The findings of the re-licensure survey conducted 10/11/21 through 10/13/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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

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

OAR 411-057-0160 Behaviors.

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

The findings of the revisit to the re-licensure survey of 10/13/21, conducted 02/22/22 through 02/23/22 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 57 for Memory Care Communities.

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

During the survey, conducted 10/11/21 through 10/13/21, 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.  

* Upon arrival to the facility on 10/11/21, staff were observed working with residents without required eye protection;

* Staff were observed removing their eye protection equipment at the end of shifts and during breaks without properly disinfecting and storing the equipment; and

* There was no designated staff member to complete screening of all staff and visitors for signs and symptoms of COVID-19. Additionally, there were no supplies or instructions for disinfecting the screening equipment (thermometers/pens) between each use.

The need to ensure the facility implemented proper infection control practices to protect residents and staff from the COVID-19 virus was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings.

C160: OAR 411-054-0025

(Reasonable precautions) Covid infection control will be followed. All visitors entering the facility will be screened by the receptionist/Staff. Staff will also assure that pens will have 2 containers one for clean and one for dirty. Sign in area will also have hand sanitizer and or wipes to sanitize used pens and table area during hourly cleaning. Receptionist will also hand out mask and shield at time of visit to assure Covid rules are being followed and initial after each screening to assure for consistency.

Med Tech on duty will do screening and document temperatures and initial after taking temps of oncoming staff. Staff will also sanitize and sterilize thermometer. Staff will also assure that pens will have 2 containers one for clean and one for dirty. Sign in area will also have hand sanitizer and or wipes to sanitize used pens and table area. Med Tech will check staff has all proper PPE for their shift and routine checks to assure staff is wearing PPE correctly during their shift.

Sanitizing tables/Area will be set up by Housekeeper for the front lobby and in the breakroom to be able to sanitize shields/goggles between usage. Proper containers with labeled names for staff on tables in the lobby and step by step instructions for storage and disinfecting/sanitizing.

Business Office Manager to review screening logs daily.

6. Resident 6 was admitted to the MCC in 2018 with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and chronic pain. The resident was receiving hospice services at the time of the survey, spent a majority of the day in bed and was being treated for several skin conditions. Observations of the resident during the survey indicated the resident was minimally verbal and could not reliably respond to questions.

Progress notes between 7/10/21 and 10/10/21 were reviewed, along with Resident 6's current service plan, Temporary Service Plans (TSPs) and hospice visit notes. The following issues were identified:

* On 08/03/21, a MT documented "I am adding [resident] to alert [charting] for a small skin tear to [his/her] left elbow."

* On 10/06/21, A MT documented "Placing resident on alert [charting] due to [s/he] got a skin tear on [his/her] left elbow its a silver dollar size skin tear [MT] bandage it and will call family and hospice [resident] also has a small bump on the back of [her/his] head was draining a little bit will continue to monitor."

The two skin tears to the left elbow and the bump to the back of the head represented injuries of unknown cause. There was no documented evidence the facility either conducted an immediate investigation of the injuries which reasonably concluded and documented that the injuries were not the result of abuse, or reported the injuries to the local SPD office as suspected abuse.

The injuries of unknown cause were reviewed with Staff 1 (ED) on 10/13/21 at 12:00 pm. She acknowledged the injuries represented injuries of unknown cause, acknowledged no investigation to rule out abuse had been conducted and confirmed the injuries had not been reported to the local SPD office as suspected abuse.

Staff 1 was instructed by the surveyor to report the injuries of unknown cause to the local SPD office. Confirmation the incidents had been reported was received on 10/14/21.

3. Resident 3 was admitted to the facility in June 2020 with diagnoses including Alzheimer's Disease. A review of the resident's records during the survey revealed the following:

* An incident report dated 7/20/21 indicated staff had witnessed Resident 3 and another resident "inappropriately touching" each other. The residents were separated, and both went back to their separate halls. Resident 3 was unable to say what happened. There was no further documentation.

There was no documented evidence the facility conducted a thorough investigation of the incident to rule out abuse. The facility lacked documentation of required investigative components, including individuals present, a description of the inappropriate touching, follow-up action, and the administrator review.

The need to ensure the facility investigated all incidents and documented all required investigative components was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings.

4. Resident 4 was admitted to the facility in 6/2021 with diagnoses including dementia.

Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents:

* Incident reports dated 07/20, 08/07, 08/25, 08/26, 08/27, 08/31, 09/07, and 09/18, indicated Resident 4 expressed unwanted sexualized behaviors towards other residents; and

* Progress notes dated 08/05, 08/28, 09/04, 09/15, 10/01, 10/05, 10/06, 10/07, and 10/10, indicated Resident 4 displayed unwanted sexualized behaviors towards other residents.

There was no documented evidence the facility reported the incidents to the local SPD office as abuse, immediately conducted an investigation, took measures to prevent reoccurrence of the abuse and the facility administrator reviewed the incidents.

On 10/13/21, the need to ensure all allegations of abuse and neglect were immediately investigated and reviewed by the facility administrator, and incidents were reported to the local SPD office was discussed with Staff 1 (ED). She acknowledged the findings.

The surveyor directed the facility to self-report the incidents. Confirmation the incidents had been reported was received on 10/14/21.

5. Resident 5 was admitted to the facility in 8/2020 with diagnoses including dementia.

Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents:

* An incident report dated 10/02, indicated Resident 5 kicked an unsampled resident in the leg; and

* A progress note dated 08/20, indicated Resident 5 was found with a cut on their shin.

There was no documented evidence the facility reported the kicking incident to the local SPD office as suspected abuse. There was no documented evidence the facility either conducted an immediate investigation of the shin injury which reasonably concluded and documented that it was not the result of abuse, or reported the injury to the local SPD office as suspected abuse.

On 10/13/21, the need to ensure all allegations of abuse and neglect were immediately investigated and reviewed by the facility administrator, and incidents were reported to the local SPD office was discussed with Staff 1 (ED). She acknowledged the findings.

The surveyor directed the facility to self-report the incidents. Confirmation the incidents had been reported was received on 10/14/21.

Based on interview and record review, it was determined the facility failed to conduct an immediate investigation of an allegation of abuse and injury of unknown cause to rule-out abuse or report the injury as suspected abuse to the local Seniors and People with Disabilities (SPD) office, for 6 of 7 sampled residents (#s 1, 3, 4, 5, 6, 7). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 6/2019 with diagnosis including Alzheimer's disease.

Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents:

* Temporary service plans dated 6/22/21 and 6/30/21 indicated Resident 1 was exposed to inappropriate sexual behavior and inappropriate sexual gestures from another resident;

* A progress note dated 7/17/21 indicated Resident 1 was on alert for inappropriate behaviors with a known resident. An incident report was initiated on 7/16/21, that documented "they were holding hands, near the other resident's private parts."; and

* An incident report dated 8/25/21 indicated another resident came up and started to push Resident 1 and grabbed his/her walker and threw it. Resident 1 lost his/her balance as s/he was being shoved and fell on the floor.

These incidents represented instances of sexual and physical abuse. There was no documented evidence the facility immediately reported the instances of abuse to the local SPD office. The facility failed to immediately investigate and take measures to prevent reoccurrence of the abuse that occurred on 8/25/21.

* Progress notes dated 8/23/21 and 10/3/21 indicated a half dollar size skin tear to the right leg and bruising on the right side of the face, respectively.

These represented injuries of unknown cause. There was no documented evidence the facility either conducted an immediate investigation of the injuries which reasonably concluded and documented that the injuries were not the result of abuse, or reported the injuries to the local SPD office as suspected abuse.

2. Resident 7 was admitted to the facility in 7/2019 with diagnoses including Alzheimer's disease - late onset and dementia with behavioral disturbance.

Interviews with staff and review of progress notes, temporary service plans and incident reports were conducted during the survey and identified the following reportable incidents:

* A progress note dated 9/14/21 indicated Resident 7 was sitting in the living room when another resident was seen kissing his/her hand, arm, and mouth.

This incident represented an instance of sexual abuse. There was no documented evidence the facility immediately reported the instance of abuse to the local SPD office. The facility failed to immediately investigate and take measures to prevent reoccurrence of the abuse.

* A progress note dated 10/9/21 indicated Resident 7 had a black left eye, goose egg above the left eye and bruising on both forearms.

These represented injuries of unknown cause. There was no documented evidence the facility either conducted an immediate investigation of the injuries which reasonably concluded and documented that the injuries were not the result of abuse, or reported the injuries to the local SPD office as suspected abuse.

The need to ensure allegations of abuse and injuries of unknown cause were investigated promptly or reported if necessary was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/13/21. Staff 1 did not provide any documentation the allegations and injuries were investigated, and abuse was ruled out.

The surveyor directed the facility to self-report the incidents. Confirmation the incidents had been reported was received on 10/14/21.

C231 OAR 411-054-0028 Abuse Reporting.  

Instances when abuse could not be ruled out were reported at the time of survey.                                                                               

Inservice with APS on Documentation/Investigation for reporting on 10/28/21 by Geoff Clark. Inservice was recorded for future training and or as needed for All Staff training.     

RN/RCC/Med Tech will have Clinical meeting daily to review IR, Alert charting, review previous progress notes, Medication administration, Medication given/PRN'S, Medication exemptions. Clinical meeting will be done daily, ED will be in charge to monitor to assure daily compliance.

Incident Reports (IR) will be initiated by Med Tech (MT) at time of any incident: Res to Res, Skin issues (bruises, skin tears, skin discoloration, bumps). The MT will gather witness statements and notification for Primary, Family, RN, RCC, ED and detailed documentation entered regarding Incident. MT will also have TSP in place.  RCC will review and continue investigation at that time if needed to Self-Report and send Face Sheet, Progress note, Care Plan, TSP pertaining to the IR. RN will monitor for compliance.

Executive Director be notified of all Incident Reports to be reviewed/signed off and will verify self- report(s) this will be done daily.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required care/service elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include but are not limited to:

Resident 2 was admitted to the facility in 09/2021, with diagnoses including dementia.

Resident 2's move-in evaluation was reviewed during survey and lacked information related to the following required elements:

* Fall risk;

* Pain including non-pharmacological interventions; and

* Elopement risk.

The need to ensure move-in evaluations addressed all required care/service elements was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings.

C252 OAR 411-054-0034 Resident Evaluation

New Move-in evaluations will be done prior to moving in. RCC will be the designated person to assure all elements are answered as stated in the rule. RN will review all Evaluations. Executive Director will review new move in evaluations for required elements.

RCC is designated to update 30- day evaluations/quarterly Evaluations/Change of conditions; these are updated with TSP's and updates from Care-partners, Med Techs, New orders from primary, outside services, Family, RN, ED, RCC, Resident, Case Manager.

Family Care conferences are scheduled to review and sign updates. All care team are invited to Care Conferences. Family, POA have options to attend or participate via phone, email, zoom. Family/Resident will be offered a copy of Updated Care Plan. Care Conferences will be documented. All updated Care Plan will have signatures of the Care Team involved, Family, RN, RCC, ED.

Resident #2 Care Plan will be reviewed and updated for Fall risk, Pain including non-Pharmacological interventions; and elopement risk. RCC will update and RN will Review medications and to have interventions when needed.

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 5 of 7 sampled residents (#s 1, 2, 4, 5 and 6) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1, 2, 4, 5 and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 10/13/21, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED). She acknowledged the findings.

C262 OAR 411-054-0036 Service Plan: Service Planning Team Refer to C252:

RCC is designated to update 30- day evaluations/quarterly Evaluations/Change of conditions; these are updated with TSP's and updates from Care-partners, Med Techs, New orders from primary, outside services, Family, RN, ED, RCC, Resident, Case Manager.

Family Care conferences are scheduled to review and sign updates. All care team are invited to Care Conferences. Family, POA have options to attend or participate via phone, email, zoom. Family/Resident will be offered a copy of Updated Care Plan. Care Conferences will be documented. All updated Care Plan will have signatures of the Care Team involved, Family, RN, RCC, ED.

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for the resident following a change of condition, monitor and document on the progress of the condition at least weekly until resolved and monitor the resident consistent with his/her evaluated needs and service plan, for 3 of 7 sampled residents (#s 4, 6 and 7) who had resident altercations, skin issues and falls. Findings include, but are not limited to:

1. Resident 6 was admitted to the MCC in 2018 with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and chronic pain. The resident was receiving hospice services at the time of the survey, spent a majority of the day in bed and was being treated for several skin conditions.

Review of Resident 6's progress notes between 7/10/21 and 10/10/21, current service plan, Temporary Service Plans (TSPs) and incident reports indicated the following deficiencies related to changes of condition:

a. On 07/05/21 the resident was found on the floor of his/her room. The resident sustained a laceration to the head. The resident was placed on Alert Charting and staff documented on the progress of the wound until 7/20/21. There was no documentation as to whether the wound was healed and considered resolved. Additionally, there was no documented facility review of service-planned fall interventions to determine whether they were being followed at the time of the fall, were effective or whether additional interventions needed to be developed to minimize the risk for further falls.

b. On 8/13/21, a MT documented the resident was being placed on Alert Charting for "open site to coccyx." MTs documented on 8/15/21, 8/16/21 and 8/17/21 that treatments were being administered and the area was "healing." There was no further documented monitoring of the wound by the facility until Staff 2 (RN) documented on 9/10/21, per hospice, the wound was resolved.

c. On 10/6/21, a MT documented the resident was being placed on Alert Charting for a skin tear to the left elbow and a bump on the back of the head. No written instructions for monitoring of the bump were provided to staff, and there was no documented monitoring of the bump by the facility.

The need to ensure actions/interventions were documented and communicated to staff, changes of condition were monitored at least weekly until resolved and existing interventions were monitored for effectiveness was discussed with Staff 1 (ED) and Staff 2 (RN) on 10/13/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 6/2021 with diagnoses including dementia.

Resident 4's record was reviewed for changes of condition and identified the following:

* Between 7/15/21 and 10/11/21, Resident 4's record indicated the resident had 17 incidents of unwanted sexualized behaviors towards other residents.

There was no documented evidence the facility reviewed service-planned interventions to determine whether they were effective. The facility failed to implement additional interventions to try to minimize further behavior toward other residents.

On 10/13/21, the need to monitor the effectiveness of interventions and develop new interventions as needed was discussed with Staff 1 (ED). She acknowledged the findings.

Refer to Z165.

3. Resident 7 was admitted to the facility in 7/2019 with a diagnosis of Alzheimer's disease. During the acuity interview on 10/11/21, Resident 7 was identified as a fall risk who had a history of falls with a fracture.

Progress notes, incident reports, service plans and temporary service plans were reviewed during the survey.

The facility failed to adequately determine and document what actions or interventions were needed for the resident and communicate the interventions to staff in response to repeated falls, exposure to inappropriate sexual behavior and an injury of unknown cause.

Additionally, the facility failed to monitor service-planned interventions for effectiveness in response to the following incidents:

* On 7/9/21, the resident was found on the floor in the shower;

* On 7/31/21, staff documented the resident was being added to alert for a non-injury fall;

* On 8/4/21, staff documented the resident was found on floor in bedroom. Resident was lying on the right side on top of the fall mat;

* On 8/9/21, staff documented the resident was found on floor in bedroom. The resident was lying on right side in the fetal position by chair that s/he was previously sleeping in;

* On 9/13/21, staff documented the resident was kissed on the hand, arm and mouth by another resident; and

* On 10/9/21, staff documented the resident had a left black eye, goose egg above the left eye and bruising on both forearms.

The need to ensure interventions were developed in response to changes of condition, the interventions were communicated to staff on all shifts, and the interventions were monitored for effectiveness was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 5 (RCC) on 10/13/21. They acknowledged the findings.

C270 OAR 411-054-0040 Change of Condition monitoring refer to C231

RN/RCC/Med Tech will have Clinical meeting daily to review IR, Alert charting, review previous progress notes, Medication administration, Medication given/PRN'S, Medication exemptions. Clinical meeting will be done daily, ED will monitor to assure daily compliance.

MT are aware to place any resident on Alert for any changes of Medications, Falls, Skin issues, illness, Behaviors, RES to RES, Any incidents. MT are aware to notify the RN/RCC/ED of these changes or issues. Alert Charting will be reviewed daily and RN to assess Resident and document findings as needed and will instruct Med Tech's of what is needed to monitor and document. RN will at that time initiate if needed a Change of condition status. RN will instruct RCC to Update Care Plan and ISP of instructions for staff of what to monitor and report. RN will notify family/Primary of changes of condition. Monthly MT meeting and All Staff meeting for education/training.  RCC will review Charts and Audit for #4,6,7. This Audit will be completed by 12/12/21.

Based on interview and record review, it was determined the facility failed to ensure a timely RN assessment was completed for residents with a significant change of condition, for 2 of 2 sampled residents (#s 6 and 7) who experienced pressure ulcers and a hip fracture. Findings include, but are not limited to:

1. Resident 6 was admitted to the MCC in 2018 with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and chronic pain. The resident was receiving hospice services at the time of the survey, spent a majority of the day in bed and was being treated for several skin conditions.

Progress notes between 07/10/21 and 10/10/21 were reviewed along with Resident 6's current service plan, Temporary Service Plans (TSPs), physician orders, MAR and hospice visit notes. The following issues were identified:

* A "Hospice Physician Order" dated 08/09/21 indicated "Right coccyx pressure injury. Apply calmazine BID and PRN."

* Staff 2 (RN) documented in a "Skin/Wound Note" dated 09/23/21 "Resident has reddened buttock with an approximately 7 cm x 2 cm wide area, outer skin deep, area washed covered with foam."

These documented skin conditions represented pressure ulcers, which are considered significant changes of condition. There was no documented evidence the facility RN conducted a thorough assessment of each of the conditions and documented her findings. In an interview on 10/13/21, Staff 2 (RN) acknowledged no assessments of the skin conditions had been completed.

The need to ensure conditions that represent significant changes of condition are assessed by the facility RN was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings.

2. Resident 7 was admitted to the facility in 07/2019 with diagnoses of Alzheimer's disease and dementia with behavioral disturbance. The resident was admitted to the hospital on 07/21/21 for left hip replacement surgery. Progress notes and temporary service plans were reviewed during the survey.

Progress notes identified the resident returned to the facility on 07/27/21. A temporary service plan dated 07/30/21 noted the resident had experienced a decline in ADL functioning related to the hip replacement in the following areas:

* Ambulation;

* Two person transfers with a gait belt;

* Pain with transfers; and

* Toileting assistance every two hours.   

The overall decline in health and changes in ADL needs constituted a significant change in condition for which an RN assessment was required. There was no documented evidence the facility RN completed a significant change of condition assessment for the decline in ADL functioning which included documented findings and resident status.

The need to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 5 (RCC) on 10/13/21. They acknowledged the findings.

C280 OAR 411-054-0045 Resident Health Services

Significant changes of condition for sampled residents have been completed.

RN/RCC/Med Tech will have Clinical meeting daily to review IR, Alert charting, review previous progress notes, Medication administration, Medication given/PRN'S, Medication exemptions. Clinical meeting will be done daily, ED or their designee will monitor  daily for compliance.

Med tech to initiate TSPs for all changes in condition. RN to determine if change in condition is short term or signficant and consult with ED or RCC.

Residents with significant changes of condition to be monitored by RN. This monitoring to take place during daily reviews of electronic health record system's dashboard. The RN will conduct and document an assessment of the significant change of condition and update the service plan based on his/her findings.

RN is responsible for reviewing system weekly.

3. Resident 6 was admitted to the MCC in 2018 with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and chronic pain. The resident was receiving hospice services at the time of the survey and was being treated for several skin conditions.

Review of the most recent set of signed physician orders, dated 08/04/21, indicated the resident was prescribed three PRN medications to treat constipation. Instructions on the MAR directed staff to administer the medications in the following order:

* Milk of magnesia - "Try 1st. If ineffective after 24 hours may give suppository."

* Bisacodyl suppository - "Try 2nd. If ineffective after 24 hours may give Fleets."

* Fleet enema - Try 3rd. Hospice to initiate fleets."

Review of medication administration notes between 07/10/21 and 10/10/21 indicated the facility failed to administer the medications as ordered on five occasions. The suppository was administered on 08/4/21, 08/31/21, 09/11/21, 09/18/21 and 09/23/21 without the milk of magnesia (MOM) first being administered and noted as ineffective.

The facility's failure to follow the orders was reviewed with Staff 2 (RN) on 10/13/21 at 9:00 am. She stated the MTs may have been instructed by a hospice nurse to administer the suppository without trying the MOM first. At 9:30 am, Staff 2 informed the surveyor she had reviewed the MARs and found no documented evidence the MOM had been administered first, or that a hospice nurse had instructed the MTs to administer the suppository.

The facility's failure to ensure physician orders were followed was reviewed with Staff 1 (ED) on 12/13/21. She acknowledged the findings.

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

1. Resident 3's physician orders, 09/01/21 through 10/12/21 MARs and progress notes dated 7/11/21 through 10/12/21, were reviewed and identified the following:  

a. The resident was prescribed two PRN psychotropic medications for anxiety and restlessness: haloperidol and lorazepam. The order for haloperidol included instructions to administer first and "if haloperidol ineffective in 30 minutes, use lorazepam." The 09/2021 MAR indicated lorazepam had been administered on 09/7/21 first, with no documented evidence the haloperidol had been administered prior with ineffective results.

b. The resident was prescribed two PRN pain medications for moderate to severe pain and osteoarthritis: acetaminophen and morphine. The orders for acetaminophen included instructions to administer first, and the morphine had instructions to administer second if the acetaminophen was ineffective. The 09/2021 MAR indicated the morphine had been administered on 09/11/21 first, with no documented evidence the acetaminophen had been administered prior with ineffective results.

An interview on 10/13/21 at 11:30 am, Staff 15 (MT) confirmed that on 09/07/21 and 09/11/21, the MT had not followed the order of administration for the PRN medications.

The need to ensure orders were administered as prescribed was discussed with Staff 1 (ED) on 10/13/21. She acknowledged the findings.

2. Resident 5's signed physician orders and 10/01/21 through 10/11/21 MAR were reviewed, and the following deficiencies were identified:

a. The resident had a signed physician order for citalopram 40 mg 1 time daily. However, the MAR indicated the resident was receiving citalopram 20 mg one time daily. Observation of the citalopram drug card confirmed that the resident was receiving the 20 mg dose one time daily.

b. Resident 5's MAR displayed loperamide 2mg, magnesium hydroxide 1200 mg/15 ml, calcium carbonate 500mg, and acetaminophen 500mg as PRN medications. There were no signed physician orders for these medications found in the resident record.

On 10/13/21, the need to ensure orders were carried out as prescribed, and signed provider orders were documented in the resident's record for all medications, was discussed with Staff 1 (ED). She acknowledged the findings.

C303

Refer to C231, C252, C262, C270

Medications for sampled residents reviewed and reconciled with primary care physician.

RN/RCC/Med Tech will have Clinical meeting daily to review IR, Alert charting, review previous progress notes, Medication administration, Medication given/PRN'S, Medication exemptions. Clinical meeting will be done daily, ED or their designee will monitor to assure daily compliance. Inservice to be held for med techs related to documentation, following nursing parameters, and The 6 Rights of Medication Administration.

System of triple checks with stamped step by step instructions check off for person to initial after task is completed

First check: Med Tech that receives any order(s) must send to pharmacy, progress note, Alert Charting/TSP in place if applicable.

Second Check: RCC to review to assure the first check was completed and accurate.

Third Check: RN to review and document for accuracy in Progress note.

RN will review medications Quarterly.

Chart Review audit will be conducted every quarter to assure all medications have current orders. RCC/RN will review/Audit charts for residents #1, 2,3,4,5,6, 7 this will be completed 12/12/21. Executive Director to monitor for compliance

Based on interview and record review, it was determined the facility failed to ensure a written fire drill record was maintained and included all required components in accordance to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill records for April through September 2021 were reviewed during survey.

The following required components were not consistently documented in fire drill records:

* The escape route used;

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

* Evacuation time period needed; and

* Number of occupants evacuated.

The need to ensure a written fire drill record was maintained and included all components in accordance to the Oregon Fire Code (OFC) was discussed with Staff 1 (ED) and Staff 9 (Maintenance Director) on 10/13/21. They acknowledged the findings.

C420 OAR 411-054-0090 Fire and Life Safety: Drills/Instruction

The following additions were made to our existing fire drill logs; escape route used, residents evacuated, special circumstance training, problems encountered and comments relating to residents who resisted or failed to participate in the drills, actions taken to overcome the problems, evacuation time period (begin and end time), and number of occupants evacuated.

Care staff will be expected to explain the escape route used based on our evacuation map. Care staff will be escorting at least one resident on fire drills (every other month minimum) beyond at least the first set of fire doors of the fire sector involved in the drill and questioned about problems or issues that arose during the evacuation and actions they took to overcome the problems. Information will be given on what to do for residents who refuse. Refusals to participate in drills or actual emergencies are dealt with as such; When we evacuate, we evacuate most able bodied people first then least able bodied. If a resident refuses after all non-physical persuasion methods, they become least able bodied. It is the responsibility of all staff to use non-physical methods to get residents evacuated first (motivation, encouragement, persuasion, change of face, and diversion), then if those tactics are unsuccessful, we move to physical techniques (using a wheelchair to escort them, multiple person assisted walking, and as a last resort using bedsheets or fall mats to assist the resident out of danger). Care staff will be given special circumstances (i.e. natural disasters, equipment failures, building failures, and other unique scenarios) for each fire drill and be educated/questioned on how to react to those situations. Care staff will be timed on response time, total time of the drill, and evacuation time of each resident.

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 C160, C231 and C420.

Z142

OAR 411-057-0140 Administration Compliance Refer to C160, C231, C420

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:

Refer to C252, C262, C270, C280 and C303.

Z162 OAR 411-057-0160 Compliance with Health Rules.

Refer to C252, C262, C270, C280, C303

Based on observation, interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 6 sampled residents (#s 1, 2, 3, 5 and 6) whose activity plans were reviewed and failed to provide meaningful activities to all residents. Findings include, but are not limited to:

1. Residents 1, 2, 3, 5 and 6's service plans were reviewed during the survey. The facility was documenting quarterly activity evaluations, however, the evaluations lacked one or more of the following required components and were not included on the residents' service plan:

* 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 individualized activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.

2. The facility was divided into four neighborhoods. Observations in each of the neighborhoods during the survey revealed there were some residents who were either in their rooms or not engaged in any activities. Observations in the Walnut neighborhood on 10/11/21 through 10/13/21 identified multiple non-sampled residents seated in front of a TV in the common area. No other activities were observed in the Walnut neighborhood.

On 10/11/21 and 10/12/21, a non-sampled resident approached the surveyor stating, "Can you help me find something to do" and " I need something productive to do." Each time the resident approached the surveyor there were no direct care staff in the immediate area. The surveyor went to find a staff member to relay the information. Staff approached the resident, gave him/her some paper and coloring pencils and walked away from the resident.

Observations of Resident 1 on 10/11/21 through 10/13/21, identified Resident 1 was wheelchair bound and unable to successfully propel the wheelchair without staff assistance. Staff were not observed to offer to escort the resident to and from group activities occurring in other areas of the community and nor were staff observed to engage the resident with 1:1 activity during the survey. The only activity offered to the resident was watching TV in his/her room, alone.

In an interview on 10/13/21, Staff 6 (Activities Director) reported she was usually the only person available for activities. She stated the care partners try to help, but they were usually busy and would help when an activity involved food because she was not familiar with each resident and their ability to independently eat. Staff 6 reported the facility was still in the process of developing the activity program and she recently started working with Staff 5 (RCC) on activity evaluations for new admissions, but had not gone through each resident's service plan.

On 10/13/2021, the need to evaluate and develop individualized activity plans was discussed with Staff 1 (ED), Staff 2 (RN), Staff 5 and Staff 6. They acknowledged the findings.

Z164 OAR 411-057-0160 Activities

RCC and Activities will review up-coming care plans and update to add missing components to all care plans to assure all Service Plans are reflective and followed. Audits to be done monthly. ED to monitor for compliance. Activities will reflect likes/dislikes, limitations, level of participation, tools if needed.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted 1 of 2 sampled residents (#4) and others in the community. Resident 4 exhibited repeated sexually abusive behaviors towards other residents which posed an immediate jeopardy situation that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 06/2021 with diagnoses including dementia and major depressive disorder.

Resident progress notes and incident reports from 07/15/21 through 10/11/21 indicated the resident had at least 17 documented incidents of sexualized behaviors on 07/16, 07/20, 08/05, 08/07, 08/25, 08/26, 08/27, 08/28, 08/31, 09/04, 09/07, 09/15, 09/18, 10/01, 10/05, 10/06, 10/07, and 10/10 toward other residents. Those incidents included pulling down his/her pants and showing other residents his/her genitalia, putting his/her genitalia in other resident's faces and/or up to their mouths, looking at other residents near him/her and touching his/her own genitalia, and taking other residents' hands and placing their hands on his/her genitalia.

On 10/12/21, the surveyor witnessed Resident 4 sit next to an unsampled resident on the couch unsupervised. Resident 4 proceeded to place his/her hand on the unsampled resident's upper thigh and/or groin area four different times, with the unsampled resident moving Resident 4's hand off each time. The surveyor asked Staff 1 (ED) to separate Resident 4 and the unsampled resident.

Resident 4's most recent service plan, dated 08/24/21, did not address the resident's sexualized behaviors towards other residents and include effective resident-specific interventions or approaches for staff to utilize for the behaviors. The facility's failure to evaluate and develop an individualized behavior plan to address Resident 4's behaviors resulted in continuation of the behaviors and exposed other residents to sexual abuse.

On 10/12/21, at 2:15 pm, the survey team requested an immediate plan of correction addressing the Resident 4's behaviors. At approximately 5:45 pm, the survey team received and accepted the plan of correction.

On 10/13/21, the need to ensure an individualized behavior plan was developed and implemented to address behaviors which negatively impacted residents and others in the community was discussed with Staff 1. She acknowledged the findings.

Z165 OAR 411-057-0160 Behaviors

Resident #4 continues to have a companion. APS have made surprise visits to assure that this is accurate and is maintained. Executive Director working with Policy Analyst Debbie Concidine for contacts for All Male facilities. Requested assistance from Referral contacts for placement.

All Upcoming Care Plans will be reviewed and Audit quarterly or as needed by RCC to meet the rule. Executive Director will monitor for compliance. This Audit will be done every 3 months

Based on observation, interview and record review, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to:

The building consisted of four units or "neighborhoods." There were two separate outdoor courtyards, each shared by two neighborhoods. There were doors in each neighborhood which allowed access to the courtyards. There was also a common living/activity area, central to the building, that allowed access to each of the courtyards.

The facility was toured on 10/11/21 at 12:50 pm. The doors to the courtyards from three of the four neighborhoods and from the common area were locked. Staff 14 (CG) acknowledged the doors were locked and stated that if a resident wanted to go outside, staff opened the door for them. Another CG stated the doors were locked when the weather was cold or rainy but didn't know why the doors were currently locked because the weather was sunny and mild.

On 10/12/21 at 9:00 am, the courtyard doors were all observed locked. In an interview at 10:35 am, Staff 1 (ED) was informed the courtyard doors had been locked the previous day, and was asked for the facility's policy regarding when the courtyard doors were to be locked and unlocked. Following the interview, the courtyard doors were observed to be unlocked.

The facility's "Courtyard Door Policy" stated the doors were to be unlocked between 8:00 am and 6:00 pm except in situations of snow, ice and extreme heat. On 10/13/21 at 10:05 am, the doors were, again, observed to be locked, preventing residents free access to and from the courtyards.

The need to ensure residents had access to an outdoor space which allowed them to enter and return without staff assistance was reviewed with Staff 1 on 10/13/21 at 12:00 pm. She acknowledged the findings.

Z168 OAR 411-057-0160 Outside Area

Outdoor Policy revised for Residents to access courtyard. Outdoor Policy states:

Courtyard Door Policy- 02/14/2020

Courtyard Doors will be unlocked at 8:00am and re-locked at 6:00pm to allow residents to allow residents direct access to a secure outdoor recreation area.

Staff must do a visual check of each courtyard before locking/securing courtyard door to ensure that no residents or staff are currently occupying the courtyards.

The paging system is connected to all outdoor recreation door sensors to alert staff when a resident enters or exits the outdoor space.

This schedule may vary based on inclement weather conditions such as; Snow, Frost /Ice, Extreme Heat above 75 degrees or heavy rain.