 13 was admitted to the facility May 2023 with diagnoses including liver cancer.

During the acuity interview on 7/17/23, Resident 14 was identified as having outside provider services related to hospice services.

Resident 13's progress notes from 05/02/32 through 07/18/23, service plan and outside provider notes were reviewed and revealed the following:

* The facility documented outside provider notes three times from 05/30/23 through 06/28/23.

An interview with Resident 13 on 07/18/23 stated the bath aide comes once a week on Wednesdays and the nurse comes once or twice a week.

An interview with Staff 14 (MT) on 07/18/23 reported that the resident "will often have four hospice visits in a week."

On 7/18/23, additional outside provider notes were requested from Staff 25 (Regional Health Service Support, RN) and she reported that "this is all I have."

The need to ensure coordination of care was documented and recommendations were followed was discussed with Staff 6 (RCC) Staff 22 (Executive Director) and Staff 25 on 7/18/23. They acknowledged the findings.

{C 290} OAR 411-054-0045 (2) Res Hlth Srvc: On- and Off-Site Hlth Srvc

1.  Community has a system for sign-in/out of all outside resources and a process for documentation by the provider that is to be reviewed by the Health Services Team with service plan updates as needed. We are not making changes to this system but reinforcing it with education for our Health Services Team, the RN and the Executive Director. As we are currently reevaluating all residents and updating service plans, we are reviewing all provider documentation for past quarter to ensure recommendations are implemented. The RN is responsible for reviewing all service plan updates made as a result of the providers recommendations.

2.  Community will meet with outside providers to ensure they understand our policies/requirements for documentation to be left with health services.

3.   Review and/or monitoring of provider documentation will occur within 24 hours after the visit. If updates need to occur immediately, the service providers have been educated to meet with the Health Services Team prior to leaving the facility. The Executive Director, RN and Health Services Team are responsible to review routinely at clinical meeting.

2. Resident 1 moved into the facility in 04/2016 with diagnoses including osteoarthritis and dementia.

Physician orders and MARs for Resident 1, reviewed from 02/01/23 - 02/27/23, revealed the following orders were not followed:

* Morphine 0.25 ml three times daily for pain was not administered at the 2:00 pm dose and the 8:00 pm dose on 02/13/23 and was not administered at the 8:00 am dose on 02/16/23. Staff coded "MN" on the MAR, which according to the MAR "chart codes," refers to the medication not received. There was no additional documentation as to why the medication was not administered.  

* Mupirocin 2% ointment apply three times daily for a rash was not applied on 02/22/23, 02/23/23, 02/24/23, and the 9:00 am application on 02/25/23, 02/26/22, and 02/27/23. Staff coded "MN" on the MAR. There was no additional documentation as to why the ointment was not applied.

During an interview on 03/02/23, Staff 3 (Regional Support Nurse) confirmed the above orders were not followed.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3, Staff 6 (RCC) and Staff 7 (RCC) on 03/02/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a physician or other legally recognized practitioner were carried out as prescribed for 2 of 6 sampled residents (#s 1 and 4) whose records were reviewed.  Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 05/2019 with diagnoses including dementia and had a recent diagnosis of failure to thrive.

Resident 4's MAR, dated 02/01/23 through 02/27/23, and current signed physician orders were reviewed.

a. The following medications were documented as not administered on the following occasions:

* Mirtazapine 7.5 mg daily (for anorexia/depression), on five occasions, from 02/23/23 through 02/27/23; and

* Vitamin D3 125 mcg daily (supplement), on two occasions, from 02/10/23 through 02/11/23.

In an interview on 03/01/23 at 01:25 pm, Staff 14 (MT) checked the medication supply and stated the Mirtazepine was not currently available for administration and the pharmacy would be contacted.

b. The following supplement was documented on the MAR as having been administered from 02/01/23 through 02/26/23:

* "Medication Order: Nutritional shake by mouth daily at bedtime" (for nutrition).

Observations of the resident's refrigerator and kitchenette on 02/28/23 and 03/01/23 showed there were no nutritional shakes in the resident's room. During an interview on 03/01/23 at 01:25 pm, Staff 14 confirmed there were no nutritional shakes located in the medication room or the medication cart. During an interview with Witness 1 on 03/01/23, s/he reported Resident 4's family had not provided nutritional shakes to the facility for "at least six months" and believed the facility was providing the shakes.

During an interview on 03/01/23 at 2:45 pm, Staff 1 (Executive Director) reported it was facility policy that families provide nutritional shakes. Staff 1 acknowledged that despite the MAR being marked as "administered", the nutrition shakes were not available in the facility, and therefore, the physician's order was not followed.

On 03/01/23, documentation on the MAR was reviewed with Staff 1 and the need to ensure all physician's orders were carried out as prescribed was discussed. She acknowledged the findings.

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

1.  Resident 1 is deceased.

2.  An audit of resident 4 has been reviewed to ensure medication lists match EMAR and medications are given as prescribed. Any discrepancies found have been clarified with the physician and corrected.

3.  Health Services Team will train staff to follow current policy and procedure for the ordering, receiving and storing of medications. All medications and treatments, prior to staff administration, will have a signed order by an authorized medical provider. Health Services Team and staff will follow physician's orders for resident's medications and treatments.

4.  Central Support Team will provide training with the Executive Director and Health Services Director on the Prestige policy for ordering, receiving and storing of medications and requirements of OAR 411-054-0055. Med Techs will be in-serviced on medication room policy and procedures and medication assistance procedures.

5.  24 hour med pass will be reviewed routinely at clinical meeting.

6.  Administrator and RN are responsible for training of Med Techs and ensuring medications are in the community and being administered correctly.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 10, 11, 12 and 17) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 4 (Business Office Manager) and Staff 7 (RCC) on 03/01/23.

There was no documented evidence Staff 10 (CG), hired 01/19/23, Staff 11 (MT), hired 01/10/23, Staff 12 (CG), hired 12/15/22, or Staff (17) (CG), hired 12/22/22 demonstrated competency in the following areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety and sanitation.

The need to ensure all newly hired staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Executive Director), Staff 4 and Staff 7 on 03/01/23. They acknowledged the findings and no further documentation was provided.

OAR 411-054-0070 (6) (9) Training within 30 days:  Direct Care Staff

1.  All staff will complete the required pre-service dementia training and pre-service infection control.

2.  Community is adding fall prevention, abuse reporting and food safety and sanitation (i.e., food handlers card) to pre-service training as well.

3.  Certificates of completion will be retained in employee files.

4.  Health Services Team will be responsible for making sure that 30 day competency reviews are completed, signed and retained in employee files.  Administrator/Office Manager review monthly.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 long-term staff (#s 15 and 19) completed 12 hours of annual in-service training, including 6 hours related to dementia care. Findings include, but are not limited to:

Staff training records were reviewed on 03/01/23 with Staff 4 (Business Office Manager) and Staff 7 (RCC) and revealed the following:

There was no documented evidence Staff 15 (CG), hired 06/27/13 or Staff 19 (MT), hired 07/06/15 completed at least 12 hours of training related to the provision of care in CBC, including 6 hours of training related to dementia care.

The need to ensure long-term staff completed the required number of hours of annual in-service training, including 6 hours related to dementia care was discussed with Staff 1 (Executive Director), Staff 4 and Staff 7 on 03/01/23. They acknowledged the findings and no further documentation was provided.  

OAR 411-054-0070 (5-7) Annual Training and Other Requirements

1.  Records of annual staff training are kept in the Administrator office and have been completed Jan 2022- Jan 2023.  Administrator was not asked for records.

2.  Prestige maintains a schedule of monthly training assigned automatically to appropriate staff by Learning Management System (LMS).  This listed is updated annually and as needed.  

3.  All staff are required to take assigned trainings.  

4.  Health Services Team will ensure training is complete.

5.  6 hour dementia training requirement will be added via electronically through department approved online learning courses.   

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

On 02/28/23, fire drill and fire and life safety training records for the previous six months were reviewed, and the following was identified:

* Fire drills were not consistently completed every other month during the six-month time frame reviewed.

* Fire drill records lacked the following components:

- Escape route used;

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

- Number of occupants evacuated; and

- Evidence alternate routes were used during fire drills.

* There was no documented evidence the facility provided fire and life safety training on alternating months of the fire drills for staff.

During an interview on 3/03/23 Staff 1 (Executive Director) and Staff 5 (Maintenance Director) indicated the facility was not evacuating or relocating residents during fire drills.

The need to ensure fire drills were conducted in accordance with OFC and fire and life safety instruction to staff was provided and documented on alternate months was discussed with Staff 1 and Staff 5 on 03/03/23. They acknowledged the findings.

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

1.  Prestige Fire Life and Safety policy and procedure reviewed with maintenance director.

2.  Training for correct utilization of Prestige form, containing all state required documentation provided to maintenance director.

3.  Fire drills are in TELs as a task with a reminder to be completed every other month.  

4.  Alternate months will include a fire and life safety in-service. These will include evacuation and evacuation routes, use of fire extinguishers, point of safety, communicating with fire department, radio communications with coworkers and additional as needed.  

5.  Maintenance director is responsible for all training with Administrator oversight in accordance with OAR.

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

On 07/18/23 and 07/19/23, fire drill and fire and life safety training records were reviewed and interviews with Staff 22 (Executive Director) and Staff 5 (Maintenance Director) were conducted. The following was identified:

* Fire drills were not consistently completed every other month during the time frame reviewed. The last fire drill performed was on 04/24/23. Staff 5 stated he planned to do a fire drill once every quarter. There was no plan in place for fire and life safety training on alternating months of the fire drills.

The need to ensure fire drills were conducted in accordance with OFC and fire and life safety instruction to staff was provided and documented on alternate months was discussed with Staff 22 and Staff 5 on 07/19/23. They acknowledged the findings.

{C 420} OAR 411-054-0090 (1-2) Fire Life and Safety:  Safety

1.  Prestige Fire Life and Safety policy and procedure reviewed with maintenance director.

2.  Extra training conducted by Regional Maintenance team for correct utilization of Prestige forms, containing all state required documentation provided to maintenance director. Maintenance Director will fill out the forms completely and accurately.

3.  Fire drills are in TELs as a Regulatory task with a reminder to be completed every other month.  

4.  Alternate months will include non-fire life safety in-services. These will include but not be limited to: training on elopements, earthquakes, floods, active shooter, water boils, etc.

5.  Maintenance director is responsible for all training with Administrator oversight in accordance with OARs.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and annually. Findings include, but are not limited to:

Fire and life safety records were reviewed on 02/28/23. There was no documented evidence residents were instructed on general safety procedures, evacuation methods and responsibilities within 24 hours of admission and annually.

The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 03/03/23. They acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety:  Training for Residents

1.  Facility does have a policy to educate/train residents on fire, life and safety procedures including the evacuation process.  (P&P "Move-In Process").

2.  A "Move In Checklist" to document the all items and trainings received by the resident will be used and saved in the resident file.  

3.  Training to be provided by the Maintenance Director within 24 hours of move in and semi annually with documentation.

4.  Administrator/Office Manager to review at the time of resident move in and quarterly.   

Based on interview and record review, it was determined the facility failed to ensure all residents received fire and life safety training within 24 hours of admission and annually. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records were reviewed on 07/18/23 and 07/19/23. There was no documented evidence all residents were instructed on general safety procedures, evacuation methods and responsibilities within 24 hours of admission and annually.

The need to ensure all residents received fire and life safety training within 24 hours of admission, and were re-instructed at least annually, was discussed with Staff 22 (Executive Director) and Staff 5 (Maintenance Director) on 07/19/23. They acknowledged the findings.

{C 422} OAR 411-054-0090 (5) Fire and Life Safety:  Training for Residents

1.  Facility does have a policy to educate/train residents on fire, life safety and general safety procedures including the evacuation process.  (P&P "Move-In Process").

2.  A "Move In Checklist" to document all of the items and trainings received by the resident will be used and saved in the resident file.  

3.  Training to be provided by the Maintenance Director within 24 hours of move in and semi annually with documentation.

4.  Administrator/Office Manager to review at the time of resident move in and quarterly.  

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 C 154, C 231, C 260, C 270, C 280, C 290, C 420, C 422, C 610.

{C455} OAR-411-054-0105 (2-4) Inspections and Investigation: Insp Interval (p49-50 on SoD)

1.  All citations in this report have been reviewed and a plan of correction is being implemented. See all specific details in the plans outlined below. Plan of Correction date 09/02/2023

2.  Administrator will enforce monthly quality control audits to be completed by each department as designated.  

3.  Any concerns identified through quality control audits will be corrected.

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 C 231, C 260, C 270 and C 280.

{C 455} OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

1) All citations in this report have been reviewed and a plan of correction has been implemented. See all specific details in the plan outlined above. Plan of correction date 11/25/23.

2) Administrator will enforce monthly quality control audits to be completed by each department as designated.

3) Any concerns identified through quality control audits will be corrected.

4) Executive Director

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair and facility grounds were free of litter and refuse. Findings include, but are not limited to:

The exterior of the building was toured on 02/27/23. The following deficiencies were identified:

a. Multiple drop off's, up to three inches in depth, were observed along pathway edges throughout the exterior courtyard which created a potential tripping hazard for residents; and

b. A grassy area of the exterior courtyard had an accumulation of pet waste.

The findings were reviewed with Staff 5 (Maintenance Director) during a tour of the facility grounds on 02/27/23 and discussed with Staff 1 (Executive Director) on 03/01/23. They acknowledged the findings.

OAR 411-054-0300 General Building Exterior

1.  Facility has ordered bark to be refilled along the pathways to ensure equal height of hard and soft ground.  Refilling will be added to TELs as an annual task to be done at the end of winter.

2.  Maintenance Director will check weekly for yard presentation and pet excrement.  Signage has been posted in pet areas to remind residents to remove their pet waste.  Maintenance Director will remove waste that was not picked up.  

3.  No trespassing signs will be added if needed due to neighbors using our area to walk their pets.   

Based on observation and interview, it was determined the facility failed to ensure outside surfaces were maintained in good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of the outside of the building on 07/17/23 revealed the following areas which could have presented tripping hazards:

* Multiple drop-offs along the pathways, from 2 to 3.25 inches; and

* Multiple areas of broken and/or uneven concrete.

The drop-off areas and uneven concrete were shown to and discussed with Staff 22 (Executive Director) on 07/18/23. She acknowledged the need for smooth surfaces to prevent tripping hazards.

{C 610} OAR 411-054-0300 (3)(a-h) General Building Exterior

1.  Facility has had a representative come out to the community to give a quote for bark to be redone along walk ways to a minimum of 3" to fill the gaps against the sidewalks. New bark around complete exterior of the community and grounds will be completed before compliance date.

2. Refilling will be added to TELs as an annual task to be done at the end of each winter.

3.  Community rented a scarification machine that smoothed and evened out all uneven surfaces to eliminate trip hazards along the sidewalks/walkways.

4. Community hired an outside company to remove roots under parking space and repaved it to ensure smooth surface and no trip hazard.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

The interior of the facility was toured on 02/27/23. The following areas needed cleaning or repair:

* Overhead ceiling fans in the resident dining room had a heavy build-up of dust and dirt debris; and

* The drip pans on the stove in the resident "Cafe Room" appeared charred and had a heavy build-up of blackened stains.

The areas in need of cleaning and repair were discussed with Staff 5 (Maintenance Director) during a tour of the facility on 02/27/23 and discussed with Staff 1 (Executive Director) on 03/01/23. They acknowledged the findings.

OAR 411-054-0300

1.  Maintenance Director has purchased a tool that will allow him to reach the ceiling fans for cleaning.  

2.  Cleaning will take place quarterly and will be added to TELs for reminder.  Maintenance Director will review routinely.  Administrator will review monthly.  

3.  Cleaning will take place after resident's dinner meal and the dining room is empty.  

4.  Drip pans have been replaced.  Replacement of drip pans has been added to TELs for reminder quarterly.  

5.  Life Enrichment Director will include cleaning the drip pans after each cooking activity.