The findings of the relicensure survey, conducted 02/14/22 through 02/17/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 survey to the re-licensure survey of 02/17/22, conducted 07/18/22 through 07/21/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

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

OAR 411-054-0025 (4) Reasonable Precautions

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

The findings of the second re-visit to the re-licensure survey of 02/17/22, conducted on 02/22/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

During the relicensure survey, conducted 02/14/22 through 02/17/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

Refer to deficiencies in report.

A new ED has been hired and has had over 4 weeks of training that also includes completing the 40-hour class on regulatory compliance.

The community will hire an outside state approved consultant to provide additional oversight and training and oversight the new leadership team through the next 4-6 weeks.

Weekly

ED and Ops Support

Based on observation, interview and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations, and supervision and training of staff. This is a repeat citation. Findings include, but are not limited to:

1. During the first re-visit survey to the re-licensure survey of 02/17/22, conducted 07/18/22 through 07/21/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the severity of findings and number of repeat citations.

2. A situation was identified which represented an immediate threat to residents' health and safety, and required an immediate plan of correction in the following area:

OAR 411-054-0025(4): Reasonable Precautions

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

Refer to deficiencies in the report.

Refer to tag # C 160, C 240,C 260

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

1. Witness 1 (Ombudsman) shared concerns that residents were dissatisfied with the facility meals and food.

Food Committee meeting notes 05/30/22 through 07/11/22 and Town Hall notes from 06/28/22 were reviewed and showed concerns including:

* "Food choices";

* "Cold food";

* "Orders being taken out of order";

* "Try using warming cart for hot foods to the dining room";

* "Soups not flavorful";

* "Rice overcooked, not hot..salmon too fishy, overcooked ...";

* "Comment cards on tables";

* "Bread alternatives, larger dessert portions"; and

* "Alternates need to be made sooner."

There was no documented follow-up or resolution to the concerns expressed by the residents.

During the days of the survey, 07/18/22 through 07/21/22, random resident interviews during meals and outside mealtimes revealed complaints of the following:

* Food was delivered late, waiting one to two hours for meals;

* Allergies and food preferences were frequently ignored;

* Kitchen often ran out of foods for alternates or scheduled menu items;

* Menu changes without any notice;

* Residents without modified texture needs were given mechanical soft and pureed foods when regular food ran out;

* Too many starches all at once and a lot of canned fruit;

* Food was cold regardless if eaten in the dining room or apartment; and

* Poor tasting and poor-quality food.

Observations on 07/18/22 through 07/19/22 showed residents who ate in the dining room waited upwards of 30 minutes for their orders to be taken and receive a beverage. An additional wait of up to 40 minutes occurred before meals were delivered to all residents. Residents who ate in their apartments were served after all the residents in the dining room had been served. The breakfast meal delivery to apartments was completed by 10:00 a.m., lunch delivery was completed between 2:00 p.m. and 2:15 p.m., and dinner apartment delivery was finished between 7:00 p.m. and 7:15 p.m.

A test tray was requested by the surveyor for the dinner meal on 07/18/22 of both the mechanical soft diet and regular diet items.

The dinner menu indicated a starter of a green salad, a main course of fried chicken, ranch mashed potatoes, mixed vegetables, and a biscuit, and a dessert of lemon cookie.

The chicken breading was soggy with a white color. The mashed potatoes were extremely dry and crumbly. The carrots were stiff, and peas were shriveled and dry. The hot dog bun was dry/stale. The mechanical soft meat dish had some flavor but had a grainy texture and was cold. All the other hot food items were cold.

Interviews with residents were conducted on 07/18/22 during the lunch and dinner meal. The residents indicated the following:

* "Food is always cold";

* "Doesn't taste good";

* "Alternates are hard to get";

* "Meals always late";

* "Wrong textures given to residents";

* "Too many canned fruits"; and

* "Rarely get the starters listed on the menu."

In interviews with Staff 12 (Executive Director) on 07/19/22 and 07/20/22 she acknowledged she was aware residents had complaints about the food.

2. During survey entrance on 07/18/22, multiple residents approached the survey team and expressed concerns regarding the smoking area.

The residents indicated at the time of the last survey concerns were brought up regarding the shared smoking area. Residents were advised by the facility that the smoking areas would be separated so staff and residents had their own designated areas. The residents stated there was no follow-up on this issue or communication with residents regarding the resolution, and it was brought up more than once to administration.

Sampled and non-sampled resident interviews on 07/20/22 indicated the smoking area was very small. There was not much room for residents in scooters and wheelchairs when multiple staff were also out smoking. The residents indicated it was difficult to talk with other residents freely due to staff presence. The residents further indicated the language and information being discussed by staff in the smoking area was not information the residents needed or wanted to hear. Hearing too much of the staff discussions created some anxiety for residents and increased the "gossip mill" and lack of communication.

Multiple residents stated the Administrator seemed to ignore complaints or concerns or there was no follow-up. They said the turnover in Administrators had resulted in a lack of resolution when complaints were brought to their attention.

The complaints of residents were discussed with Staff 12 (Executive Director) on 07/20/22. She was aware of a previous discussion about the smoking area, but indicated she was not directly involved. Staff 12 acknowledged there was no documentation regarding follow-up to residents' concerns.

1.Greivence log will be reviewed at daily stand up with management team

2.All managers have been trained on entering greivences. The greivences that are received will be entered into our system and there will be verbal follow up with the resident in addition to documenting how and when the greivence was resolved and what action was taken.

3.Greivence log will be reviewed once weekly for for follow up and resolution documented.  Auto emails are sent to ED and Ops weekly for review.

4.Executive Director or designee

Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents, and failed to implement effective methods of infection control which placed residents at risk for exposure to the COVID-19 virus. Findings include, but are not limited to:

1. Resident 5 was admitted 10/2019 with a history of skin breakdown.

During the entrance conference acuity interview on 02/14/22 at 11:20 am, staff stated the resident needed full assistance for ADL care needs and currently had skin breakdown on his/her bottom.

Observations of the resident on 02/14/22, 02/15/22 and 02/16/22 revealed a gait belt in place around his/her waist while sitting in a recliner and wheelchair and lying in bed.

Review of the current evaluation and service plan completed 12/2021, and 02/2022 MARs revealed the resident weighed 99 pounds and was at risk for skin breakdown. Staff were instructed to use a gait belt during transfers. However, there was no directive to leave the gait belt around the resident's waist when it wasn't in use.

On 02/16/22 at 1:30 pm, Staff 1 (Administrator), Staff 2 (Administrator in training) and the surveyor observed the resident in bed. A gait belt was underneath his/her torso. Staff 1 and 2 acknowledged the gait belt should not have been left underneath the resident, that it put pressure on his/her skin, and placed him/her at risk for breakdown.

2. Resident 4 was admitted to the facility in 05/2013 with a diagnosis of diabetes.

Progress notes dated 11/01/21 through 02/14/22 were reviewed during survey and indicated the following:

* Resident 4 had episodes of vomiting on 01/13/22 and 01/14/22;

* S/he had complaints of stomach upset on 01/16/22 and 01/20/22:

* Resident 4 had episodes of diarrhea on 01/21/22 and 01/22/22; and

* On 01/23/22 staff noted Resident 4 tested positive for COVID-19.

There was no documented evidence the facility placed Resident 4 on infection control precautions or tested the resident for COVID-19 when s/he had episodes of possible COVID-19 symptoms from 01/13/22 through 01/22/22.

During an interview on 02/15/22, Staff 3 (RN) stated the facility did not test Resident 4 for COVID-19 or place him/her on infection control precautions because they related the resident's symptoms to recent medication changes. The resident was tested for COVID-19 after a staff member tested positive for COVID-19 on 01/18/22.

The need to ensure recommended infection control practices were followed related to COVID-19 was discussed with Staff 1 (Administrator), Staff 2 (Administrator in training) and Staff 3 on 02/15/22. They acknowledged the findings.

3. During the survey, conducted 02/14/22  through 02/17/22, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility including, but not limited to:

* Observations on 02/14/22  and 02/15/22 determined the facility was not consistently screening visitors upon entering the building; and

* Multiple staff failed to follow the infection control guidelines for donning and doffing face shields. Individual cubbies were available for staff to store their PPE; however, multiple staff were observed leaving the facility with their face shields on.

The need to ensure the facility practiced effective methods of infection control and conducted regular auditing of these practices was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/16/22. They acknowledged the findings.

Resident 1 - service plan has been updated to provide information regarding the proper use of gait belts, it was also added that this resident has skin breakdown. Gait belt is not to be left on resident 1.

Training to be provided to all staff regarding providing care to those with skin breakdown to prevent more occurrences. During the weekly skin reviews the RN will observe those with gait belts to assure that current practices of leaving gait belts on residents is not done.

All residents that require gait belt use will be reviewed and proper instructions for gait belt use will be updated in their service plans.

All staff will be required to take the Oregon Care Partners COVID precautions class online.

All staff will be provided training on reporting signs and symptoms of COVID along with what actions need to be taken when a resident exhibits signs or symptoms of COVID.

All staff will be retrained on the procedures for screening visitors upon entering the community.

All staff will be retrained on the proper guidelines for donning and doffing face shields. Information will also be posted in all break rooms.

The ED will provide oversight.

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

During the survey on 07/20/22, Resident 9 reported to the survey team the fire alarm in the "extended addition" hall could not be heard in the back hallway of the assisted living when the fire doors shut, and the fire alarm activation did not provide notification to the front desk staff person.

The survey team interviewed Staff 12 (Executive Director) and Staff 16 (Operations Personnel Support) on 07/20/22, and they indicated the fire alarm system in the extended addition hall was connected to the fire alarm system in the memory care part of the building. They were unsure if the alarm could be heard on the assisted living side of the facility.

Staff 13 (Maintenance Manager) was interviewed on 07/20/22, and he revealed the assisted living front desk staff person was not notified if the alarm in the extended addition hall was activated, but the fire panel in his office showed the alarm was activated.

On 07/21/22, the surveyors and Staff 18 (Director of Environmental Services) tested the alarm in the extended addition hall by having the memory care alarm activated. The fire doors between the extended addition hall and the rest of the assisted living facility closed, and the alarm could be heard for approximately 30 yards from the fire doors. There were no strobe lights activated on the assisted living side of the building to indicate the fire alarm had been activated in the extended addition hall.

The situation was identified as posing an immediate threat to the health, safety, and/or welfare of the residents. The surveyors requested an immediate short-term plan of correction, which was provided, approved, and implemented.

The need for the fire alarm system in the extended addition hallway to be connected to the fire alarm system on the assisted living side of the building, rather than to the memory care side, was discussed with Staff 18 (Director of Environmental Services), Staff 17 (Director of Operations), and Staff 12 (Executive Director) on 07/21/22. The surveyors requested an immediate long-term plan of correction.

The facility developed an immediate long-term plan of correction, and the immediate jeopardy situation was abated.

1.Proposal/bid from Omlid & Sweeney has been signed and will start updating fire system once parts are secured.  Current system was deemed in compiance by FM and Licensing upon re-survey.

2. Fire alarm system in the MC/AL will be tied together

3. Monthly fire drills will be conducted to ensure system is working  appropriately.

4. Maintenance, Executive Director and or designee will monitor the fire system.

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#12) was treated with dignity and respect related to ADL needs, and multiple sampled and non-sampled residents were treated with respect related to a homelike environment. Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 08/2021 with diagnoses including blindness.

Review of the resident's service plan, dated 06/14/22, showed the resident required ongoing assistance with orientation to his/her environment in order to walk independently around the facility and campus, due to vision impairment. The resident had very minimal vision when s/he moved in and had a decline in her/his remaining vision due to a corneal eye transplant procedure on 07/13/22. Additionally, the resident's food was to be cut up and s/he had several food allergies reflected in the service plan which included tomatoes, bananas and nitrate high foods such as hot dogs/sausage/bacon. The resident would suffer from severe migraines if these foods were consumed.

Interviews with Resident 12 between 07/18/22 and 07/20/22 revealed:

* The resident was frequently given foods containing the documented allergens. The resident indicated s/he would repeatedly send things back to the kitchen and re-inform them of the items s/he could not have. The staff would acknowledge the issue, but then the resident would again get items such as BBQ sauce, meatloaf with ketchup, tomatoes, tomato based soups, or breakfast meats. When s/he ate any of these items s/he was guaranteed a severe migraine that would last up to several days. The resident further indicated s/he infrequently received assistance with walks and orientation to the building. The increased loss in vision with the transplant surgery "killed my confidence." The resident had asked repeatedly of multiple staff to walk with him/her and orient him/her to the different routes to locations in the building and outside. The resident stated the activity staff tried to offer walks with the walking club, but it did not happen more than maybe once a week.

* The resident stated it was frustrating to stumble around the facility and dining room without feeling like s/he knew where s/he was at. This was only made worse by repeatedly receiving foods s/he could not have. Every time the resident received items s/he could not eat s/he would send them back, which would elicit responses from residents around him/her. The resident further stated it was "embarrassing, frustrating, and dehumanizing to send things back over and over." The resident indicated it made him/her so uncomfortable and depressed s/he started just staying in his/her room. S/he was trying to work up the confidence and courage just to get out and make it to the dining room, but had not quite gotten there yet. The resident additionally indicated staff were supposed to orient him/her to his/her foods based on the face of a clock, but this did not consistently occur. The resident was left to feel around and guess at what was on the plate before taking a bite. The resident stated there were times s/he received the mechanical soft diet because they didn't have anything else to give him/her, saying it was a "blended" texture. The resident stated s/he had no swallowing issues and no need for a special texture diet.

Observations of the resident from 07/18/22 through 07/20/22, and in the kitchen on 07/18/22 and 07/19/22, showed the resident spent meals in his/her apartment. The resident was observed out of his/her apartment very minimally. The resident left his/her apartment to leave the facility with a friend and to attend an appointment. The resident was provided items s/he could not eat due to allergies at multiple meals, including sliced tomatoes, vegetable soup with a tomato base, and a ground meat mixed with soup. Dietary needs were documented on a dry erase board posted on the wall in the kitchen. The resident was not observed on any walks with staff or participating in the walking club listed on the activity calendar.

Interviews with staff between 07/18/22 and 07/21/22 indicated care staff and kitchen staff were inconsistently aware of the resident's accommodation needs and diet restrictions. The resident's diet restrictions and adaptive equipment needs were documented in the service plan and verbalized by a portion of the kitchen staff. Activity staff worked with the resident once a week on routes in the building and one route outside, but had not worked with the resident the last two weeks.

The need to ensure a resident was treated with dignity and respect around their individualized needs for accommodations was discussed with Staff 12 (Executive Director) on 07/20/22 and 07/21/22. She acknowledged the findings.

2. At the time of entrance to the facility on 07/18/22, multiple residents approached the survey team with statements of concerns. Residents were addressed as both sampled and non-sampled residents.

The residents indicated they were upset regarding multiple things, including dining room decorations and the garden club supplies. Residents stated several of them had made yarn flowers in small displays for the dining room tables. The displays were only allowed to be present for a very short time and then were taken away because the areas were too cluttered. The flower decorations were observed stacked together on a table in the back of the activity room.

The residents further indicated the gardening table previously had plants, soil, and supplies, but that was all moved and put away at the direction of corporate staff. Several of the plants and other items were put up on a shelf unit that residents in wheelchairs could not reach.

Resident statements regarding the decoration removal and supplies included the following:

* "...like we don't matter ...";

* "Management does whatever they want without talking to us ...";

* "The morale of residents is terrible";

* "Came in and took away all the table décor ... too cluttered, after residents worked to make the small baskets";

* "Really poor communication ...";

* "How can someone in a wheelchair reach the top shelves?";

* "There was no mess, no reason to move all the garden supplies";

* "Swooped in and moved all the supplies, many we can't get to on our own now"; and

* "Why can't we have any joy?"

The need to ensure residents were treated with respect related to a homelike environment was discussed with Staff 12 (Executive Director) on 07/21/22. She acknowledged the findings.

1.All staff will be re-trained on resident rights immediately and as needed during manager rounding: Resident's service plan has been updated to reflect the resident's accommodation needs and

diet restrictions

2.Review of daily scheduled and personalized activities, in addition to meal service will be reviewed daily at manager meetings.

3.Monthly at town hall meeting that includes residents and management team.

4.Executive Director and or designee

Based on interview and record review, it was determined the facility failed to ensure incidents of unwitnessed falls with injury and injuries of unknown cause were thoroughly investigated and reported to the local SPD office as required for 1 of 3 sampled residents (#1) whose incidents were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2021 with diagnoses of stroke and left sided weakness.

Review of Resident 1's progress notes dated 11/01/21 through 02/14/22, incident reports, service plans, hospital discharge records, and facility evaluations and assessments indicated the following incidents occurred:

a. An incident report dated 01/02/22 stated staff found Resident 1 in his/her unit lying on his/her back on the floor near the bathroom. Staff noted Resident 1 had hit his/her head, complained of hip pain, and was transported by emergency medical services to the ER for evaluation. Upon the resident's return to the facility on, 01/04/22, an RN assessment dated 01/02/22 stated, Resident 1 had a fall and "was transported to [hospital] via EMS services and found to have a fractured hip and pelvis, inoperable."

The facility's investigation provided conflicting information related to the resident's cognitive status, staff's actions prior to the fall and staff's compliance related to following the service plan. Additionally, there was no documented evidence the unwitnessed fall, which resulted in a pelvis and hip fracture, had been reported to the local SPD office.

b. A progress note dated 01/15/22 stated care staff reported Resident 1 had a "football sized bruise on [his/her] left inner thigh, that is greenish in color on the edges and darker in color in the center. Resident is unable to tell staff how [s/he] got the bruise, only that [s/he] noticed it this morning."

There was no documented evidence the facility investigated the cause of the bruise or reported the incident to the local SPD office.

The need to ensure incidents of unwitnessed falls with injury and incidents of injuries of unknown cause were thoroughly investigated and reported to the local SPD office was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/15/22 and 02/16/22. They acknowledged the findings and reported the incidents to the local SPD office per the survey team's request. The facility provided confirmation of the report submittals prior to exit.

All staff will be required to retake the Oregon Care Partners abuse and neglect training courses online.

Every fall at the community will be evaluated using the fall evaluation tool that requires a full interview with staff and the resident.

All staff will be provided retraining on completing incident reports.

The community leadership team will review all incidents each morning during the morning clinical meetings to assure full investigations have been completed on all incidents and that incidents have been reported to APS as required. The team will also review the 24 hours log each morning during this meeting to assure that there are not notes in the progress notes that indicate an incident occurred without and incident report being completed.

The ED will provide oversight.

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000 and failed to provide palatable meals. Findings include, but are not limited to:

The kitchen was toured on 02/14/22. The following was observed:

1. Food spills, splatters, debris, and dirt was observed on, inside, or underneath the following:

* Floors throughout the kitchen and storage area, under all equipment, appliances, and counters;

* Floors of the walk-in refrigerator and walk-in freezer;

* Ceiling vent covers;

* Floor drains;

* Top of the dish machine; and

* The coffee counter and sink outside of the kitchen.

Observations in the walk-in refrigerator and freezer revealed multiple plastic bags of leftovers with foods unlabeled, improperly labeled, or labeled with conflicting dates. In addition, there were boxes of food stored on the floor in the freezer and refrigerator. Two bags of thawed chicken without a pull date from the freezer was observed in a plastic tub in the refrigerator.

On 02/14/22, the undated, uncovered, and unlabeled food items were removed by staff.

The areas needing cleaning were discussed and reviewed with Staff 1 (Administrator) on 02/14/22 and 02/16/22. She acknowledged the findings.

2. During the days of the survey, 02/14/22 and 02/15/22, random resident interviews during meals revealed complaints of the following:

* Food was delivered late, waiting two to three hours for meals;

* Food was cold; and

* Poor tasting and poor-quality food.

Observations and interviews during the lunch meal on 02/14/22 at 11:45 am noted the following:

* Residents waited in the dining room until 1:21 pm for lunch to be served. Residents who ate meals in their apartments waited until 2:30 pm for lunch to be delivered. Lunch was potato soup, tuna melt sandwich, and french fries. Multiple residents eating in the dining room made the following comments about the lunch meal: "The soup is awful," and the "sandwich is too hard."

Due to resident concerns regarding the quality of food served at the facility, a test tray was requested by the surveyor on 02/14/22.

The soup, sandwich, and french fries were temperature tested and sampled by the surveyors. The soup had a thick and lumpy consistency that was unpalatable and the bread on the sandwich was tough to chew.

Observations of the tray line during the dinner service on 02/14/22 showed staff inconsistently washing their hands between tasks and glove changes. Dinner was plated and served without using a thermometer to confirm the proper temperature as required by Oregon Food Sanitation Code. The cook stated she had checked the temperatures before placing the food on the steam table.

Observations and interviews during the dinner meal on 02/14/22 at 4:45 pm noted the following.

* Residents waited in the dining room until 6:00 pm to 6:43 pm for dinner to be served. Residents who ate in their apartments waited until 7:52 pm for dinner to be delivered. Dinner was chicken fried steak, mashed potatoes, gravy, green beans, and a dinner roll. The following comments were made: "The meat is tough and rubbery," "The breading on the meat is too hard," and "The potatoes and vegetables have no flavor."

A test tray was requested on 02/14/22 for the dinner meal. The chicken fried steak had a white-colored, powdery coating that was hard, the meat had a grisly chewy texture, the mashed potatoes and gravy lacked flavor, the roll was dry and had no flavor, and the green beans were overcooked and not fresh. The meal was determined unpalatable, and the surveyors showed the meal to Staff 2 (Administrator in training), who confirmed by the meal's appearance it was unpalatable.

During an interview with Staff 1 (Administrator) on 02/14/22, she stated the new kitchen manager had just started on 02/14/22. They were developing new procedures and systems for the kitchen, and she had been managing the kitchen for the last three months until recently.  

The need to ensure the kitchen was maintained in a clean and sanitary condition, the meals were palatable, and staff followed safe food handling practices in accordance with Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 and Staff 2 on 02/16/22. They acknowledged the findings.

The kitchen will receive a deep clean by the new dining manager and team.

Daily, weekly and monthly cleaning tasks sheets will be implemented to include daily sign off by the kitchen team. The Dining Manager will assure completion daily.

The ED will inspect the kitchen weekly with the new Dining Manager to ensure compliance.

The ED will complete a weekly on one meeting with the new Dining Manager to assure compliance is being met.

The new Dining Manager has been provided training offsite and will implement the weekly QA programs in the kitchen and complete his own weekly QA.

The Dining Manager will have a kitchen team meeting weekly for the next 4 weeks and 2 times monthly after to provide training and oversight to general cleaning, food storage, labeling and overall kitchen compliance needs.

The new Dining Manager will track food delivery times for the next 4 weeks to assure and evaluate the delivery times. This will be evaluated daily at stand up with all managers and the ED.

Meal surveys will be implemented, and feedback will be reviewed daily at the morning stand up and during the weekly one on ones with the ED.

Meals will be temperature checked prior to serving from the steam tables to the residents and tracked on the temperature charts. The new Dining Manager will review temperature charts daily to assure compliance is met.

The Dining Manager will implement a QA tool that requires that cooks taste all meals prior to being served and review all dining feedback cards with the team.

All staff will receive retraining on proper handwashing, and this will be observed by the new Dining Manager daily and observations tracked on the Dining Manager weekly QA followed by a weekly one on one meeting with the Dining Manager.

The ED will provide oversight.

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000 and failed to provide palatable meals. This is a repeat citation. Findings include, but are not limited to:

1. The kitchen was toured on 07/18/22 and 07/19/22, and the following was observed:

a. Food spills, splatters, debris, dust, cobwebs, and/or dirt was observed on, inside, or underneath the following:

* Floors throughout the kitchen and dry storage areas, under equipment, appliances, and counters;

* Floors of the walk-in refrigerator;

* Floor drains;

* Shelving units in the dry storage areas and shelving in the walk-in refrigerator;

* Clean dish/pan storage shelves and on canned goods;

* Open bags of noodles and corn starch in dry storage;

* Top of the water heater in the dry storage area; and

* Both ovens.

b. Observation of the dry storage areas on 07/18/22, and again on 07/19/22 after shipment delivery, showed an insufficient supply of non-perishable foods. The non-perishable items included canned soups, green chilis, garbanzo beans, tomato juice, pancake mix, jello mix, corn bread mix, and canned fruits. The items were not sufficient to cover seven days of meal needs for all of the facility's residents.

c. Observations during the 07/18/22 lunch and dinner meals showed the following:

* Serving staff came in and out of the kitchen grabbing items from the front of the steam table, walking between the stove and back of the steam table to grab items, removed items from the refrigerator, and pulled food from the cooler at the end of the tray line with inconsistent glove use or handwashing;

* A kitchen staff dropped a package of tortillas on the floor near the stove, picked it up, and placed it on the counter of the serving area next to resident food. The staff member was asked to disinfect the counter prior to continuing to serve plates;

* Food preferences, allergies, and adaptive dishes were inconsistently provided for the residents;

* Multiple plates used for the meals had large chips which exposed unglazed/unsealed surfaces;

* A lack of prepared mechanical soft items were available for lunch, bowls of vegetable soup were given with no other accompaniment;

* Temperatures were not taken of foods removed from the stove or oven to restock the steam table. Staff were directed by the surveyor to take temperatures of the items before serving;

* Numerous bowls of ice cream and bowls of cucumber/zucchini salad were uncovered while transported around the facility to resident rooms;

* The food processor bowl was cracked; and

* The convection oven located to the right of the cooktop was not functioning appropriately, with temperatures running very low or high without warning. The left side of the oven was hot, while the right side of the oven was intermittently cold.  

The need to ensure the kitchen was kept clean and in good repair, diet and texture needs were addressed, and staff followed safe food handling practices was discussed with Staff 12 (Executive Director) and Staff 23 (Cook) on 07/18/22, 07/19/22, and 07/20/22. They acknowledged the findings.

2. During the survey, between 07/18/22 and 07/21/22, sampled and non-sampled resident interviews were completed both during and outside mealtimes. The resident interviews revealed concerns in the following areas:

* Food was delivered late, waiting one to two hours for meals;

* Allergies and food preferences were frequently ignored;

* Kitchen often ran out of foods for alternates or scheduled menu items;

* Residents without modified texture needs were given mechanical soft and pureed foods when regular food ran out;

* Food was cold regardless if eaten in the dining room or apartment; and

* Poor tasting and poor-quality food.

Observations and interviews with staff, sampled residents, and non-sampled residents during the breakfast, lunch, and dinner meals on 07/18/22 and 07/19/22 were completed.

Multiple kitchen staff interviewed revealed the following;

* Kitchen staff indicated they were out of cottage cheese for the alternate menu choice requested by a few residents. The chicken breast filets for dinner were cut in half, as most residents would not eat the larger size piece and to ensure there were enough chicken breasts for all residents.

* The kitchen staff further indicated there were not enough rolls for all the residents, so hot dog buns were cut in half and put on plates as well. There was only one kitchen staff in the evenings and there was not time to make the scheduled dessert. The staff indicated they received shipments on Tuesdays and Fridays; however, by Sunday/Monday things were very low or totally gone so they did what they could for meal components. When the kitchen ran out of regular food items during meal service, mechanical soft items were used for other residents.

* Kitchen staff stated they were not required to meet any special diets/preferences such as gluten-free, vegetarian, or diabetic diets. They tried to have some options available, but were not always able to provide something to meet the special requests.  

Observations and interviews of residents who ate meals in their apartments showed they routinely waited until 10:00 a.m. for breakfast, 2:00 p.m. or later for lunch, and 7:00 p.m. or later for dinner to be delivered.

Due to resident concerns regarding the quality of food served at the facility, a test tray was requested by the surveyor for the dinner meal on 07/18/22 of both the mechanical soft diet and regular diet items.

The dinner menu indicated a starter of a green salad, a main course of fried chicken, ranch mashed potatoes, mixed vegetables, and a biscuit, and a dessert of lemon cookie.

The residents and survey team received a cucumber/zucchini salad, half of a breaded chicken breast, mashed potatoes, carrots/peas, and a roll or half a hot dog bun. The mechanical soft diets were given mashed mixed vegetables, mashed potatoes, and a ground turkey mixed with left-over vegetable soup. The listed dessert item for dinner was not available for residents.

The chicken breading was soggy with a white color. The mashed potatoes were extremely dry and crumbly. The carrots were stiff, and peas were shriveled and dry. The hot dog bun was dry/stale. The mechanical soft meat dish had some flavor, but had a grainy texture and was cold. All the other hot food items were cold. The temperatures of the foods tested were as follows:

* Mechanical soft meat dish 85.2 degrees;

* Mashed potatoes 92.4 degrees;

* Mixed vegetables 83.2 degrees;

* Cucumber/zucchini salad 63.6 degrees;

* Chicken breast 96.8 degrees; and

* Cup of milk 60.2 degrees.

In an interview on 07/19/22, Staff 12 (Executive Director) indicated there were multiple changes in the kitchen recently. She was unsure why there were still so many concerns with the food and ordering. They were working on systems and training. Staff 12 had been at the facility for only a few weeks.   

The need to ensure the kitchen served palatable meals at an appropriate temperature was discussed with Staff 12 (ED) on 07/19/22. She acknowledged the findings.

1. Deep cleaning in the kitchen will be complete to include the following: Food spills, splatters, debris, dust,cobwebs, and/or dirt was observed on,

inside,Floors throughout the kitchen and dry

storage areas, under equipment,

appliances, and counters; Daily cleaning schedule has been implemented to ensure cleanliness of the kitchen.

Sufficient food supply to cover daily needs in addition to seven days of emergency meals

 New Dining Services Manager has been hired.

2.Kitchen staff will have inservice/training in the following areas: glove use or handwashing, disinfecting counters, Food preferences, allergies, and

adaptive dish use, having enough prepared mechanical soft items,taking temps after food is placed in the steam table, food being covered while transported around the facility to resident rooms,how and when to report kitchen appliance that are not in good working order,following safe food handling practices

3.Dining service manager or designee will hold bi-weekly meeting with kitchen staff.

4. Dining service manager or designee will ensure corrections are maintained.

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

Resident 1 was admitted to the facility in 05/2021 with diagnoses of stroke and left sided weakness.

Resident 1's service plan dated 02/02/22, was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following care areas:

* Fall prevention interventions and frequent safety checks;

* The resident's preference to keep door locked; and

* Episodes of hallucinations.

The need to ensure service plans were reflective of residents' care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/16/22. They acknowledged the findings.

Resident 1 service plan has been updated to include current care needs for fall prevention interventions and safety checks. The resident's preference to keep the door locked as well as episodes on hallucinations.

All resident service plans will be reviewed over the next quarter to assure compliance and that resident care that is required is reflected in the resident's service plans.

Weekly team interdisciplinary meetings will be implemented to review all residents that are due for service plan reviews together as a team where progress notes, incidents, staff feedback ect are included in the service plan.

All managers will receive training on fall prevention interventions as well as detailed training on fall evaluations.

The ED will provide oversight

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were completed, reflective of residents' needs, provided clear direction regarding the delivery of services, and/or were followed by staff for 2 of 7 sampled residents (#s 8 and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 02/2021 with diagnoses including anxiety, delusions, and hallucinations.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 07/13/22 and progress notes dated 05/30/22 to 07/19/22 showed the service plan did not provide clear direction to staff and/or was not followed in the following areas:

* Self-administration of medications;

* Seizures;

* Motrin use and pain treatment;

* Large portions and large variety of foods;

* Fear of dogs and profound dislike of males near room;

* Refusal to allow care staff in room;

* Housekeeping needs and completion; and

* Paper products for meals due to throwing glass items.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were consistently followed was discussed with Staff 12 (Executive Director) on 07/20/22 and 07/21/22.  She acknowledged the findings.

2. Resident 12 was admitted to the facility in 08/2021 with diagnoses including anxiety and blindness.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/14/22 and progress notes dated 05/30/22 to 07/19/22 showed the service plan was not reflective of the resident's current care needs and/or was not followed in the following areas:

* Frequent assistance with walks;

* Food allergies and migraine triggers;

* Orientation to food items and their location on plate for meals;

* Use of sided plate for meals; and

* Verbal notification of daily activities due to vision impairment.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were consistently followed was discussed with Staff 12 (Executive Director) on 07/20/22 and 07/21/22.  She acknowledged the findings.

1. Service plans for resident 8 and 12 were both updated to provide clear insturcions as presented in the citation. All service plans going forward will be completed quarterly or upon change of condition and will include the care planning team. Personal care services will also be reviwed with resident and or responsible party/case manager

2.Quarterly care conferences with resident's families and case managers if applicable

3.Service plannning team meets once weekly to review service plans coming due for review and any ISP that have been initiated within the quarter that is reflective of the residents personalized care needs.

4.Executive Director and or designee

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents 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 that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/17/22. They acknowledged the findings.

The management team will meet each Wednesday and review all service plans that are due and complete the QA tool that is labeled Interdisciplinary Team Meeting. All Managers will be required to attend.

Service plan reminder letters will be mailed to families, caseworkers and residents at the beginning of each month with a proposed time and date to review the service plan.

All current families, residents and caseworkers will be given a copy of their current service plans.

The ED will provide oversight.

3. Resident 3 was admitted in 10/2015.

Resident 3's clinical record and charting notes, reviewed from 11/01/21 through 02/14/22, revealed the following:

a. On 11/18/21, the resident reported vomiting. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the change in condition.

b. An RN progress note, dated 11/16/21, revealed the resident had an "abrasion, shiny and red ..." on his/her back. The RN noted that the facility would "continue to monitor." No further monitoring of the injury was noted in the record.

c. On 01/23/22, the resident reported vomiting, and monitoring was initiated. The record revealed no documented monitoring of the resident's condition at least weekly until resolved.

d. On 02/02/22, the resident was placed on alert monitoring for nausea, vomiting and feeling "crampy."  Review of the record revealed no documentation on the progress of the resident's condition at least weekly until resolved.

Additional information was requested on 02/16/21.

On 02/16/21 at 2:35 pm, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved.

Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 and Staff 2 (Administrator in training) on 02/16/22. They acknowledged the findings. No further information was provided.

4. Resident 2 was admitted in 10/2019.

Observations, staff interviews and review of the record revealed s/he was dependent for ADL care needs and needed two staff for transfers.

Resident 2's charting notes indicated s/he fell on 12/10/21. The facility initiated short-term change monitoring. However, no monitoring until resolution was documented.

Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Administrator) on 02/16/22 at 2:50 pm. She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions determined, documented and communicated to staff, and the residents' conditions, including effectiveness of interventions, were monitored weekly through condition resolution for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who had documented changes of condition. Resident 1 experienced repeated falls with injuries, one fall resulted in a pelvic and hip fracture. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2021 with diagnoses of stroke and left sided weakness.

The following information was documented in Resident 1's service plan dated 11/09/21:

* Resident 1 was in the early stages of dementia, was oriented to person, place and time, and occasionally displayed episodes of disorientation;

* Resident 1 ambulated independently with the use of a walker but had weakness, poor balance, poor gait, and decreased mobility; and

* Resident 1 was considered a "frequent faller" with a history of falls at home and "multiple falls since moving into" the facility.

The service plan provided the following interventions:

* Staff to provide reminders and walk with the resident to meals and activities;

* Ensure good footwear was in place when the resident ambulated; and

* Staff to assist the resident with changing incontinence briefs before and after meals and once in the middle of the night.

a. Progress notes dated 11/01/21 through 02/14/22, incident reports, service plans, evaluations, assessments, and hospital discharge records indicated Resident 1 experienced the following unwitnessed falls:

10/31/21- Staff found Resident 1 on the floor near his/her kitchen. Staff noted Resident 1 sustained skin tears to the right knee and the right lower calf.

11/02/21- Staff found Resident 1 on the floor next to the bed. No injury was noted.

11/10/21- Staff found Resident 1 on the floor near his/her recliner. The incident report noted the resident stated s/he slipped while getting out of the shower and then crawled to the recliner. No injury was noted.

11/21/21- Staff found Resident 1 on the floor in his/her apartment. Resident 1 stated s/he was trying to use the bathroom. Staff noted the resident sustained an abrasion to the left knee and a bruise on the right finger.

01/02/22- Staff found Resident 1 lying on his/her back on the floor near the bathroom in his/her apartment. Staff noted Resident 1 hit his/her head and complained of hip pain. Resident 1 was sent to the ER via emergency medical service for further evaluation. An RN assessment dated 01/04/22 noted Resident 1 returned to the facility following a hospital stay where s/he was found to have a fractured hip and pelvis related to the fall on 01/02/22.

01/10/21- Staff responded to Resident 1's call pendant and found him/her on the floor near the foot of the bed. No injury was noted. Staff noted the resident's family was considering a higher level of care and the resident had memory issues and did not always remember to use the call light. No injury was noted. An interim service plan was developed but did not provide relevant or new fall interventions.

01/13/21- Staff noted Resident 1 sustained bilateral abrasions to both knees as the result of fall when the resident stated s/he was not able to transfer self from his/her recliner. An interim service plan was developed but did not provide relevant or new fall interventions.

01/19/22- Staff responded to Resident 1's call light and found him/her sitting on the floor in front of his/her chair. No injury was noted. An interim service plan was developed but did not provide relevant or new fall interventions.

01/21/22- Staff found the resident lodged between a wheelchair and his/her front door. No injury was noted. An interim service plan was developed but did not provide relevant or new fall interventions.

01/22/22- At 1:30 pm, staff heard the resident yell for help and found Resident 1 on his/her "backside" near the bathroom in his/her apartment. No injury was noted. At 6:00 pm staff found Resident 1 on the floor near his/her recliner. The resident stated s/he slide out of the chair. No injury was noted.

01/23/22- Staff found Resident 1 on the floor in his/her apartment while staff was doing their rounds. Resident 1 complained of back pain but no injury was noted.

01/27/22- Staff found Resident 1 on the floor in front of his/her recliner with an incontinent brief next to him/her. No injury was noted. The incident report noted staff applied non-slip material to the resident's recliner. There was no documented evidence the intervention was communicated to other staff members.

01/31/22- Staff responded to Resident 1's call light and found the resident on his/her side on top of a load of laundry on the floor. Staff noted the resident sustained a skin tear to the right knee.

02/03/22- Staff found Resident 1 sitting on the floor next to his/her dining room table. No injury was noted. There was no documented evidence the facility developed new fall prevention interventions.

02/05/22-Staff found Resident 1 sitting on the floor near his/her recliner. No injury was noted. There was no documented evidence the facility developed new fall interventions.

02/10/22- Staff found Resident 1 on the floor lying flat in front of his/her recliner. No injury was noted. There was no documented evidence the facility developed new fall interventions.

There was no documented evidence the facility monitored the effectiveness of fall prevention interventions and the facility failed to consistently determine and communicate new and relevant fall prevention interventions when Resident 1 experienced numerous falls. The resident sustained skin tears and/or bruises as the result of falls which occurred on 10/31/21, 11/21/21, 01/13/22 and 01/31/22 and the resident sustained a fractured pelvis and hip as a result of a fall which occurred on 01/02/22.

b. A progress note dated 01/15/22 stated care staff reported Resident 1 had a "football sized bruise on [his/her] left inner thigh, that is greenish in color on the edges and darker in color in the center. Resident is unable to tell staff how [s/he] got the bruise, only that [s/he] noticed it this morning".

There was no documented evidence the facility monitored the status of the resident's bruise.

The need to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented and communicated to staff and the residents' condition, including effectiveness of interventions, was monitored weekly through condition resolution was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/16/22.

2. Resident 4 was admitted to the facility in 05/2013 with diagnoses of diabetes and hypertension.

Review of progress notes and incident reports dated 11/01/21 through 02/14/22 indicated the following:

Staff documented Resident 4 fell on 11/15/21, 12/22/21 and 01/20/22. Staff noted the falls were not witnessed and no injuries occurred.

The incident report dated 11/15/22, stated the Resident 4 fell from bed and the suggested intervention was to have the resident's mattress lowered. There was no documented evidence the intervention was implemented or monitored for effectiveness.

The incident report dated 12/22/22, stated Resident 4 fell from bed and directed the evening med-tech to ensure the resident was not too close to the edge of the bed during evening medication pass. There was no documented evidence the intervention was communicated to staff or monitored for effectiveness.

The incident report dated 01/20/22, stated Resident 4 fell trying to transfer from his/her recliner to wheelchair and the resident stated his/her call pendant was broken. There was no documented evidence the facility developed or monitored new fall prevention interventions.

The need to ensure residents who experienced changes of condition were evaluated, necessary actions/interventions were determined, documented and communicated to staff and the residents' condition, including effectiveness of interventions, was monitored weekly through condition resolution was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in Training) on 02/16/22. They acknowledged the findings.

Resident 1 the RN will document a change of condition to include a full fall evaluation as well as an update on the evaluation and service plan. The RN will document weekly on the COC until resolved or new baseline is set.

Resident 4 The RN will document a change of condition to include a full fall evaluation as well as an update on the evaluation and service plan. The RN will document weekly on the COC until resolved or new baseline is set.

Resident 3 The RN will document a change of condition to include a full fall evaluation as well as an update on the evaluation and service plan. The RN will document weekly on the COC until resolved or new baseline is set.

Resident 2 The RN will document a change of condition to include a full fall evaluation as well as an update on the evaluation and service plan. The RN will document weekly on the COC until resolved or new baseline is set.

All resident with frequent falls will be evaluated with the fall evaluation QA tool and all falls going forward will receive an in-depth fall evaluation and interventions.

The clinical management team will review all COC each morning at the morning clinical meeting to assure that COC is being monitored until resolved or new base line is set.

Training on fall evaluations will be conducted with the leadership team as well as fall interventions and the process of completing ISPs and updates to staff.

The RN and ED will sign up for the role of the RN class or receive COC training by the state approved consultant to better understand the COC requirements.

The ED will provide oversight.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task. Additionally, the RN instructs the unlicensed person that the task being taught and delegated is "specific to this client only and is not transferable to other clients ..."

During the acuity interview on 02/14/22, Resident 3 was identified to be administered insulin injections by non-licensed staff.

Resident 3's MARs, reviewed from 02/01/22 - 02/14/22, revealed insulin had been given by Staff 5 (Resident Service Manager) and 10 (Medication Room Manager) on multiple occasions.

Delegation documentation, reviewed on 02/15/22, revealed the following:

* Delegations for Staff 5 and 10, completed 12/21/21 and 01/06/22 respectively, were not specific to Resident 3. Staff 3 (RN) indicated in the documentation that Staff 5 and 10 could perform blood sugar checks and insulin administration for any diabetic resident when the situation presented itself.

In an interview on 02/15/22 at 2:30 pm, Staff 3 reviewed the documentation. She was unaware that delegation for unlicensed staff needed to be specific to Resident 3 and not transferable to other residents.

Failure to ensure delegation was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules was reviewed with Staff 1 (Administrator) on 02/16/22 at 1:20 pm. She acknowledged the findings.

Resident 3 the RN will re-delegate staff to this resident specifically.

The RN will review redelegate all med techs to each individual resident.

The RN and ED will sign up for the role of the RN class or receive delegation training by the state approved consultant to better understand the delegation requirements.

The RN will complete the delegation class/test with the board of nursing.

All med techs will be re-trained on delegation requirements.

The ED will provide oversight

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 4 sampled residents (#3) whose orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted in 2015 with diagnoses which included insulin dependent diabetes.

Resident 3 had an order for Lispro insulin; 8 units before breakfast, 5 units before lunch and 6 units before dinner. If the CBG (blood sugar) was less than 139, staff were to hold the insulin.

Resident 3's MARs, reviewed from 02/01/22 - 02/14/22, revealed the following insulin orders were not followed:

* On 02/09/22, the 8:00 am CBG was 102. Staff gave the insulin when it should have been held; and  

* On 02/05/22 at 12:00 pm, no CBG or insulin administration was documented as done.

The need to ensure orders were followed was reviewed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/16/22 at 1:20 pm. They acknowledged the findings.

Resident 3 MAR will thoroughly be reviewed by the RN and clarification and training will be provided to all Med Techs that administer the insulin.

A complete review of all diabetic resident records will be completed by the RN to assure that there are no other diabetics insulin being poorly administered.

The RN and ED will attend the Role of the RN training or review training on proper administration and oversight of the MARs and diabetic care.

The ED will provide oversight

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

Resident 3 was admitted in 2015 with diagnoses which included insulin dependent diabetes.

Resident 3 had orders order for Lispro insulin; 8 units before breakfast, 5 units before lunch and 6 units before dinner, and Tresiba insulin 58 units daily before breakfast.

The resident's MAR, reviewed from 02/01/22 - 02/14/22, and delegation documentation revealed the following:

* Staff 11 (MT) initialed on the MAR that she administered Lispro insulin on 02/06/22 and 02/07/22, and administered the Tresiba insulin on 02/06/22 and 02/12/22; and

* No delegation had been completed for Staff 11.

In an interview on 02/15/22 at 4:45 pm, Staff 3 (RN) said there was no delegation documentation for Staff 11 because she was not trained to administer insulin. Staff 3 was unsure why Staff 11 had initialed that she gave the Lispro and Tresiba.

On 02/16/22 at 10:55 am, Staff 3 informed the surveyor that she spoke with Staff 11. Staff 11 reported that another delegated MT gave the insulin, but she signed for it. Staff 3 acknowledged the MAR was inaccurate.

Resident 3 MAR will thoroughly be reviewed by the RN and clarification and training will be provided to all Med Techs that administer the insulin.

A complete review of all diabetic resident records will be completed by the RN to assure that there are no other diabetics insulin being poorly administered.

The RN and ED will attend the Role of the RN training or get training from the state approved consultant on proper administration and oversight of the MARs and diabetic care.

The ED will provide oversight

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:

The facility was home to 67 residents at the time of the relicensure survey. During the acuity interview on 02/14/22, the facility identified residents with high ADL needs, two of which required a two person assist with transfers. Additional interviews with the caregiving staff identified thirteen residents with high ADL care needs.

The posted staffing plan was three caregivers and two medication technicians on day and swing shifts, and one caregiver and one medication technician on the overnight shift.

During observations and interviews, it was revealed that staff were not direct caregivers, but universal workers. Staff duties included resident care, setting up for meals, serving food in the dining room, delivering room meal trays, cleaning up after meals, laundry, and housekeeping as needed. The regulation required that if a facility used universal workers, whose duties included other tasks (i.e., housekeeping, laundry, food service, etc.), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services. The number was not increased to meet resident needs.

The facility staff schedule from 02/01/22 through 02/14/22 revealed there were seventeen shifts that did not meet their staffing plan needs.

Review of the facility's staffing policy dated 02/2019 indicated staffing was based on residents' current care needs and service level; however, the facility's resident acuity report for January revealed residents' ADL care needs were not evaluated and there was no documented evidence in the staffing policy indicating the facility used Universal Workers.

a. Interviews with random unsampled residents from 02/14/22 through 02/16/22 expressed the following concerns:

* "They don't have enough staff;"

* "Care staff are getting pulled to work in the dining room;"

* "Staff in the dining room get pulled away to help elsewhere or answer call lights;"

* "Meals are 1 -2 hours late in the dining room and even later if residents eat in their rooms;"

* "We want are caregivers back;" and

* "Caregivers are delivering meals too, by the time it's delivered meals are cold."

b.  During interviews with staff on 02/15/22 and 02/16/22, they stated the following:

* Often staying after shifts in order to finish work;

* Resident meals were delivered late;

* There's only two people delivering trays and that's after the dining room has been served;

* Residents not getting dinner until 8:00 pm;

* Staff were also cleaning up after the meals;

* There's not enough staff to provide quality care; and

* Staff are required to assist resident's with care, ADL's, housekeeping if needed, laundry, meal service including set up and clean up, escorting residents, incontinent care and toileting, safety checks, showers and answering call lights.

The need to ensure sufficient number of caregiving staff to meet the 24 hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/16/22. No additional information was provided.

The community will initiate the staffing acuity tool provided by the state until an in-house tool is approved for use.

A complete review of resident acuity will be completed by shift to assure appropriate staff are scheduled to work to meet the scheduled and unscheduled needs of the residents.

Staff turnover will be evaluated weekly by the ED and management team at every level. Exit interviews will be conducted for all staff that are termed.

The Community will have a staffing agency contract in place for emergency use.

Dining room attendants/servers will be added to the staffing plan.

A laundry attendant that focuses on resident laundry will be added to the staffing plan on NOC shift to not take up the laundry facilities during the residents waking hours.

The ED will provide oversight

Based on observation, interview, and record review, it was determined the facility failed to have staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. This is a repeat citation. Findings include, but are not limited to:

During the survey, from 07/18/22 through 07/21/22, multiple residents and staff reported there was frequently an insufficient number of staff in the building. Sampled and unsampled residents reported the following:

* "They don't have enough staff";

* "Care staff are getting pulled to work in the dining room";

* "Staff in the dining room get pulled away to help elsewhere or answer call lights";

* "Meals are an hour or more late in the dining room and even later if residents eat in their rooms";

* "Staff are working very hard but need more help";

* "Caregivers are delivering meals too; by the time it's delivered meals are cold";

* "Call lights can take up to 45 minutes to answer when staff are slow";

* "Residents aren't given information and included in decisions; we don't know what is going on most of the time";

* "I will be right back is the favorite phrase, but you never see the staff again"; and

* "All the staff are expected to do too many jobs and are spread too thin."

The following observations were made during the survey:

* On 07/18/22, dinner service had one cook in the kitchen and caregivers helping serve in the dining room;

* On 07/18/22, dining room service finished at 5:40 p.m., the list of hall trays was received at 6:17 p.m., the cart left the kitchen at 6:35 p.m., and the last tray was delivered at 7:05 p.m.;

* Activities observed between 07/18/22 and 07/20/22 there was a bingo activity which residents were running, a food committee meeting, and card games run by residents;

* Scheduled balloon volleyball and walking club were not observed; and

* Meal trays were observed in front of resident rooms for extended periods, many times up until the next meal.

Interviews with staff revealed the following:

* Kitchen staff indicated most evenings there was only one staff in the kitchen to prep, do dishes, cook, and plate the food;

* There was not always a server to get the meals to residents in the dining room, which caused extended waits;

* During the day there were additional staff in the kitchen, but there was inconsistently a dishwasher or servers;

* Care giving staff frequently had to serve the dining room and take orders;

* Care staff delivered all the room trays;

* Staff stated the housekeeper had to complete 13-14 rooms per day in order to get through all of them in the week, so she was not always able to clean resident apartments thoroughly;

* There was one housekeeper who worked Monday through Friday;

* There was no housekeeping staff on the weekend;

* There was no longer a night-time staff to do laundry, so it was falling behind;

* MT and CG interviews indicated there were several shifts when there was a single caregiver on the floor, and serving meals and helping in the dining room took staff off the floor. When residents rang for assistance, those calls needed to be answered, which then delayed help for meals;

* The hours of the receptionist were cut, so other staff were trying to cover phones and pick up any other tasks normally handled by the front desk during their shift;

* There were several residents who required a lot of staff attention, either due to behaviors or physical needs, which kept staff tied up;

* When there were only one or two staff on the floor, it was difficult to respond to residents' needs as quickly as they would like and give residents as much time as they consistently needed;

* Staff indicated there were times when call lights were not answered in a timely manner;

* Laundry and cleaning were prioritized after resident care;

* Activity staff indicated she did not always have time to run the activities for the day but had several strong residents who would get things started when she couldn't;

* Activity staff helped cover the front desk since the receptionist's hours were cut and also helped in the dining room, the kitchen, and on the floor answering call lights as needed;

* The residents wanted to go on some outings and add more activities but there was not enough help to do extra outings safely;

* Resident meals were delivered late;

* There were only two people delivering meal trays and that was after the dining room had been served;

* Residents were not getting dinner until 7:00 p.m. or later;

* There were not enough staff to provide quality care; and

* Staff are required to assist residents with care, ADL's, housekeeping if needed, laundry, meal service including set up and clean up, escorting residents, incontinence care and toileting, safety checks, showers, and answering call lights.

On 07/21/22, facility call light logs were reviewed. The following was identified:

* 06/21/22 through 06/30/22: 110 occasions when call lights were over 20 minutes; 65 of these were over 30 minutes;

* 07/01/22 through 07/11/22: 95 occasions when call lights were over 20 minutes; 47 of these were over 30 minutes; and

* 07/12/22 through 07/17/22: 89 occasions when call lights were over 20 minutes; 45 of these were over 30 minutes.

The facility's staffing plan noted two caregivers and two med techs were to be on day and evening shifts and one caregiver and one med tech on the graveyard shift. Payroll records, for both facility and agency staff, from 06/20/22 through 06/30/22 and 07/04/22 through 07/17/22 were reviewed, . The following shifts appeared to be short-staffed in comparison to their staffing plan:

* 06/20/22: 1 MT on evening shift; no CGs on graveyard shift;

* 06/21/22: 1 MT on day shift;

* 06/23/22: 1.5 MTs on evening shift; no CGs on graveyard shift;

* 06/24/22: 1 MT on day shift; 1 MT on evening shift;

* 06/25/22: No MT on graveyard shift;

* 06/26/22: 1 MT for four hours on graveyard shift;

* 07/04/22: No CG or MT on graveyard shift;

* 07/05/22: 1 MT on evening shift; 0 MT on graveyard shift;

* 07/07/22: 1 MT on day shift;

* 07/08/22: 1.5 CGs and 1 MT on evening shift;

* 07/12/22: 1 MT on evening shift; and

* 07/16/22: 1.5 MTs on evening shift; no MT on graveyard shift.

In a interview on 07/20/22 and 07/21/22, Staff 12 (Executive Director) and Staff 16 (Operations Personnel Support) stated agency staff worked on the dates which payroll records indicated the facility did not have enough staff.

The need to have a sufficient number of staff to meet all scheduled and unscheduled needs of residents was discussed with Staff 12 and Staff 16 on 07/21/22. The survey team received additional payroll documents from staff at the exit interview and indicated they would review them off-site and notify facility administration if staffing would be cited. On 07/28/22, Staff 12 was notified by telephone that staffing would be cited.

1.Facitily will ensure staffing levels are met per the acuity based staffing tool. Dedicated servers and housekeeper, laundry aide have been hired for universal duties that are not assigned to direct care duties.

2.Community is actively hiring through ads on indeed, communicating with agency to meet any shortages.

3.Staff shcedules will be reviewed daily at stand up to ensure adequate staffing levels are met.

4.Executive director or designee will be reponsible for ensuring proper staffing levels.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to residents at least annually, in accordance with the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Review of facility records on 07/20/22 identified the following deficiencies:

There was no documented evidence annual training on fire safety was provided to residents.

On 07/21/22 the need to provide and document fire and life safety instruction for residents at least annually, in accordance with the OFC, was discussed with Staff 12 (Executive Director) and Staff 13 (Maintenance Manager). They acknowledged the findings.

1. Fire and Life Safety/evacuation Training for Residents will be completed at Town hall.

2. Service plans will be reflective to show knowledge of evacuation procedures. A written record of fire safety training, including content of the training sessions

and the residents attending will be in town hall notes.

3. Service plans are updated quarterly or as needed.

4. ED, Maintenane or designee will monitor for compliance

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C 150, C 154, C 160, C 200, C 240, C 260, C 360, and C 422.

Refer to tag # C 150, C 240, C 260, C 360,

Based on observation and interview, it was determined the facility failed to ensure exterior grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:

On 02/14/22 and 02/15/22, the facility grounds were toured during the survey, and the following was observed:

* The interior courtyard off the dining room had an accumulation of yard debris throughout the grounds and pathways; and

* The courtyard located on the west side of the building had multiple areas of pet waste along the pathway where residents walked.  

The need to ensure facility grounds were kept orderly and free of litter and refuse was discussed with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/16/22. They acknowledged the findings.

The interior courtyard of the dining room will be cleaned and debri removed.

The courtyards with multiple pet waste will be cleaned as well as a policy for residents and their pets care reviewed with each resident with pets.

The Maintenance Manager will be required to complete a weekly walk through of the community with a first impressions QA tool as well as a weekly one on one with the ED to review areas out of compliance

The ED will provide oversight

2. Observations of Resident 2's room on 02/14/22 revealed the following:

* Cove base was missing from the wall next to the closet; and

* Bathroom walls, corners, door and jamb had gouged and scraped areas.

The surveyor toured the resident's apartment with Staff 1 (Administrator) and Staff 2 (Administrator in training) on 02/16/22 at 1:30 pm. They acknowledged the above areas needed to be repaired.

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

1. On 02/15/22, the following was observed:

* A laundry room located on the left side of the building was missing a large section of the baseboard behind the washer and dryer machines and the remaining baseboards were peeling away from the wall. Additionally, there was a buildup of lint, dust and debris behind the laundry appliances.

The need to ensure the interior areas of the facility were kept clean and in good repair were discussed with Staff 1 (Administrator) and Staff 2 ( Administrator in training) on 02/16/22. They acknowledged the findings.

The laundry room missing section of baseboards will be fixed.

Resident 2 cove base, and bathroom walls, corners, door jam and scrapes will be corrected.

The Maintenance Manager will be required to complete a weekly walk through of the community with a first impressions QA tool as well as a weekly one on one with the ED to review areas out of compliance.

A housekeeping checklist to report repairs will be implemented so that each apartment in the community is reviewed weekly for repair needs.

The ED will provide oversight.