The findings of the re-licensure survey conducted 04/04/22 through 04/05/22 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, 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

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the initial survey of 04/05/22, conducted 09/20/22 through 09/22/22, 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, OARs 411 Division 57 for Memory Care Communities and Community Based Services Regulations OARs 411 Division 004.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 04/22/22, conducted from 03/13/23 through 03/14/23 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, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 2) who were recently admitted to the facility.  Findings include, but are not limited to:

Move-in evaluations for Residents 1 and 2 were reviewed during the survey. The evaluations lacked the following required components:

*Personality: including how the person copes with change or challenging situations;

*Environmental factors that impact the residents behavior: noise, lighting, room temperature; and

*Effective non-drug interventions for behaviors.

On 04/05/22 the need to ensure new move in evaluations addressed all required elements was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA).  They acknowledged the findings.

C252 -Resident Move In and Evaluation:

Immediate: Administrator/Designee will reassess residents 1 & 2 to incorporate personality including how the person copes with change or challenging situations. It will also include environmental factors that impact the resident's behavior, noise, lighting, room temperature, and non drug interventions for behaviors. This will be completed by 5-7-22.

Systemic: Administrator/Designee will provide training on identifying personality, environmental factors and effective non drug interventions. These items will be included in the assessment if they are missing.

Frequency/Monitoring: Administrator/Designee will review new admissions within 30 days of initial assessment to ensure personality, environmental factors and non drug behavioral interventions are included in the assessment. Administrator/Designee will review completed assessments before meeting with the Service Plan Team to ensure the information identified above is included in the assessment.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

Current service plans for Residents 1 and 2 were reviewed during the survey. There was no documented evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 04/05/22 the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA). They acknowledged the findings.

C262 Service Plan - Service Planning Team:

Immediate:Administrator/Designee will complete a service plan review with the service plan team for residents 1 & 2. Completion of this service plan review with the team will be evidenced by signatures on the assessement from which the service plan was developed by members of the service plan team. Documention in the record of the date, time, attendees and a brief narrative of the outcome of the service plan meeting. This will be completed by 5-7-22.

Systemic: Administrator/Designee will provide training to staff involved with Service Plan Meeting; who is a part of the service plan team, when to schedule the meeting and how to document the meeting in record. Training will also include forms used and signatures obtained. Administrator/ Designee will audit records for the last 3 months to identify residents with upcoming reassessments and reschedule a meeting with The Service Plan Team once the assessement is completed. Administrator/Designee will ensure signatures are obtained and notes are entered into the record. This will be completed by 5-7-22.

Frequency/Monitoring: Administrator/Designee will audit the clinical record for assessments, signatures and notes of the service plan meeting and the members of the service team on a quarterly basis.

Based on interview and record review, it was determined the facility failed to ensure residents with changes of condition were evaluated and resident-specific instructions or interventions were determined, documented and monitored for effectiveness at least weekly through condition resolution for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition.  Findings include, but are not limited to:

1.  Resident 2 was admitted to the facility in February 2022 with a diagnoses including dementia and macular degeneration.

The resident's records including progress notes dated 02/16/22 through 04/24/22, incident reports, service plans and interim service plans were reviewed during survey and indicated the following:

The resident's service plan dated 03/21/22 indicated the resident had a history of falls, had "very poor vision", was not oriented to persons, place or time, had poor memory and judgement and s/he was unable to use the call light. Resident 2 required assistance with all ADLs and one to two person assist for transfers. The service plan instructed staff to complete safety checks every hour, ensure the bed and chair alarms were in place at all times and to make sure a pathway was clear of clutter and spills or items on the apartment floor that could pose a trip hazard.

The resident experienced four falls, both injury and non-injury, between 02/16/22 and 04/04/22.

There was no evidence an interim service plan or other documentation was recorded to show the facility had determined resident specific interventions, evaluated current interventions for effectiveness and determined the need to implement additional interventions when the resident experienced the following falls:

*02/20/22 at 1:35 pm: The resident was found sitting behind his/her walker by the Administrators office. There was redness to the lumbar back and coccyx area.

*02/20/22 at 3:15 pm: An incident report revealed the resident was found on the floor of his/her apartment. No injury was noted.

*02/21/22: Staff responded to the resident's alarm sounding and found the resident on the floor. The resident was transferred to the hospital and had sustained a hip fracture.

*03/28/22: Staff observed resident fall to the floor while trying to get up from the wheelchair.  No injury was noted.

On 04/04/22 Staff 3 (Community Liaison/MA) reported there were no interim service plans for the above falls.

The need to ensure residents with changes of condition were evaluated and resident-specific instructions or interventions were determined, documented and monitored for effectiveness at least weekly through condition resolution was discussed with Staff 1 (Administrator) and Staff 3 on 04/05/22. They acknowledged the findings.

2. Resident 1 was admitted to the memory care community in 02/2022 with diagnoses including congestive heart failure, dementia, hypertension and diabetes.

Review of Resident 1's service plan, dated 02/28/22, progress notes, temporary service plans and incident reports indicated the resident experienced multiple short-term changes. The records lacked evidence that resident-specific interventions were implemented or monitored for effectiveness, or that conditions were monitored, at least weekly, to resolution in the following areas:

*New admission to facility;

*Fall with injury;

*New admission to Hospice;

*New bed alarm (for safety); and

*New orders for Haldol (for agitation) and PRN oxygen (for shortness of breath).

On 04/05/22 the need to ensure resident specific interventions were developed and monitored for effectiveness was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA). They acknowledged the findings.

C270 Change Of Condition and Monitoring:

Immediate: Administrator/Designee will review and update the service plans for residents 1 and 2. The SP interventions will include resident specific interventions and will be documented and monitored. Administrator/Designee will include a weekly note to determing the effectiveness of interventions until the condition is resolved. This will be completed by 4-24-22.

Systemic: Administrator/Designee will provide training to staff to on the areas to observe and document on a weekly basis. This will include but is not limited to: new admission, fall with injury, new admission to hospice, new bed alarm for safety, and new orders for Haldol (for agitation) and PRN O2 for shortness of breath. Training will how and when to update the service plan with start dates and end dates of new interventions and f/u for effectiveness. This will be completed by RN/RCC by 5-7-22.

Frequency/Monitoring: Administrator/Designee will evaluate atleast quarterly for changes in condition and concurrent updates in the service plans as well as documentation in the record for effectiveness of the interventions.

Based on interview and record review, it was determined the facility failed to determine and document what actions and interventions were needed for residents when they experienced short-term changes of condition, communicate them to staff on all shifts, and monitor the changes at least weekly for 2 of 4 sampled residents (#s 3 and 6) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 11/2019 with diagnoses including Alzheimer's Disease.

Review of the resident's current service plan, 08/25/22 through 09/20/22 temporary service plans and progress notes revealed the resident fell on 08/29/22 and 09/06/22. There was no documented evidence the facility determined and documented what actions and interventions were needed for the resident and communicated them to staff on all shifts after the falls.

The need to communicate the needs of the resident to staff on all shifts was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison/MA), and Staff 4 (RCC). They acknowledged the findings.

2. Resident 6 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's Disease.

Review of the resident's current service plan, 08/25/22 through 09/20/22 temporary service plans and progress notes, revealed the resident experienced the following short-term changes of condition which were not monitored through resolution:

a. A progress note dated 08/24/22 indicated the resident "smashed" his/her finger in the door of his/her daughter's car while out of the facility. Monitoring of the finger was discontinued on 08/31/22, though documentation in progress notes on that date indicated the resident's finger was still bruised.

b. A progress note dated 08/27/22 stated Resident 6 fell out of bed and complained of left-sided rib pain. The resident was sent to the emergency department of the local hospital and diagnosed with a rib contusion. Monitoring of the resident for the rib contusion was discontinued on 08/31/22. Multiple progress notes between that date and 09/15/22 stated the resident still complained of rib pain. During an interview on 09/22/22, the resident confirmed s/he still had rib pain.

The need to monitor short-term changes of condition through resolution was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison/MA), and Staff 4 (RCC). They acknowledged the findings.

Immediately created an updated Interim Service Plan form (s) to provide detail for all care staff communication which includes any incidences, medication changes, and any short term change of condition. The document will be signed by all staff upon reporting to work at the front desk. Resident #3 has been resolved; Resident #6 was added back to AC until resolve.

Policies GP 18: End of Shift communication and Clinical 03 Change in Status reviewed, and training provided to staff re: change in condition and communicating the change in condition. The End of Shift communication tool will be trained on and implemented.

Communicating the needs of the resident: The End of Shift communication tool will be implemented. Staff will review at the beginning and throughout their shift. Staff will add information to the tool as it occurs. Staff will initial at the beginning of their shift that they read the information contained in the tool.  RCC/Designee will review and sign the tool acknowledging the review each day. Short term changes in condition: will be identified, the service plan will be updated to reflect the interventions implemented and staff notified of updates through the end of shift communication tool. Documentation will be included in the progress note at least weekly until the concern is resolved.

Administrator/RCC/Designee

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 3 of 3 sampled residents (#s 5, 6 and 7) 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.

During interviews with Staff 1 (Administrator) and Staff 4 (RCC) on 09/21/22 at 9:15 am and 9:25 am respectively, they stated the facility had been without a RN since the middle of August, 2022. Staff 4 (RCC) identified Residents 5, 6 and 7 were administered insulin injections daily by non-licensed staff.

Review of the 09/01/22 through 09/20/22 MARs for each of the residents revealed Staff 3 (MA/Community Liaison), Staff 9 (MA/Resident Assistant), and Staff 12 (MA/Resident Assistant), had administered insulin to the residents on multiple occasions.

Review of the delegation documentation revealed Staff 3, 9, and 12 had been delegated to administer insulin to Residents 5 and 7 by the previous RN, but did not have current delegations.  

There was no documented evidence any staff had been delegated to administer insulin to Resident 6. Staff 1 and 4 confirmed this during an interview at 11:54 am on 09/21/22. At that time, the facility was directed to ensure staff were delegated to administer insulin to Resident 6 prior to any future administrations of the medication.

At 3:48 pm, Staff 1 apprised the survey team, that Staff 2 (the previous RN) would return to her position that day to initiate delegation of Staff 12 for the administration of insulin to Resident 6 and would update delegations for the other staff in a timely manner.  

During an interview with Staff 1, 2, 3 and 4 at 5:00 pm on 09/21/22, Staff 2 stated she had initiated the delegation of Staff 12 for the administration of insulin to Resident 6. Staff 1 and 2 provided a written plan stating residents would only be administered insulin by delegated staff and all delegations would be updated timely.

The need 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 residents who received insulin injections by unlicensed facility staff was discussed with Staff 1, 2, 3 and 4 on multiple occasions throughout the day on 09/21/22. They acknowledged the findings.

Immediately, our staff was delegated by our RN.

Systemic: The residents will be assessed every 90 days by the RN. The staff will be redelegated every 90 days. New residents will be reassessed after 60 days. New Med Aides will be redelegated after 60 days.

Frequency/Monitoring: The RN or designee will ensure that these delegations and assessments will be completed on a timely basis.

The system will be corrected by not administering insulin by a non delegated staff member in the future.

A written plan stating residents would only be administered insulin by delegated staff and all delegations would be updated timely was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules.

Based on interview and record review, it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 6 and 7) whose facility records were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 08/2022 with diagnoses including insulin-dependent diabetes.

Review of the resident's 08/16/22 physician orders and 09/01/22 through 09/20/22 MAR revealed the following:

a. Resident 6 had a physician order for Humalog (insulin) which stated, "Inject 0-11 units subcutaneously as directed per sliding scale, total daily dose max 35 units."

The MAR reflected the medication was scheduled TID, though the physician had not indicated the frequency the medication was to be administered. There was no documentation the facility had clarified the order.

There was no documentation on the MAR how many units of insulin staff administered for each administration of the medication.

b. Toujeo (insulin) was ordered by the physician to be administered subcutaneously every morning. The facility held the medication 09/02/22, 09/05/22, 09/08/22, and 09/11/22 secondary to low blood glucose levels, though no instructions to do so were indicated by the physician.

The need to follow physician orders as written and clarify orders when needed was discussed with Staff 1 (Administrator), Staff 3 ( MA/Community Liaison) and Staff 4 (RCC) on 09/21/22. They acknowledged the findings. The facility provided documentation a fax had been sent to the physician for clarification related to the frequency for administration of the Humalog prior to exit.

2. Resident 7 was admitted to the facility in 01/2021 with diagnoses including insulin-dependent diabetes.

Review of the Resident's 08/19/22 physician orders and 09/01/22 through 09/20/22 MAR revealed the following:

Resident 7 had a physician order for staff to administer 4 units of Humalog (insulin) PRN to the resident subcutaneously when the resident's blood glucose levels exceeded 300 and to recheck the resident's blood glucose one hour after administration of the medication.

The resident experienced blood glucose levels greater than 300 seven times between 09/01/22 through 09/20/22. There was no documented evidence the facility administered the PRN insulin on four of the occasions and no documentation the resident's blood glucose levels had been re-checked after administration of the medication.

The need to follow MD orders as written was discussed with Staff 1 (Administrator), Staff 3 (MA/Community Liaison) and Staff 4 (RCC) on 09/22/22. They acknowledged the findings.

Orders for residents #6 and #7 will be reviewed. Any clarifications required (frequency, "as directed", hold if ...) will be sent to the PCP for clarification.

Communication/coordination with pharmacy re: review of orders and communication with community if orders are not completed. Training provided to staff re: med policies: Med 03: med room work flow and Med 33- Medication orders.

Administrator/RCC/Designee

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction to staff was provided on alternate months and that documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed for October 2021 through March 2022. The following deficiencies were identified:

* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts for the memory care community;

* There was no documented evidence the facility was providing fire and life safety training on alternating months for staff; and

* The conducted evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, the number of occupants evacuated, or evidence that alternate routes were used during fire drills.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) and Staff 6 (Maintenance Director) on 04/04/22. The staff acknowledged the findings.

C420 Fire & Life Safety: Drills and Instruction

Administrator/Maintenance Director will conduct Fire & Life Safety instructions to staff every other month starting 5-22-22. Administrator/Maintenance Director will conduct fire drills every other month for memory care beginning  4-22-22. A written record will be kept for each fire drill. This will be kept in a binder.

Systemic: Administrator/Director will create a template for documentation that will include: date/time of day/location of simulated origin/escape route used/problems encountered and comments relating to resident who resisted or failed to participate/evacuation time period needed/staff members on duty and participating number of occupants evacuated. Training documents will be completed and filed in the same binder. This will be completed by 5-2-22.

Frequency/Monitoring: Administrator/ Maintenance Director will review the binder each month after training or the drill to evaluate compliance and effectiveness of the fire drills and the training.   

Based on interview and record review, it was determined the facility failed to ensure fire drill documentation reflected all required components. This is a repeat citation. Findings include, but are not limited to:

The 09/01/22 fire drill record, reviewed on 09/20/22, failed to include documentation the time the drill was conducted, the escape route used, and any problems encountered.

The need to ensure file drill records included documentation of all required components was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison/MA), Staff 4 (RCC), and Staff 6 (Maintenance Director) on 09/22/22. They acknowledged the findings.

Document created to track and document all required components for Fire and Life Safety Drills

The drills are unannounced. The Administrator will schedule the drills every even month starting with October. Documentation will be completed as indicated on the form.

Administrator/Designee

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

Refer to C270, C420, C510, C513, Z163, Z164

See Plan Of Correction For Each Tag.

A survey binder will be created. The Statement of Deficiencies will be inserted. Tabs will be created that will indicate each citation by tag number. Documents that support compliance with the plan of correction will be included in the binder

The binder will be reviewed weekly to identify the corrective action and to stay on target with the corrective acgtion

Administrator/Designee

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

Observations of the secure courtyard on 04/04/22 showed there were multiple drop-offs of 2-3 inches along sitting areas in the courtyard and a drop off of approximately 5 inches off the sidewalk in front of the west wing exit door to the courtyard.

The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director) on 04/05/22. They acknowledged the findings.

Immediate: Administrator/Maintenance Director will remove lightweight furniture from courtyard until it can be replaced or tied;weighted down. Our landscape company was immediately contacted on 4-21-22 and they will be at our community on 4-25-22 to repair drop offs to ensure that pathways are free of tripping hazards.

Systemic: Administrator/Maintenance director will obtain professional advice and repairs will be observed and completed by Thompson's Landscape by early next week.

Frequency/Monitoring: Administrator/Maintenance Director will conduct a weekly walkthrough of the courtyard to ensure any safety hazards are addressed and resolved to remain in compliance with OAR  411-054-0200.

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

During a tour of the secured courtyard on 09/20/22, multiple drop-offs of 2-5 inches were noted along the concrete pathway edges.

The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 (MC Administrator) and Staff 6 (Maintenance Director) on 9/20/22. They acknowledged the findings.

Immediately: Maintenance Director or designee will contact the landscape vendor to come in and fill the drop offs in the courtyard so that it remains safe and leveled for the residents.

Intermediate: Administrator/Designee will inspect the secured courtyard on a weekly basis to ensure there are no drop offs.

Administrator or Designee will meet with senior leaders during monthly safety meetings to address the issue or any concerns to make sure the courtyard does not have any drop off area or any safety concerns.

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

During a tour of the facility on 04/04/22 with Staff 6 (Maintenance Director) the following areas were found in need of cleaning or repair:

* Multiple walls in the dining room had scrapes or gouges and/or splatters/drips;

* There were broken slats on two of the the blinds in the dining room windows;

* Three areas of linoleum in the dining room had square and triangular pieces missing;

* The service table in the dining room had missing laminate on one edge, exposing bare wood surface;

* Cove base in the dining room was being secured to one wall with black tape, approximately six feet in length;  

* Multiple door frames throughout the facility had chips, gouges and/or scrapes;

* Multiple walls throughout the facility had scrapes or gouges;

* Hand rails were worn and scraped, showing bare wood surfaces throughout the facility;

* Overhead light fixtures in the hallways had debris and dead insects;

* Two overhead light fixtures were cracked or broken;

* Linen closet door had a large cracked/broken area;

* Restroom number three had a large area of warped and chipped linoleum on the floor;

* Restroom number two had areas on the walls around the sink chipped and worn without paint and there were areas missing stain protection on the wood mount of the grab bar above the toilet;

* All bathrooms had dirt and/or debris on the floors, sinks, toilets and showers; and

* Beige chairs in the sun room had gray and black colored stains.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) and Staff 6 on 04/05/22. They acknowledged the findings.

Immediate: Administrator/Maintenance Director assessed each issue separately to devise an action plan.

Systemic: We hired a new housekeeper to begin working on 5-3-22 and she will be designated to clean the drips and splatters on the walls. The broken blinds will be ordered and installed onsite in the dining room. We are obtaining bids on a full dining room floor installation and need approval from corporate to proceed. The laminate on the dining room service table will be replaced or fixed to elimnate wood surface exposure. The cove base will be removed when the flooring for the dining room is repaired. There will be a new rubber base installed at that time.The door trim will be removed and reinstalled and painted. The Maintenance Director will go around and patch any holes, scrapes or gouges and painted. Hand rails will be removed, sanded, painted and reinstalled by Maintenance Director And Dietary Services Director. The overhead light fixtures will be cleaned and/or replaced. Linen closet will be repaired or replaced. Restroom linoleum will be removed and replaced. Restroom number 2 will be patched, repaired and painted. The bathrooms will be cleaned professionally by new housekeeper. We will be purchasing a shampoo unit to keep furniture cleaned and without stains.

Frequency/Monitoring: Administrator/Maintenance Director will do a weekly walkthrough to check to make sure doors, walls and odors are in compliance with OAR 411-054-0200

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

During a tour of the facility with Staff 1 (Administrator) and Staff 6 (Maintenance Director) on 09/20/22, the following areas were found in need of cleaning or repair:

* Multiple walls and door frames in the dining room and bathrooms had smudges, gouges and chipped paint;

* Overhead light fixtures throughout the building had debris and dead insects;

* Multiple overhead light fixtures were cracked or broken or missing covers;

* Floors throughout the building had a build-up of dirt and debris; and

* The beige chairs in the sun room had gray and black colored stains.

The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 6 on 09/22/22. They acknowledged the findings.

Administrator will identify the areas and locations that require repair. A tracking form was created.

Maintenance repair tracking form created and will be filled out and completed as repairs are completed. Progress towards completion and maintenance of the building in other areas will be monitored weekly

Administrator

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

Observations on 04/04/22 showed that the two exit doors leading out to the secured courtyard did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Administrator) and Staff 6 (Maintenance Director) on 04/05/22. They acknowledged the findings.

C555 Call system, Exit Doors, Alarm, Phones, TV or Cable:

Immediate: Administrator/Maintenance Director will obtain a portable alarm system (purchased from a local hardware store if possible) and mount them on the two exit doors leading to the secured courtyard. This will be completed by 5-1-22 if not earlier.

Systemic: Administrator/Maintenance Director will evaluate exit doors for working alarms and integration into the call system to be manually shut off when a resident goes outside into the courtyard.

Frequency/Monitoring: Administrator/Maintenance Director will check and troubleshoot the alarm system/call system on a weekly basis to ensure compliance.

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

Refer to C 420, C 510, C 513 and C 555.

Refer to corrective action for C420,C510,C513, and C555.

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

Refer to C420, C510 and C513.

Refer to plan of correction for C420, C510, C513

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 C 252, C 262 and C 270.

Refer to C252, C262 and C270.

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

Refer to C270, C282 and C303.

Refer to plan of correction for C270, C282, C303.

Based on interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in the service plan for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the memory care community in 02/2022 with diagnoses including congestive heart failure, dementia, hypertension and diabetes.

Resident 2 was admitted to the MCC in 02/2022 with diagnoses including dementia and macular degeneration.

Resident 1's service plan, dated 02/28/22 and Resident 2's service plan, dated 03/21/22 were reviewed during the survey. In both cases, the service plans lacked documentation of individualized nutrition and hydration plans for the residents.

On 04/05/22 the need to develop individualized nutrition and hydration plans was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA). They acknowledged the findings.

Immediate: Administrator/Designee will update resident 1 & 2 service plans to include individualized nutrition and hydration plans. This will be completed by 5-7-22.

Systemic: Administrator/Designee will review any upcoming assessments and service plans before meeting with the Service Plan Team to ensue nutrition and hydration information is included and individualized

to resident needs.

Frequency & Monitoring: Administrator/Designee will review service plans for individualized nutrition and hydration plans during quarterly assessments and service plan meetings.  

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 2 sampled residents (#s 3 and 4) whose service plans were reviewed. This is a repeat citation.  Findings include, but are not limited to:

Resident 3 and 4's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison /MA) and Staff 4 (RCC). They acknowledged the findings.

#Residents #3 and #4 will have updates to their service plans which includes information and staff instructions on their individual nutrition and hydration needs.

Resident service plans will be reviewed. Those who are missing individualized nutrition and hydration needs and staff instructions will be updated. Service plan reviews to be completed with new residents and 90 days or change in condition

RCC or Designee will be responsible in seeing that the corrections are completed.

Based on interview and record review, it was determined the facility failed to develop individualized activity plans based on activity evaluations, and reflective of each resident's current needs and preferences for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed.  Findings include, but are not limited to:

Current evaluations and service plans for Residents 1 and 2 were reviewed during the survey. The records lacked evidence that individualized activity plans were developed, based on an activity evaluation, for meaningful activities that promoted the physical and emotional well-being of each resident, were person-directed and available during the resident's waking hours.

Both Resident 1 and 2's evaluations failed to address the following required elements:

-Past and current interests;

-Current abilities and skills;

-Emotional and social needs and patterns;

-Physical abilities and limitations;

-Adaptations necessary for the resident to participate; and

-Activities for behavior interventions.

On 04/05/22 the need to develop individualized activity plans that were reflective of each resident's current status and available during resident's waking hours was discussed with Staff 1 (Administrator) and Staff 3 (Community Liaison/MA).  They acknowledged the findings.  

Z164 Activities:Administrator/Designee will update the service plans for residents 1 & 2 to include individualized activity plans. Individual activities will include past current interests, current abilities and skills, emotional needs and patterns, physical abilities or limitations, adaptations necessary for the resident to participate and activities for behavioral interventions. This will be completed prior to reassessment on resident 1 & 2.

Systemic: Administrator/Designee will review service plans for residents to identify  those plans without individualized activities. Any missing information will be added to the plans.

Frequency/Monitoring: Administrator/Designee will review service plans to ensure individualized activites are included at least quarterly when assessments are completed. Focus on the following items: past and current interests, current abilities and skills, emotional social needs and patterns, physcial abilities and limitations, adaptations necessary for the resident to participate and actiivites for behavioral interventions.  

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 2 sampled residents (#s 3 and 4) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 3 and 4's service plans were reviewed. There was no documented evidence activity plans had been developed for the residents based on their activity evaluations.  

The need to ensure activity evaluations were thorough and activity plans developed for each resident was discussed with Staff 1 (Administrator), Staff 3 (Community Liaison), and Staff 4 (RCC). They acknowledged the findings.

Residents #3 and 4 will have their service plans updates to include individualized. Review of GP 04 Resident Activities/Interests Questionnaire policy and the actual questionnaire along with training to staff on the policy and the questionnaire

. Service plans will be reviewed and those who do not have activities based on their activity evaluation will be updated. Service plan reviews to be completed with new residents and 90 days or change in condition.

Administrator/RCC

Based on observation and interview, it was determined the facility failed to ensure furniture in the outdoor recreation area was of sufficient weight and design to not aid in elopement. Findings include, but are not limited to:

A tour of the facility courtyard on 04/04/22 with Staff 1 (Administrator) and Staff 6 (Maintenance Director) was completed and identified the following:

Multiple metal patio chairs, one metal dining size table and three benches, were not of sufficient weight.

The need to ensure outdoor furniture was of sufficient weight and design to not aid in elopement was discussed with Staff 1 and Staff 6. They staff acknowledged the findings. Staff 1 also stated the patio furniture would be removed.

Immediate: Administrator/Maintenance Director will remove all chairs/tables that may be able to be picked up by a resident and keep them out of the courtyard until they are weighted down and cannot be carried or removed.Completed.

Systemic: Administrator/Maintenance Director will purchase sandbags and tiedowns to install onto the lightweight furniture that will permanently remain in the courtyard or hire our Landscape company to purchase and install sandbags onto the furniture to prevent removal.

Frequency Monitoring: Administrator/Maintenance Director will conduct a weekly tour of the courtyard to be certain that the furniture remains tied down and unable to be removed from the area by a resident. The goal is to remain in compliance with OAR 411-057-0170.