The findings of the re-licensure survey, conducted 04/29/24 through 05/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

A situation was identified where there was a failure of the facility to comply with the Department's rules which was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:

C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

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

The findings of the first re-visit to the re-licensure survey of 05/03/24, conducted 09/03/24 through 09/04/24, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 09/04/24, conducted 04/10/25, 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, OARs 411 Division 57 for Memory Care Communities, 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 for the operation of the facility and to ensure the quality of services rendered in the facility. Findings include, but are not limited to:

During the relicensure survey, conducted 04/29/24 through 05/03/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity of the citations.

1. A situation was identified which constituted an immediate threat to the health and safety of the residents in the following area:

C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching.

The facility developed and implemented an immediate plan of correction during the survey to address the threat to residents' safety, and the situations were abated.

2.  Refer to deficiencies in the report.

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 04/29/24 through 05/03/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.

The need to ensure the facility developed and conducted an ongoing quality improvement program that evaluated services, resident outcome and satisfaction was discussed during the exit interview. No additional information was provided.

Refer to the deficiencies in the report.   

Based on interview and record review, it was determined the facility failed to investigate incidents to rule out abuse, document all required areas of an investigation, and/or immediately report to the local Seniors and People with Disabilities (SPD) office if abuse could not be ruled out for 4 of 4 sampled residents (#s 1, 2, 3, and 4 ) reviewed for resident-to-resident altercations and unwitnessed falls. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 11/2022 with diagnoses including dementia with behavioral disturbance.

A review of the resident's 04/26/24 service plan, 01/29/24 through 04/29/24 progress notes and incident reports for the same time period were completed. Resident 1's service plan identified the resident as having recurrent aggressive and sexually inappropriate behaviors.

A review of the resident's records identified the following:

* On 01/30/24, progress notes and an incident report noted, "[Resident 1] was rubbing [another resident's] buttocks with [his/her] hand and [the other resident] was witnessed kissing [Resident 1] on [his/her] forehead."

An investigation was completed but no report was made to the local SPD office until  02/07/24, eight days after the incident.

* On 02/04/24, progress notes and an incident report noted that staff had found another resident lying in Resident 1's bed. Resident 1 was not wearing pants and was standing at the bedside.

An investigation was completed, but no report was made to the local SPD office until 02/07/27, three days after the incident.

* On 02/05/24, progress notes and an incident report noted, a resident-to-resident altercation in which Resident 1 had slapped another resident with an open hand.

An investigation was completed, but no report was made to the local SPD office until 02/07/24, two days after the incident.

In addition, the facility failed to ensure the above incidents had been reviewed by the administrator.

The need to ensure incidents of abuse or suspected abuse were immediately reported to the local SPD office and promptly investigated was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.

A review of the resident's 04/03/24 service plan, 01/29/24 through 04/24/24 progress notes and incident reports for the same time period were completed. Resident 4's service plan identified the resident as having physical and verbally aggressive behaviors toward other residents and staff.  

A review of the resident's records showed the following:

* On 02/25/24, staff documented in a progress note that Resident 4 had charged and screamed in another resident's face. "[Resident 4] slapped [the resident] in the face and was going to punch [him/her]." [Resident 4] picked up a chair and was going to throw it at [the resident]."  

* On 03/03/24, staff documented in a progress note Resident 4 was in a resident-to-resident altercation and had obtained a skin tear.

Investigations were completed at the time of the incidents; however, the incidents were not reported to the local SPD office.

The facility was directed to self-report the incidents to the local SPD office. Confirmation the reports had been sent was received on 05/03/24.

The need to immediately report resident altercations to the local SPD office was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

3. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.

Interview and record review revealed the following:

* On 02/12/24, Resident 3 experienced an unwitnessed fall with an abrasion to his/her back. The incident was investigated, however, there was no documented evidence of an administrator review of the incident.

* On 03/10/24, Resident 3 experienced an unwitnessed fall with fractured ribs. The incident was investigated, however, there was no documented evidence of an administrator review of the incident.

On 05/03/24, the need to ensure investigations of suspected abuse were reviewed in a timely manner by the facility administrator was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations) Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.

4. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia.

The resident's record, including progress notes and incident reports, was reviewed, and staff were interviewed. The following was identified:

A progress note dated 03/05/24 indicated the resident was found on the floor in his/her room with "a laceration on the back of [resident's] head that was bleeding."

Staff 1 (Associate Executive Director) confirmed in an interview on 05/03/24 that the incident report dated 03/05/24 did not include an investigation which ruled out abuse or neglect.

The surveyor requested the facility report the incident to the local Seniors and People with Disabilities (SPD) office on 05/03/24. Confirmation was provided of the report prior to survey exit.

The need to investigate unwitnessed falls with injury to rule out abuse and/or neglect, and to report the incident to the local SPD office if abuse and/or neglect could not be ruled out, was discussed with Staff 1, Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

2. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and dementia with behavioral disturbance.

Resident 1's most recent quarterly service plan was updated 04/26/24. There was no documented evidence of a quarterly evaluation which corresponded with the 04/26/24 service plan update.

In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported that she had not completed the resident's quarterly evaluation.

The need to ensure the facility completed resident evaluations quarterly was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

3. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.

Resident 4's most recent quarterly service plan was updated 04/03/24. There was no documented evidence of a quarterly evaluation which corresponded with the 04/03/24 service plan update.

In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported that she had not completed the resident's quarterly evaluation.

The need to ensure the facility completed resident evaluations quarterly was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 4 of 4 sampled residents (#s 1, 2, 3, and 4), whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.

Resident 3's most recent quarterly service plan was updated 12/28/23. There was no documented evidence of a quarterly evaluation which corresponded with the 12/28/23 service plan update.

On 05/02/24, Staff 1 (Associate Executive Director) reported the service plan dated 12/28/23 was all she had related to a quarterly evaluation for Resident 3.

On 05/03/24, the need to ensure a quarterly evaluation was completed timely was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.
 

4. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia. A review of the resident's record identified his/her quarterly evaluation had not been completed.

Staff 4 (RN/Health and Wellness Director) confirmed in an interview on 05/02/24 that she had completed the resident's current service plan, dated 04/06/24, without completing a quarterly evaluation.

The need to ensure resident evaluations were completed quarterly, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear instructions to staff for 2 of 4 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and dementia with behavioral disturbance.

The resident's 04/26/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan failed to provide clear direction to staff in the following areas:

* Frequency of supervision related to behaviors; and

* Emergency evacuation ability.

The need to ensure service plans included clear direction to staff was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.

The resident's 04/03/24 service plan was reviewed, observations were made of the resident, and interviews with staff occurred throughout the survey. The service plan failed to provide clear direction to staff in the following areas:

* Frequency of toileting assistance and brief changes;

* Oral care and clear instructions on what staff were to complete;

* Pain areas and treatment; and

* Emergency evacuation ability.

The need to ensure service plans included clear direction to staff was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 4 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1, 3, and 4's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of their service plans.

On 05/03/24, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure interventions for changes of condition were determined, communicated to staff, and/or were monitored and evaluated for effectiveness for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced changes of condition related to skin, behaviors, and falls. Resident 1's wounds worsened. Findings include, but are not limited to:

1. Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes and diabetic polyneuropathy.  

a. During the acuity interview on 04/29/24 and interviews with care staff between 04/29/24 and 05/02/24, staff indicated Resident 1 had wounds on both feet.

A record review showed the resident's feet were treated by HH until 02/08/24. On 02/08/24, the HH RN left the following wound care recommendations for the facility:  

Washing the resident's feet at least every other day and apply vaseline or lotion.

There was no documented evidence the facility washed the resident's feet every other day or applied lotion to the resident's feet. The facility failed to communicate those instructions to staff.

The resident's 01/29/24 through 04/29/24 progress notes and skin documentation indicated the resident experienced the following changes of condition:

On 02/14/24, staff documented in a progress note that the resident had a visit from a podiatrist. "Services performed: debridement of nails times ten with use of nail nippers and debulked with [the] use of a dremel. Nursing staff will continue to monitor [resident's] feet on a routine basis. Recommended routine debridement of nail plates at three-month intervals or sooner if any pathological problems occur with the feet. Recommended use of protective shoe gear to prevent incidental damage to the feet."

On 03/17/24, staff documented in a progress note that the resident was found on the floor of his/her bedroom. "Staff noticed blood and found wounds on several toes that were bleeding." The resident was sent to the emergency room.

Between 02/14/24 and 03/17/24 the facility failed to monitor and document on the progress of the wounds.

On 03/23/24 staff documented in a progress note that the resident had fallen. The MT noted the following: "saw some blood from [his/her] feet and checked [his/her] toes and saw some sores and a new open area."

On 03/27/24, staff documented in a progress note that the "resident has wounds on [his/her] left foot. Big toes [on left foot were] bleeding and had dry blood build up. MT has cleaned and disinfect. Ring toe is swollen, red and warm to the touch." It was further noted that staff were instructed by the facility RN to put socks and shoes on the resident. The resident was placed on alert charting.

On 03/28/24, the RN completed a significant change of condition note related to wounds on toes. The RN noted the following: "[Resident 1] has developed open wounds on [his/her] 2nd, 3rd, and 4th toes on the dorsal aspect of both feet. [S/he] also has a closed, calloused wound on [his/her] right 2nd toe on the bottom. [His/her] big toes are in need of podiatrist nail care. [Resident 1] refuses to wear socks and the wounds are present in the area where [his/her] toes come into contact with the fabric of [his/her] shoes. [Resident 1] is reluctant to have any treatment done on [his/her] toes." The RN noted the resident was very resistant to showering or changing clothes and often slept with shoes on. The RN documented the resident was encouraged to wear socks and noted the resident seemed to understand that his/her shoes were rubbing on his/her toes. It was further noted that an evaluation by the resident's PCP was needed prior to a HH referral.

On 04/23/24 the RN and LPN assessed the resident toes and documented the following:

"Right foot 2nd toenail appears to have been pulled out some time ago, as the bed is hard and dark pink. There is an abrasion on the top of this toe, appx 0.8cm roughly round. This was cleaned with wound cleanser, dried and a band aid applied. There is a black, hard calloused area on the tip of the toe, slightly medial. 4th and 5th toes have hard scaly thickened areas, pale yellow and brown in color. Several areas of the toes have peeling, thick skin. Resident denies pain anywhere on his feet. Left foot has no open areas, but 3rd and 4th toes both have the same type of hard, scaly thickened areas on the tops and at the base of both. All toes have the peeling thick skin as well."

Between 03/28/24 and 04/23/24 the facility failed to monitor the wounds consistent with the resident's evaluated needs and service plan.

The RN documented on 04/10/24 and 04/23/24. The 04/23/24 note indicated the resident's sibling was called regarding the importance of the resident to be seen for his/her feet. The sibling had stated that the resident had an appointment on 04/25/24.

On 04/25/24 a progress note documented the resident's sibling had transported the resident to an appointment at the Diabetes Care Clinic. It was noted the "diabetic nurse did nail clipping and wound debridement and had instructed the [sibling] to take [Resident 1] to Urgent Care."

On 04/26/24 a progress note documented the resident's sibling had transported the resident to urgent care. The resident was diagnosed with an infection and was prescribed an antibiotic.  

The resident's wounds worsened, and subsequently developed into infection requiring antibiotics. The following deficiencies were identified:

* The facility failed to evaluate and document the status of the wounds at the time they assumed wound care from HH. The facility also failed to monitor the progress of the wounds and evaluate the effectiveness of the interventions/treatments;  

* The facility failed to add the instructions regarding washing the resident's feet at least every other day and applying lotion to the service plan and communicate those instructions to staff; and

* The facility failed to monitor the resident's wounds consistent with his/her evaluated needs and service plan.

The facility's failure to update the resident's service plan with interventions, communicate to staff and monitor the progress of wounds, resulted in the wounds worsening and subsequently developed into an infection, was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

b. The resident's current service plan dated 4/26/24, Temporary Service Plans, progress notes dated 01/29/24 through 04/29/24 were reviewed. Interviews with care staff were completed between 04/29/24 and 05/02/24.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:

02/16/24 - Sexual and aggressive behaviors;

03/17/24 - Fall with skin injuries;

03/23/24 - Fall with injury; and

04/10/24 - Fall due to low blood sugar, resident was sent to the emergency room.

On 05/03/24, the need to ensure resident specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored at least weekly, through resolution was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

2. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.

The resident's current service plan dated 04/03/24, Temporary Service Plans, progress notes dated 01/31/24 through 04/24/24 were reviewed. Interviews with caregivers were completed between 04/29/24 and 05/02/24.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:

* 02/18/24 - Resident to staff physical altercation. The resident had fallen after hitting a staff member and was sent to the emergency room;

* 02/25/24 - Resident to resident altercation;

* 03/03/24 - Resident to resident altercation; and

* 04/19/24 - Pain in right arm and excessive drooling.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

4. Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's clinical records, including incident reports, progress notes dated 01/30/24 through 04/29/24, service plan dated 12/28/23, and weight records was conducted.

a. Record review indicated the resident experienced a 6.4 pound weight loss from 03/2024 to 04/2024 which constituted a severe 6.60% loss in one month.

There was no documented evidence of ongoing monitoring of the resident's weight, no documentation the weight loss was reported to the RN and there were no interventions implemented.

On 05/01/24, survey requested a current weight for Resident 3. The weight was noted as an increase of 2.6 pounds.

On 05/01/24, the need to respond to significant/severe weight loss with ongoing monitoring, implementation of interventions and evaluation for effectiveness of those interventions was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), and Staff 4 (RN/Health and Wellness Director). They acknowledged the findings.

Refer to C280.

b. Resident 3's record was reviewed for changes of condition and the following falls with injury were identified:

*On 02/12/24, Resident 3 was found on the floor of his/her bedroom with an abrasion near the middle of their spine. There was no evidence the facility monitored the short term change until resolution.

*On 03/10/24, Resident 3 was found on the floor of his/her bedroom with complaints of pain to his/her right side. Staff documented in a progress note, on 03/10/24, the resident returned from the local hospital with four fractured ribs. While the facility implemented interventions after the fall, there was no documented evidence the facility monitored the resident consistent with his/her evaluated needs.

On 05/03/24, the need to ensure the facility was monitoring short term changes of condition through resolution and significant change of condition with their evaluated needs was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.

3. Resident 2 was admitted to the facility in 09/2016 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's clinical record including service plan dated 04/06/24, progress notes dated 02/01/24 through 04/23/24, and weight records was conducted.

a. Weight records from 12/19/23 through 04/08/24, reviewed on 04/29/24 indicated the resident weighed:

* 09/01/23: 129.0 lbs;

* 09/08/23: 132.8 lbs;

* 10/08/23: 121.2 lbs;

* 12/19/23: 118.0 lbs;

* 01/09/24: 124.8 lbs;

* 03/01/24: 119.0 lbs; and

* 04/08/24: 118.0 lbs.

An RN assessment dated 03/05/24 noted a 13.8 pounds weight loss or 10.4% of his/her body weight. The assessment noted the following interventions:

* Second helpings; and

* Substitute calorie rich food if not interested in what s/he was served.

There was no documented evidence the interventions were communicated to staff. On 05/02/24 Staff 4 (RN/Health and Wellness Director) reported she had filled out a temporary service plan for the interventions but did not know where it was. The current service plan dated 04/06/24 did not identify the interventions.  

On 04/29/24 Resident 2 was observed during lunch to eat 100% of his/her puree meal and was not offered seconds. On 04/30/24 Resident 2 was observed during lunch to eat 100% of his/her meal, was offered seconds, and was then observed to eat 100% of the 2nd entrée that was provided. A staff member asked Resident 2 if they would like more, to which the resident nodded and the staff confirmed, but no third helping was provided.

In addition, staff initialed on the MAR they were administering a MightyShake nutrition supplement with meals however none was observed with lunch on 04/29/24 and 04/30/24.

On 05/01/24 a current weight for Resident 2 was requested and provided, which identified the resident as continuing to lose weight, at 114.8 pounds. Between 04/08/24 and the time of the survey, 5/1/24, Resident 2 lost an additional 3.2 pounds.

The need to ensure interventions for significant changes of condition were communicated to staff, and monitored consistent with the resident's evaluated needs, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

b. The following short-term change of condition lacked documentation of progress noted at least weekly through resolution:

* 03/05/24 - wound on back of head.

The need to ensure short term changes of condition were monitored at least weekly through resolution was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a significant change of condition was assessed by an RN, with resident status documented, and interventions developed as a result of the assessment, for 1 of 3 sampled residents (#3) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in February 2021 with diagnoses including dementia.

Review of Resident 3's weight records from 11/2023 through 04/2024 showed the following:

On 03/08/24, the resident weighed 95.6 pounds and on 04/08/24 the resident weighed 89.2 pounds. The resident experienced a 6.4 pound weight loss from 03/2024 to 04/2024 which constituted a severe 6.6% loss in one month and required and RN assessment.

There was no documented evidence the RN had assessed the status of the resident, documented findings, and developed interventions as a result of the assessment.

Resident 3 was observed independently eating lunch on 04/29/24 and breakfast on 04/30/24. The resident ate over 50% of the meals provided.

On 05/01/24, survey requested a current weight for Resident 3 and weighed 91.8 pounds. This was an increase of 2.6 pounds from their 04/08/24 weight.

On 05/01/24, the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), and Staff 4 (RN/Health and Wellness Director). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by an RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in Chapter 851, division 047 for 1 of 1 sampled resident (#1) and two unsampled residents who received insulin injections by a facility unregulated assistive person (UAP). These residents were at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, UAP training, and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to:

Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions, and outcomes pursuant OAR 851-045, including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client.

During the acuity interview on 04/29/24, Resident 1 was identified as receiving both sliding scale and scheduled insulin by facility UAPs.

In an interview with Staff 4 (RN/Health and Wellness Director) on 04/30/24, she reported that in addition to Resident 1, two other residents also received insulin.  

Resident 1's 04/01/24 through 04/29/24 MAR noted the resident received routine insulin every morning and at bedtime, plus sliding scale insulin before breakfast, lunch, and dinner. The MAR identified nine facility UAPs that administered insulin to the resident during the month of April.

A progress note dated 04/30/24 by the RN noted a medication error had occurred on 04/29/24. The resident had an order for 50 units of Lantus scheduled at bedtime and a sliding scale insulin Novilin R before meals. The resident's blood sugar was 298 and reference to the sliding scale order the resident should have received 10 units of Novilin R. The RN documented, "The MT instead gave 10 units of Lantus and 50 units of Novilin R" instead of the ordered 50 units of Lantus and 10 units of Novilin R.

In an interview on 05/01/24 Staff 14 (MT/Resident Care Assistant) and Staff 16 (MT), two of the UAPs who administered insulin, revealed they had not been delegated.
 

Upon review of the delegation binder, there was no documented evidence that any of the residents receiving insulin injections had documentation that the resident's condition was stable and predictable or that the determination of frequency of the resident should be reassessed, including rationale. There was no documented evidence any of the facility UAPs had been delegated by an RN, including:

* Rationale why the task could be safely delegated;

* Skills, abilities, and willingness of the UAP to complete the task;

* Task was taught to the UAP, and they were competent to safely perform task;

* Written instructions available, including risks, side effects, response, and risk factors;

* UAP were taught the task was client specific and not transferable;

* Determination of frequency of the UAP should be supervised and reevaluated, including rationale; and

* RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance.

In an interview on 04/30/24 Staff 4 was unable to find documented evidence that delegation was completed according to OSBN Division 47 rules.

On 05/01/24 at 9:19 am, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Associate Executive Director), Staff 4 and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the above findings.

On 05/01/24. the survey team requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.

On 05/01/24 at 1:00 pm, a plan to address the delegation issue which included licensed staff administering insulin until delegation was completed, was accepted and the situation was abated.

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

Resident 1 moved into the memory care community in 11/2022 with diagnoses including Type 2 diabetes with diabetic polyneuropathy.    

A review of progress notes and "Outside Provider Communication Forms" from 01/23/24 through 02/08/24 identified the resident had been receiving HH wound care until 02/08/24, which included the following information made by the provider:

* 01/23/24: "Check [left] great toe, clean [and] cover with band aide. Encourage resident to wear socks daily and HH [Skilled Nurse] to assess wound once a week;"

* 01/26/24: "Please redress wound to left foot if it becomes dislodged. Apply betadine and bandage. Also, remove bandage and reapply if wet. [The] wound is macerated from being very wet;"

* 01/29/24: "Keep wound dry and covered;"

* 02/01/24: "Replace bandage if it is soiled/dislodged;" and

* 02/08/24: "Recommending washing [resident's] feet at least every other day and applying Vaseline or lotion. If wounds on feet reopen, feel free to contact [HH] to come back in. Nurse moving to PRN [as needed]."

There was no documented evidence the facility reviewed the outside provider information, updated the resident's service plan, informed staff of the new interventions, or implemented the treatment.

In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director) reported she was unaware of the above information left by the outside provider. Staff 4 further indicated that the information and recommendations had not been added to the resident's service plan nor communicated to staff for implementation.

The need to ensure the facility coordinated care with outside providers to ensure continuity of care was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related due to lack of delegation. The findings constituted an immediate plan of correction for the health and safety of the residents. Findings include, but are not limited to:

Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following area:

C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching.

On 05/01/24 at 9:00 am, the survey team requested an immediate plan of correction to address the issues identified. A plan was developed and at 1:00 pm was accepted by the team. The immediate jeopardy situation was abated.

Refer to C282.

2. Resident 1 moved into the memory care community in 11/2022 with diagnoses including

Type 2 diabetes and dementia with behavioral disturbance.

The resident's MAR, dated 04/01/24 through 04/29/24, and physician's orders were reviewed.

Resident 1 had a physician's order to report to the licensed nurse if CBG was less than 80 or more than 400.

Between 04/01/24 and 04/29/24, Resident 1's CBG was less than 80 on eleven occasions. There was no documented evidence the facility notified the licensed nurse.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

3. Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.

The resident's MAR dated 04/01/24 through 04/29/24 and physician orders were reviewed, and identified the following medications did not have signed orders in the record:

* Candesartan cilexetil 32 mg for high blood pressure;

* Donepezil 10 mg for dementia;

* Memantine 5 mg for dementia;

* Sertraline 25 mg for depression;

* Acetaminophen 500 mg for pain;

* Olanzapine 2.5 mg for behaviors;

* Guaifenesin 20 ml for cough;

* Haloperidol 0.5 mg PRN for agitation; and

* Hydrocodone 0.5 mg PRN for pain.

During an interview on 04/03/24, Staff 4 (RN/Health and Wellness Director) acknowledged the resident did not have signed physician orders. Staff 4 stated the resident had recently switched providers and the new provider had been at the facility on 05/02/24; however, the provider failed to leave signed orders. Staff 4 was working with the provider to obtain current signed orders.  

The need to have signed physician orders for all medications administered by the facility was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's record for all medications the facility was responsible to administer, and medication and treatment orders were carried out as prescribed for 3 of 4 sampled residents (#s 1, 2, and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 09/2016 with diagnoses including dementia.

The resident's MAR dated 04/01/24 to 04/29/24 was reviewed, and identified the following:

a. In an interview on 04/29/24, Staff 1 (Associate Executive Director) reported physician orders for Resident 2 were unable to be located, and that hospice would be faxing orders to the facility.

A fax transmission dated 04/29/24 with physician orders signed 04/29/24 was provided on 04/30/24.

b. Resident 2 had an order for morphine sulfate 20 mg/ml solution .5 ml (10 mg) by mouth every hour as needed for pain or shortness of breath. On 04/21/24 the MAR documented .25 ml was administered, which corresponded to the narcotics log.

In an interview on 05/02/24, Staff 4 (RN/Health and Wellness Director), confirmed that she had administered less than the prescribed dose.

The need to ensure written, signed physician orders were in the resident's facility record, and that physician's orders were followed, was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff attempted non-pharmacological interventions and documented they were ineffective prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed a PRN psychotropic medication. Findings include, but are not limited to:

Resident 4 moved into the memory care community in 12/2022 with diagnoses including dementia with behavioral disturbance.

A review of Resident 4's MAR, dated 03/01/24 through 04/29/24, indicated the resident was prescribed haloperidol PRN, 0.5 mg every four hours for behaviors and agitation.

Resident 4 was administered haloperidol on 03/18/24, 03/19/24, 03/31/24, and 04/10/24. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administration.

In an interview on 05/02/24, Staff 14 (MT/Resident Care Associate) confirmed there was no documented evidence on the MAR that showed non-pharmacological interventions were attempted with ineffective results prior to administration.   

The need to document that non-pharmacological interventions were attempted without success prior to administering a PRN psychotropic medication was discussed with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:

The facility posted staffing plan indicated the facility staffing levels were:

* Day shift 2 MT's and 4 CG's;

* Evening shift 1 MT and 3 CG's; and

* Night shift 1 MT and 2 CG's.

Review of the facility schedule for the month of April 2024 indicated the facility was staffing 2 MT's and 3 CG's for day shift.

During interviews on 05/03/24, Staff 11 (Resident Care Associate), Staff 14 (MT), and Staff 17 (Resident Care Associate) indicated when the facility had 2 MT's and 3 CG's, the facility was understaffed and some of the scheduled showers were not always completed. Some resident showers got delayed to swing shift or the resident was first for showers on day shift the following day.

On 05/03/24, the need to ensure the facility had adequate staff to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN). They acknowledged the findings.

Refer to C361.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

The facility's ABST was reviewed on 05/01/24.

There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST being used by the facility.

The need to use an ABST which addressed all the 22 activities of daily living for each resident and the amount of staff time needed to provide care in each area was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. This is a repeat citation. Findings include, but are not limited to:

The facility's ABST was reviewed on 09/04/24.

There was no documented evidence all 22 required activities of daily living were addressed separately on the ABST being used by the facility.

On 09/04/24, the need to use an ABST which addressed all the 22 activities of daily living for each resident and the amount of staff time needed to provide care in each area was discussed with Staff 21 (Associate Executive Director), Staff 2 (Executive Director), and Staff 3 (District Director of Operations). They acknowledged the findings.

1. As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff according to our Brookdale acuity based staffing tool.

2. Our home office team will continue to establish proper communication with DHS regarding

The ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or above staffing levels currently identified in our tool.

3.  This will be evaluated by the Health and Wellness Director/Resident Care Coordinator to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met.

4. The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool       

Based on record review and interview, it was determined the facility failed to ensure 2 of 2 sampled newly hired direct care staff (#s 13 and 14) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 05/02/24 and 05/03/24. The following deficiencies were identified:

Staff 13 (Resident Care Associate) and Staff 14 (MT/Resident Care Associate), hired 02/16/24 and 02/01/24 respectively, did not have documented evidence of having completed abdominal thrust training.

The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

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

Refer to C 361.

See correction C361

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

Observations of the facility on 04/29/24 and 05/03/24 identified the following areas in need of repair:

*Coffee Bar and Dining room floors had gouges and scrapes; and

*Coffee Bar and Dining room chairs were worn down to bare wood.

On 04/30/24, an environment tour was conducted with Staff 1 (Associate Executive Director), Staff 3 (District Director of Operations), and Staff 5 (Maintenance Manager). They acknowledged the findings.

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

H 1518: Individual Door Locks: Key Access OAR 411-004-0020 (2)(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C150, C156, C231, C360, C361, and C513.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 361.  

See correction C361

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

a. Situations were identified where there was a failure of the facility to comply with the Departments rules that caused or were likely to cause an immediate threat to residents' health and safety. An immediate plan of correction was requested in the following area:

C282: OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching.

b. Refer to C252, C260, C262, C270, C280, C290, C300, C303, and C330.

Based on interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3 and 4's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the following required components:

* Residents' current preferences;

* Abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

There was no specific activity plan, reflecting the residents' activity preferences and needs, which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Associate Executive Director), Staff 2 (Executive Director), Staff 3 (District Director of Operations), and Staff 21 (Health and Wellness Coordinator/LPN) on 05/03/24. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to:

Observations of the facility interior on 04/29/24 revealed interior courtyard doors were locked, preventing residents from entering and exiting without staff assistance. There were no observations of inclement weather during that time.

During an interview on 04/29/24 Staff 11 (Resident Care Associate) reported the interior courtyard doors were always locked.

During an interview on 04/29/30 Staff 5 (Maintenance Manager) reported the interior courtyard doors have always been locked, and care associates are the ones who let residents in and out to the courtyard.

On 04/30/24 the need to provide access to secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (Associate Executive Director) and Staff 5 (Maintenance Manager) . They acknowledged the findings.