Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/01/22.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified:

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on observation, interview, and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24, and 05/29/24, it was confirmed the licensee failed to be responsible for the operation of the facility and the quality of services rendered in the facility. Findings include, but are not limited to:

The licensee is responsible for the operation of the Assited Living Facility, and responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties.

During the LCU investigation, conducted on 05/23/24, 05/24/24, 05/28/24, and 05/29/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations in the following areas:

OAR 411-054-0025(7)(f) Facility Administration; and

OAR 411-054-0070 Staffing Requirements and Training.

LCU requested plans of correction on 05/24/24 and 05/28/24.

Plans of correction were accepted on 05/24/24 and 05/28/24.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

The Department placed a condition on the facility on 05/24/24.

Based on observation, interview, and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility falsified the narcotics log. Findings include, but are not limited to:

On 05/23/24, the facility's narcotics log was observed to have numerous entries missing signatures.

During an interview on 05/23/24, Staff 4 (Resident Care Coordinator) stated the logbook should be signed by both the incoming and outgoing med tech at shift change and "we need to get better at that [signing the log]."

On 05/24/24, the facility's narcotics log was observed to have been signed on the lines of the previously missing signatures, with sticky notes indicating med techs needed to continue to go back and sign the blank entries.

In an interview on 05/24/24, Staff 4 stated "I had people go back and sign."

It was determined the facility falsified the narcotics log.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Staff have been retrained, notices have been posted for staff to not go back and sign documents. All-staff training to be completed by 05/31/24.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to report instances of abuse or suspected abuse to the local Seniors and Peoples with Disabilities (SPD) office for 2 of 2 sampled residents (#s 7 and 14). Findings include, but are not limited to:

During an interview on 05/29/24, Witness 2 (Adult Protective Services (APS)) stated:

-An incident regarding Resident 14 running out of medication, including pain medication, had not been reported by the facility; and

-An incident regarding Resident 7 not being monitored when his/her Furosemide (water retention) had been discontinued had not been reported by the facility.

An incident report for Resident 14, dated 04/08/24, indicated s/he had missed medication and been sent to the hospital.

There was no documented evidence the facility reported the incident to the local SPD.

There was no incident report or documented evidence the facility had reported the incident for Resident 7.

It was confirmed the facility failed to report two instances of abuse or suspected abuse.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal Plan of Correction: RN will be trained on performing self-reports. Events will be reviewed during daily stand-up for the previous 24 hours. All staff to be re-trained on abuse and neglect reporting.

Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to immediately report instances of abuse or suspected abuse for 3 of 3 sampled residents (#s 1, 8, and 13). Findings include, but are not limited to:

Progress notes for Resident 1, dated 08/26/23, indicated s/he had been administered 30mg or Morphine (pain medication) instead of the prescribed 15mg of Morphine. There was no documented evidence the facility investigated the incident or reported the medication error to the local SPD.

An incident report, dated 08/16/23, indicated Resident 8 had received Amlodipine (heart medication) twice a day instead of once a day as prescribed for an indeterminate amount of time. The incident report further indicated the facility self-reported the incident to the local SPD office on 08/23/23.

An incident report, dated 06/28/23, indicated Resident 13 had gone without his/her Pregabalin (pain medication) for five days. The incident report further indicated the incident had been reported to the local SPD office on 08/08/23.

During an interview on 05/28/24, Staff 1 (Executive Director) stated the facility had created incident reports for medication errors for Residents 8 and 13.

It was determined the facility failed to immediately report instances of abuse or suspected abuse.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: RN will be trained on performing self-reports. Events will be reviewed during daily stand-up for the previous 24 hours. Staff to be retrained on abuse and neglect reporting.

Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to notify the local Seniors and People with Disabilities (SPD) department of an incident of abuse or suspected abuse for 1 of 2 sampled residents (# 12). Findings include, but are not limited to:

In an interview on 05/23/24, Staff 1 (Executive Director) stated Resident 12 had moved into the facility on 04/20/24. S/he further stated s/he didn't know the facility needed to report the incident as the local APD had already investigated.

During an interview on 05/23/24, Staff 14 stated Resident 12's family member had approached Staff 14 on 04/22/24 with concerns staff didn't know Resident 12 was living in the facility.

During an interview on 05/24/24, Staff 11 (Med Tech) stated "I was not aware [Resident 12] was here  ... I don't think anybody knew." S/he further stated the facility "usually" puts new move-ins in the "care book" and that s/he hadn't seen a Temporary Service Plan in the med tech book.

A temporary service plan for Resident 12, dated 04/19/24, was not signed by care staff until 04/24/24.

In an interview on 05/24/24, Staff 9 (Dining Services Coordinator) stated "One resident we [the kitchen staff] didn't even know she arrived. Pretty sure it was [Resident 12]. I think [s/he] moved in on a Saturday, found out on Monday."

There was no documented evidence the facility had investigated the incident or reported it to the local SPD.

It was determined the facility failed to notify the local SPD of an incident of abuse or suspected abuse.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: RN will be trained on performing self-reports. Events will be reviewed during daily stand-up for the previous 24 hours. All staff to be re-trained on abuse and neglect reporting.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to develop a service plan reflective of resident needs for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

During an interview on 05/23/24, Witness 1 (Family Member) stated there had been confusion with the facility regarding wound care for Resident 3, and that s/he had to coordinate with Resident 3's physician to begin treatment.

Resident 3's service plan, dated 03/21/24, indicated "[Resident 3] will use family support for transportation to and from medical appointments" under the "Service Coordination" section.

During an interview on 05/28/24, Staff 2 (RN) stated Resident 3's family scheduled appointments and it "should be"  in Resident 3's service plan.

During an interview on 05/28/24, Staff 8 (Med Tech) stated in regard to Resident 3 "[the receptionist] sets up appointments for us."

There was no further documented evidence Resident 3's family was responsible for coordinating health services for Resident 3.

It was determined the facility failed to develop a service plan reflective of a resident's needs.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Facility to update Resident 3's service plan and include coordination of care responsibilities as other service plans are updated.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to monitor a resident following a discontinued medication for 1 of 1 sampled resident (# 7). Findings include, but are not limited to:

During an interview on 05/28/24, Resident 7 stated s/he had been "out of the water pill" and "went for a long time before [the facility] realized."

Resident 7's service plan, dated 05/23/24, indicated s/he had a diagnoses of heart failure.

Physician orders for Resident 7 indicated s/he was to begin Furosemide 40mg/day (water retention) on 04/24/23 with an end date of 10/20/23.

Resident 7's MAR, dated 10/20/23, indicated his/her Furosemide had been discontinued on 10/21/23.

During an interview on 05/28/24, Staff 2 (RN) stated there was an "issue" with whether Resident 7's Furosemide was discontinued or not.

There was no documented evidence the facility had monitored Resident 7 regarding the discontinuation of his/her furosemide.

Resident 7 was admitted to the hospital for heart failure on 11/22/24.

It was determined the facility failed to monitor a resident following a discontinued medication.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are available for the week, posted plan pharmacy indicating refill times. Re-educating staff on three-step process to ensure at least a double check done in the first 24 hours. Facility to ensure Temporary Service Plans are in place during clinical meetings.

Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed a med tech administered insulin prior to being delegated by an RN for 2 of 2 sampled residents (#s 2 and 6). Findings include, but are not limited to:

During an interview on 05/22/24, Staff 10 (Med Tech) stated the facility RN "didn't tell me I had to be delegated" and "I didn't get delegated until a month ago." S/he further stated: "When state came [the nurse] put a different date on the paper. I never signed the delegation because it had the wrong date on it."

A review of insulin delegations and competency checklists for Staff 10 indicated the following:

-Four RN Delegation and Instructions Agreements, dated 03/02/24, were not signed or dated by Staff 10 or Staff 2 (RN);

-An "Initial Evaluation and Competency for Delegation of Nursing Tasks" form for Staff 10 had an "initial date of delegation" of 03/02/24. The form was signed by Staff 10, with a signature date of 04/17/24. The "RN signature" line was blank;

-Another "Initial Evaluation and Competency for Delegation of Nursing Tasks" form for Staff 10 had an "initial date of delegation" of 04/17/24;

-The form was signed by Staff 10, with a signature date of 04/17/24. The "RN signature" line was blank;

-Staff 10's delegation for Resident 6 was signed and dated by Staff 10 on 04/17/24. There was no RN signature;

-Staff 10's delegation for Resident 2 was dated 03/02/24 and signed by Staff 10 and Staff 2 on 04/17/24 with a note above the RN signature "late entry for 03/02/24;" and

-Staff 10's Blood Glucose Testing and Use of Insulin Pens competency checklists were signed and dated by Staff 10 and Staff 2 on 04/17/24, with notes above the RN signature "late entry for 03/02/24."

During an interview on 05/23/24, Staff 2 stated it was "correct" that s/he did not sign on the date of delegations, and further stated "if it's not signed it's not done."

MARs for Residents 2 and 6, dated 03/01/24 through 04/30/24, indicated Staff 10 had administered insulin approximately 26 times between 03/01/24 and 04/17/24.

It was confirmed a med tech was not delegated prior to administering insulin to residents.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Delegations have been completed, any staff member who has not completed competencies and delegation was not administering insulin. Delegations will be reviewed monthly by RN and Executive Director.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to carry out physician orders as prescribed for 1 of 1 sampled resident (# 4). Resident 4 did not receive ordered pain medication resulting in unreasonable pain. Findings include, but are not limited to:

During an interview on 05/28/24, Resident 4 stated s/he had missed two doses of "hydro something last Saturday" and had been in "excruciating" pain because of the missed medication.

During an interview on 05/23/24, Staff 2 (Health and Wellness Director) stated when med techs received faxes from the pharmacy they initialed the order to indicate the "first check" had been performed. S/he further stated the medication is able to be administered after the first check.

A physician order for Resident 4, dated 05/18/24, indicated s/he was to take 2mg of Hydromorphone (pain medication) three times a day. The order was not initialed by the facility until 05/19/24.

Resident 4's MAR, dated 05/01/24 through 05/28/24, indicated a start date for the Hydromorphone of 03/20/24 and confirmed the resident had not been administered two doses of Hydromorphone on 05/18/24 at 6:00 am and 3:00 pm. Notes indicated "pharmacy action required."

During an interview on 05/24/24, Staff 11 (Med Tech) stated one or two residents "slip through" with regards to medication refills.

During an interview on 05/29/24, Staff 1 (Executive Director) stated the facility "typically" didn't reorder medication before the resident had one day left, but had to have Resident 4's Hydromorphone "stat-delivered." S/he further stated the facility "possibly didn't reorder timely."

It was confirmed the facility failed to carry out a physician order as prescribed for a resident.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are available for the week, and post a chart indicating specific pharmacy refill times. Re-educating staff on three-step process to ensure at least a double check done in the first 24 hours.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to carry out physician orders as prescribed for 1 of 1 sampled resident (# 7). Findings include, but are not limited to:

During an interview on 05/28/24, Resident 7 stated s/he had been "out of the water pill" and "went for a long time before [the facility] realized."

A physician order for Resident 7, dated 11/20/24, indicated s/he was to take 40mg of Furosemide (diuretic) beginning on 11/20/24. Initials indicated the facility had reviewed the order on 11/22/24.

Resident 7's MAR, dated 11/01/23 through 11/30/23, indicated Resident 7's Furosemide had a start date of 11/23/23.

During an interview on 05/29/24, Staff 17 (Health and Wellness Coordinator) confirmed the order had not been processed until 11/22/23.

It was determined the facility failed to carry out physician orders as prescribed for Resident 7.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are available for the week, and had placed postings in the medication room indicating specific pharmacy refill times. Re-educating staff on three-step process to ensure at least a double check done in the first 24 hours.

Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to reorder medications timely for 2 of 2 sampled residents (#s 5 and 13). Findings include, but are not limited to:

During an interview on 05/28/24, Staff 1 (Executive Director) stated the facility had run out of pain medication for Residents 5 and 13.

During an interview on 05/24/24, Staff 11 (Med Tech) stated one or two residents "slip through" with regards to medication refills.

Resident 5's MAR, dated 07/01/23 through 07/31/23, indicated s/he had not received Tramadol (pain medication) from 07/24/23 through 07/28/23. Notes indicated "waiting on pharmacy action."

An incident report, dated 06/28/23, indicated Resident 13 had been without his/her Pregabalin (pain medication) for five days.

It was determined the facility failed to reorder medications timely for residents.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are ordered and available for the week, and post a sheet indicating pharmacy refill times in the medication room. Facility is re-educating staff on three-step process to ensure at least a double check on medications done in the first 24 hours.

Based on interview and record review, conducted during a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility administered the wrong dosage of medications to 2 of 2 sampled residents (#s 8 and 10). Findings include, but are not limited to:

During an interview on 05/28/24, Staff 1 (Executive Director) stated Residents 8 and 10 had received incorrect doses of medication in August 2023.

An incident report, dated 08/16/23, indicated Resident 8 had received Amlodipine (heart medication) twice a day instead of once a day as prescribed for an indeterminate amount of time.

An incident report, dated 08/16/23, indicated Resident 10 had received unknown dosages of Citalopram (antidepressant) for an indeterminate amount of time.

It was determined the facility administered the incorrect dosage of medications to residents.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Facility to establish "Medication Mondays" to ensure medications are ordered and available for the week, and post a sheet indicating pharmacy refill times in the medication room. Facility is re-educating staff on three-step process to ensure at least a double check on medications done in the first 24 hours.

Based on observation, interview, and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:

The facility's posted staffing plan indicated:

-One med tech (MT) and two-and-a-half caregivers (CG) on day shift;

-One MT and one-and-a-half CGs on swing shift; and

-One MT and one CG on night shift.

The facility's census was 52 residents, 20 were identified by staff as requiring bathing assistance, seven required transfer assistance, seven required "frequent checks," and eight required toileting assistance.

On 05/23/24, one CG and one MT were observed to be working on day shift and swing shift.

During an interview on 05/23/24, Staff 12 (MT) stated "staffing issues suck ... there should be at least three caregivers on day shift ... a lot of stuff gets missed [such as laundry an garbage]." S/he further stated when there are enough staff, showers get done but if not, they get missed.

In an interview on 05/23/24, Resident 6 stated  late at night sometimes there's nobody here because they left to get food. "

During an interview on 05/23/24, Staff 14 stated the following:

-On 05/08/24 there was one CG on day and swing shift;

-On 05/09/24 there was one CG on day shift;

-On 05/10/24 there was one CG on day and swing shift;

-On the night shift of 05/21/24 to 05/22/24, there were no CGs on night shift; and

-On 05/22/24 there was one CG on day shift.

S/he further stated family members had been observed by staff providing incontinence care for residents who had not been checked on.

During an interview on 05/24/24, Staff 13 (CG) stated when caregivers were working by themselves, showers were "postponed."

In an interview on 05/24/24, Staff 9 (Dining Services Coordinator) stated the facility had one CG on "more times than I'd like" and that s/he tried to ask care staff if they "have had eyes on residents" multiple times a day.

On 05/24/24 at approximately 9:43 am, LCU requested an immediate plan of correction to address the above issues. LCU received a plan at 11:00 am. It was not accepted. Another plan of correction was received at 12:17 pm. The plan was accepted 12:25 pm on 05/24/24.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

The facility's Acuity-Based Staffing Tool was not investigated during the site visit as the facility was already on condition imposed on 12/27/22. ALFCD22-01185.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to evaluate competencies of direct care staff prior to performing duties. Findings include, but are not limited to:

During an interview on 05/28/24, Staff 8 (Med Tech) stated s/he had one day of training and then was "on the floor."  S/he further stated no one had observed him/her perform a medication pass.

On 05/28/24, LCU asked the facility for competency evaluations for direct care staff.

During an interview on 05/28/24, Staff 1 (Executive Director) stated s/he could not find competency evaluations for any direct care staff except for Staff 1, 8, 12 (Med Tech), 16 (Caregiver), and 18 (Caregiver).

The facility's failure to evaluate competencies for direct care staff placed residents health and safety at risk.

On 05/28/24 at approximately 2:40 pm the LCU team requested an immediate plan of correction. A plan of correction was received at approximately 3:15 pm and was not accepted by the Department. A revised plan of correction was received and accepted at approximately 3:50 pm.

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Based on interview and record review, conducted during interviews on 05/22/24 and a site visit on 05/23/24, 05/24/24, 05/28/24 and 05/29/24, it was confirmed the facility failed to include residents in fire drills and had not conduct fire drills every other month. Findings include, but are not limited to:

During an interview on 05/23/24, Staff 14 stated residents were not included in fire drills.

During an interview on 05/28/24, Resident 4 stated the last time s/he had remembered residents being included in fire drills was 2020.

A review of the facility's fire drill "Logbook Documentation" for 2024 indicated the following:

-Fire drills had been conducted on 01/09/24, 01/11/24, 01/12/24, 04/06/24, and 04/09/24;

-For the fire drill on 01/11/24, the resident head count was "na";  and

-For the fire drill on 01/12/24, the resident head count was  "SEE [notes]." There were no additional notes.

It was determined the facility failed to include residents in fire drills and conduct fire drills every other month.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health and Wellness Director), and Staff 3 (District Director of Operations) on 05/29/24.

Verbal plan of correction: Fire drills will be performed monthly going forward. Maintenance Director and ED will be responsible to ensure completion of fire drills. Residents will be included depending on type of fire drill.