The findings of the re-licensure survey, conducted 02/20/24 through 02/22/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 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 revisit to the re-licensure survey of 02/22/24, conducted 07/08/24 through 07/09/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 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 second revisit to the re-licensure survey of 02/22/24, conducted  01/06/25 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 third re-visit to the re-licensure survey of 02/22/24, conducted 03/24/25, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

a. Observation of the kitchen on 02/21/24 revealed an accumulation of food spills, splatters, loose food debris, dirt and/or dust on or underneath the following:

* Dry food storage area;

* Hand washing sinks and towel dispensers;

* Refrigerator next to coffee station;

* Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen;

* The coffee and beverage countertop inside the kitchen;

* Walls throughout the kitchen;

* Floors and drains;

* Flooring inside the walk-in refrigerator and freezer;

* Fans inside the walk-in refrigerator;

* The dishwashing area walls, floors, and equipment;

* Black matter on walls above and below dishware machine;

* Food debris on top of dishware machine;

* Behind and underneath appliances;

* Food delivery carts;

* Ceiling vents;

* Fire extinguisher;

* Interior and exterior of the microwave;

* Ice machine vent had a buildup of dust;

* Janitor closet inside the kitchen;

* Stove top, griddle and oven with grease and food debris build-up;

* Can opener; and

* Mixer and mixer stand.

b. The following areas were noted to require repair and/or were not stored, dated or labeled appropriately:

* The dishware machine required repair for broken valves and buttons;  

* Doors and door frames throughout the kitchen had chipped paint, scuffs, gouges, and stains;

* Food was stored on the floor of the freezer;

* Opened and leftover food items that were stored in the refrigerator and walk-in were not consistently dated;

* Scoops were observed stored in food containers in the dry food storage area; and

* Garbage cans in food preparation areas did not have lids when not in use.

The areas that required cleaning and repair were observed and discussed with Staff 1 (ED), Staff 5 (Culinary Director), and 17 (Regional Director) on 02/21/24. They acknowledged the areas that needed cleaning and repair.

1.Areas needing cleaning will get an initial deep cleaning and those needing repair will be repaired.  

2.Kitchen has been provided with a binder containing cleaning logs, daily weekly etc tasks and instructions to refer to. Going forward items that the kitchen needs to do their job will be provided in a timely manner and oversight for areas needing additional attention given.

3.Talk about areas needing attention in daily standup and monthly all forms turned into ED so that any overlooked areas - items can be addressed.  

4.Dietary, Maintenance and Executive Directors.

4. Resident 1 was admitted to facility in 10/2022 with diagnoses including diabetes, chronic knee pain, anxiety, and depression.  

a. The resident's service plan was dated 09/23/23, and the evaluation occurred on 11/22/23. Therefore, the evaluation was not the basis of the resident's service plan.

b. Resident 1's 11/22/23 quarterly evaluation was reviewed and was not reflective of the resident's current status:  

* On-site physician visits;

* Mental health issues including the presence of depression and anxiety, history of treatment, and effective non-drug interventions;

* Activities of daily living including bathing and the use of a shower chair;

* Mobility and assistive devices used;

* Independent activities of daily living including housework;  

* Pain including pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; and

* Facility responsibility to ensure CBGs were taken daily.

The need to ensure quarterly evaluations were used as the basis of the quarterly service plan and the quarterly evaluation was reflective of the resident's current status was discussed with Staff 1 (ED), Staff 3 (Resident Services Manager), and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure evaluations were used as the foundation to develop the resident's service plan, move-in evaluations addressed all required elements, quarterly evaluations were relevant to the needs of residents, and evaluations were updated each time a resident experienced a significant change in condition for 4 of 4 sampled residents (#1, 2, 3, and 6) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility on 01/30/24 with diagnoses including hypertension.

The resident's 01/04/24 move-in evaluation and 01/22/24 service plan were reviewed and there was no documented evidence the following elements were addressed:

* Customary routines including eating;

* Spiritual and  cultural preferences and traditions;

* Interests, hobbies, and social and leisure activities;

* Emergency evacuation ability;

* Recent losses; and

* Alcohol and drug use.

The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED) and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

3. Resident 3 admitted to the facility in 08/2020 with diagnoses including polyneuropathy and prediabetes.

a. Resident 3's service plan was dated 09/16/23, and the evaluation occurred on 11/21/23. Therefore, the evaluation was not the basis of the resident's service plan.

b. Additionally, a 12/18/23 observation note entered by Staff 2 (RN) stated Resident 3 had a Stage 2 wound of the right great toe, which constituted a significant change of condition. There was no documented evidence that the evaluation had been reviewed and updated after this change of condition.

The need to ensure quarterly evaluations were used as the basis of the quarterly service plan and were reviewed and any updates documented each time a resident had a significant change in condition was discussed with Staff 1 (ED) and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.  

2. Resident 2 was admitted to facility in 09/2016 with diagnoses including osteoarthrtis and diabetes.

Resident 2's service plan was dated 09/23/23, and the evaluation occurred on 11/21/23. Therefore, the evaluation was not the basis of the resident's service plan.

The need to ensure quarterly evaluations were used as the basis of the quarterly service plan was discussed with Staff 1 (ED) and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

PROVIDER'S PLAN OF CORRECTION

1.The software August Health was presented to the state by home office and approved. However it lacks several requirements for assessments, service plans and investigations. The community will continue to use August Health per company policy but also have internal paper forms that are OR state compliant. The RN will receive training, support, and the papers needed to document properly. A Service Plan Team will be implemented to reduce errors with service plans.  

2.August Health and state compliant paper forms will be used in order to follow policy as well as the OAR's.

3.Daily at clinical  

4.Executive Director, RN and Resident Services Director.

Resident 1: As the companies software does not currently have the ability to add the missing 5 categories, the community will add a document to the Service Plan with the missing items. Then review quarterly or COC.

Resident 2: a new evaluation will be done and service plan updated accordingly. Service plan will then be reviewed quarterly or COC.  

Resident 3: A new evaluation will be done and change of condition enters with evaluation details. It will then be reviewed quarterly or COC.  

Resident 4: Service Plan will be updated with the mental health status, outside providers, ADL's etc to ensure person centered care. Then it will be reviewed quarterly or COC.  

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the move-in evaluation for 1 of 1 newly admitted resident (# 7).  This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in 06/2024 with diagnoses including congestive heart failure and hypothyroid.

Resident 7's move-in evaluation, dated 6/12/24, was reviewed during survey. The following required elements were not addressed:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

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

* Pain;

* Skin conditions;

* Nutrition habits, fluid preferences and weight if indicated;

* Fall risk, history;

* History of unexplained weight loss or gain;

* Recent losses;

*Smoking; and

* Alcohol and drug use.

The need to address all required elements in the move-in evaluation was discussed with Staff 1 (Executive Director) on 07/09/24. She acknowledged the findings.

PROVIDER'S PLAN OF CORRECTION

1.Resident 7 will have an evaluation that covers all the required elements stated in the OARs.

2.Community has developed a form outside of the companies software August Health that covers all elements in the OARs. Community will ensure that this form is on the floor/signed etc so it is able to be accepted by survey upon entry.

3.Will be reevaluated per OARs: pre admit, 30 days, 90 days, yearly or with COC.

4.ED, RN and RSD.

Based on interview and record review, it was determined the facility failed to ensure service plans were updated quarterly and provided clear direction regarding the delivery of services which included a written description of who should provide the services and what, when, how, and how often the services should be provided for 2 of 6 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 admitted to the facility in 10/2022 with diagnoses including diabetes, chronic knee pain, anxiety, and depression.   

Observations of the resident's room, interviews with staff and Resident 1, review of the resident's service plan, dated 09/23/23, and the Service Plan Detail, dated 09/14/23, were conducted during the survey.

a. There was no documented evidence the resident's service plan had been updated quarterly.

b. The service plan lacked a written description of who shall provide the services and what, when, how, and how often the services shall be provided, was not reflective of the residents current care needs and status and lacked clear direction for staff in the following areas:

* Personality including being very private;

* Resisting assistance with care;

* Staff checks on each shift relating to offering assistance and light housekeeping;  

* Bathing assistance;

* Ordering medications;

* Fall risk and interventions;

* Resistance to housekeeping and interventions; and

* Drug and alcohol use.

The need to ensure service plans were completed quarterly, were reflective of residents' current needs, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED), Staff 3 (Resident Services Manager), and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

2. Resident 3 admitted to the facility in 08/2020 with diagnoses including ataxia and cerebrovascular accident.

The current service plan dated 09/16/23 and Temporary Service Plans from 11/14/23 to 02/13/24 were reviewed, and observations and interviews with staff and Resident 3 were completed during the survey. The following was identified:

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Right leg weightbearing status;

* Use of wheelchair for mobility;

* Skin monitoring;

* Outside provider services;

* Protective covering for right foot during showers;

* Brief changes; and  

* Assistance with escort to meals.

The need to ensure service plans were completed quarterly, were reflective of residents' current needs, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED) and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

1.Service plans that are due upon move in, quarterly, COC and yearly will be directly monitored via August Health and discussed daily at clinical meeting.  

2.Clinical meeting will now be a part of daily routine to ensure service plans are done in a timely manner.  

3.Daily  

4.Executive Director, RN and Resident Services Director.  

Resident 1: Service plan will be redone with the added personal important details for this resident such as resistant to housekeeping, isolation, etc. This will then be reviewed quarterly or COC.

Resident 3: Residents service plan will be updated on residents current status and personal details such as weight barring status, outside providers etc. It will then be updated quarterly or COC.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff, were updated at least quarterly and were consistently implemented by staff for 4 of 4 sampled residents (#s 7, 8, 9 and 10) 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 02/2023 with diagnoses including diabetes and Asperger's syndrome.   

Observations of the resident, interviews with staff, and review of the resident's service plan dated 11/02/23 and progress notes dated 05/14/24 to 06/24/24 were completed. Staff indicated the resident had a recent decline and was not his/her usual self. The resident could do most of his/her ADLs on their own but did require some assistance with toileting/incontinent care. The resident could make his/her needs known and would call for additional staff assistance as needed.

The resident's service plan was not reflective and/or lacked resident specific direction for staff in the following areas:

* Behaviors;

* Incontinent care/toileting;

* Edema; and

* Skin picking and chronic skin breakdown.

The need to ensure resident service plans were reflective of current care needs, were updated quarterly and provided clear direction to staff was discussed with Staff 1 (ED) on 07/09/24. She acknowledged the findings.

2. Resident 10 was admitted to the facility in 10/2017 with diagnoses including multiple sclerosis and diabetes.   

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/06/23, were completed between 07/08/24 and 07/09/24. Staff indicated the resident did not come out of his/her room often. The resident could make his/her needs known and required a small amount of assistance from staff.  

The resident's service plan was not reflective and/or lacked resident specific direction for staff in the following areas:

* Diabetes management and meals;

* Incontinent care/toileting;

* Sleeping location and recliner preference;

* Easily overwhelmed, sensitive to large groups; and

* Side rail use and staff responsibility.

The need to ensure resident service plans were reflective of current care needs, were updated quarterly and provided clear direction to staff was discussed with Staff 1 (ED) on 07/09/24. She acknowledged the findings.

3. Resident 7 was admitted to the facility in 06/2024 with diagnoses including congestive heart failure.

Observations of the resident, interviews with staff and resident 7 between 07/08/24 and 07/09/24, and review of the resident's current service plan dated 06/25/24, temporary service plans, incident report investigations and progress notes dated 06/21/24 through 07/08/24 showed the service plan was not reflective, did not provide clear direction to staff, and/or were not implemented in the following areas:

* Fall risk, history and interventions;

* Cat in apartment, to include direction to staff for care;

* Side rail use and direction to staff for safety monitoring;

* Pain areas and non-pharmaceutical interventions;

* Hand edema with blister, to include direction for staff;

* Use of grabber; and

* Non-skid rug at bedside.

The need to ensure service plans were reflective of resident needs, included clear direction to staff, were implemented and updated quarterly was discussed with Staff 1 (ED) and Staff 9 (Resident Service Coordinator) on 03/08/24. They acknowledged the findings.

4. Resident 9 was admitted to the facility in 08/2021 with diagnoses including diabetes, neurogenic bladder, heart failure and chronic bronchitis.

The current service plan dated 09/23/23 and progress notes and temporary service plans from 04/22/24 through 07/08/24 were reviewed. Observations and interviews with staff and Resident 9 were completed during the survey. The following was identified:

The service plan had not been updated quarterly, was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Medication administration;

* Leg wounds with direction for staff;

* Cat in apartment, to include direction to staff for care; and

* Bed canes bilaterally on bed.

The need to ensure service plans were reflective of resident needs, included clear direction to staff and were implemented was discussed with Staff 1 (ED) and Staff 9 (Resident Service Coordinator) on 03/08/24. They acknowledged the findings.

Resident 8: Resident 8 will have the service plan updated to state that she has Aspergers, behaviors, incontinence care needs, edema, skin picking and chronic skin issues due to this. Service plans will be updated per the OARs: Pre, 30 day, 90 day, yearly, COC.

Resident 10: Resident 10 will have the service plan updated to reflect her diabetes management, incontinence care, sleeping in her recliner, easily overwhelmed in large social situations, side-rail use. She will also have her service plan updated per the OARs: Pre, 30 day, 90 day, yearly, COC.

Resident 7: Resident 7 will have their service agreement updated to state her history of falls, cat in the room, use of side rails, chronic pain, Hand Edema, use of grabber and the non skid rug in her room. Her service plans will be updated per OARs: Pre, 30 day, 90 day, yearly and COC.

Resident 9: Resident 9 will have their service plan updated and reflective of her Med Administration, Leg wounds, cat in the apartment and bed canes bilaterally on the bed. She will have her service agreement updated per the OARs: Pre, 30 day, 90 day, yearly and COC.

2. Service planning team RN, RSD and ED have been redoing all the service agreements for every resident to make sure that they are gone over with the resident/their representative, reflective of current resident specific information, updated per the OARs  and implemented-on the floor for staff and state to use.

3.  Will be completed per the OARs: Pre, 30 day, 90 day, yearly and COC.

4. RN, RSD, and ED.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 2 of 4 sampled residents (#s 11 and 14) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 09/2021 with diagnoses including neuropathy.   

Observations of the resident, interviews with staff and review of the service plan, dated 09/30/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Transfer assistance;

* Transfer board; Skin picking, picking at sores;

* Toileting assistance and incontinent care;

* Pet care needs; and

* Edema and lower extremity skin breakdown.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) on 01/06/25. She acknowledged the findings.

2. Resident 14 was admitted to the facility in 10/2023 with diagnoses including neuropathy and glaucoma.   

Observations of the resident, interviews with staff and review of the service plan, dated 09/29/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Cognition;

* Bathing, grooming, dressing, toileting and hygiene assistance;

* Transfer and ambulation assistance;

* Leg brace;

* Fall history and interventions;

* Hospice services; and

* Evacuation assistance needed.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 3 (RSD) on 01/06/25. They acknowledged the findings.

Resident 11 does not normally want help with transfers. Resident stated that at times she needs help, the community will have transfer assistance added to her service agreement on an as needed basis. Her board is not used by the community only her when going outside of the community. This device and its specific use will be added on to her service agreement. Skin picking, breakdown and edema will be added to skin area of service agreement. There are no pet care needs but the addition of her new cat will be added to her service agreement. Toileting and incontinent care are not normally provided by the community but as was the case with transfers resident stated she needs help at times, this will also be added to her service agreement on an as needed-requested basis.

Resident 14 will have all areas of her service agreement updated to reflect her needs with bathing, grooming, toileting, hygiene, transfers and ambulation. Her leg brace, fall history, hospice services and evacuation assistance will be updated to reflect her current abilities and needs.  

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team which consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services to the resident for 4 of 4 sampled residents (#s 1, 2, 3, and 6) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

During an interview on 02/21/24 at 12:02 pm, Staff 1 (ED) confirmed the facility was not utilizing a Service Planning Team to develop service plans.

On 02/22/24, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 and Staff 3 (Resident Services Manager). They acknowledged findings.

1.A Service Plan Team will be implemented consisting of the RN, RSD and Executive Director, who will be in direct communication with the PCP, Resident and/or POA.

2.Creating the Service Plan Team and open line of communication with the PCP, Resident and/or POA will enable the community to have better checks and balances to help prevent errors.  

3.Daily

4.Executive Director, RN and RSD.

Resident 1: Will have their service plan updated, a care conference scheduled with the service plan team and gone over together to ensure the best possible individualized care.  

Resident 2: Will have their service plan updated, a care conference scheduled with the service plan team and gone over together to ensure the best possible individualized care.

Resident 3: Will have their service plan updated, a care conference scheduled with the service plan team and gone over together to ensure the best possible individualized care.

Resident 6: Will have their service plan updated, a care conference scheduled with the service plan team and gone over together to ensure the best possible individualized care.

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 3 of 4 sampled residents (#s 8, 9 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8, 9 and 10's current service plans were reviewed during the survey.

The service plans lacked evidence 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 (ED) on 07/09/24. She acknowledged the findings.

1. Community Service Plan Team was developed after last survey visit and have been working on every single residents service plans, as well as meeting with every resident-family member involved. Service planning team consists of ED, RN and RSD. Due to needing to do all residents in the building and having to do the paperwork twice (once per company policy in August Health and once on paper to meet state compliance), not all had been put out on the floor before survey came back. The Service Planning Team will make sure that all residents are done in compliance with both the home office and state regulation and are on the floor ready to be viewed for revisit. Residents 8, 9 and 10 will have their updated versions signed and on the floor ready for staff/state.

2. Service Planning Team will continue to work together on meeting with all residents, go over their services to ensure they are reflective of current needs and implement them by having them signed-on the floor by compliance date. We will continue going forward to use both the company service plans.

3: Corrections will be made per the OARs: Pre, 30 day, 90 day, yearly and COC.

4. RN, RSD and ED.      

4. Resident 1 was admitted to the facility in 10/2022 with diagnoses including diabetes and chronic pain.  

Review of the resident's facility record revealed the resident experienced a fall on 12/21/23.

There was no documented evidence the facility determined what action or intervention was needed for Resident 1's fall, or monitored the change of condition with progress noted at least weekly through resolution.

The need to ensure short term changes of condition were evaluated and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), Staff 3 (Resident Services Manager), and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 01/2024 with diagnoses including hypertension.

Review of the resident's 01/30/24 through 02/02/24 progress notes revealed the resident experienced the following short term change of condition:

* 01/30/24 - Admission to the facility.

There was no documented evidence the facility monitored the change with progress noted at least weekly through resolution.

The need to ensure short term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED)  and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who had changes of condition had resident-specific instructions or interventions determined and documented, communicated to staff on each shift, and the conditions were monitored at least weekly through resolution for 4 of 4 sampled residents (#s 1, 2, 3, and 6) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 3 admitted to the facility in 08/2020 with diagnoses including polyneuropathy and prediabetes.

The resident's current service plan dated 09/16/23, Temporary Service Plans,  progress notes dated 11/14/23 through 02/13/24, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 02/20/24 and 02/22/24.

The resident experienced multiple short term changes of condition as outlined:

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

* 11/14/23 - Right big toe blister;

* 01/13/24 - Found on floor, non-injury fall;

b. The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution:

* 11/14/23 - New medication, antibiotics;

* 12/09/23 - Fall with skin tear;

* 01/03/24 - Non-injury fall;

* 01/14/24 - Missed medications; and

* 02/13/24 - New medications.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED) and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

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

The resident's current service plan, dated 09/23/23, and progress notes, dated 12/12/23 through 12/15/23, were reviewed. Observations of the resident and interviews with caregivers were completed between 02/20/24 and 02/22/24.

The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution:

* 12/12/23 - Cortisone injection in left shoulder.

The need to ensure short term changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED) and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

1.RN was hired around the time this resident moved in. RN had no prior LTC knowledge and was not given the proper training. ED then left in Nov. RN will be given the needed training, resources, support and forms to be able to confidently do her job.  

2.Rn will have the needed training, support, followup and forms to do her job effectively.  

3.Weekly

4.Resident Services Director and Executive Director.

Resident 3: As we cannot go back and document on what was not done prior, we will reassess for current condition and staff will be trained on how to properly document. RN RSD and RSC will double check this is occurring going forward.

Resident 6: As we cannot go back and document on what was not done prior, New Admit To Community will be resolved, staff educated and monitored going forward by RN RSD and RSC.

Resident 2; As we cannot go back and document on items that were not previously documented on, we will resolve the injection document if appropriate. If not documentation will be made and followed thru with. Staff will be educated on documenting procedures and monitored going forward by RN RSD and RSC.

Resident 1: As we cannot go back and document on what was not documented on prior, we will educate staff on the importance, proper use of and need for interventions. RN RSD and RSC will monitor for continued follow thru in this area.  

3. Resident 7 was admitted to the facility in 06/2024 with diagnoses including congestive heart failure.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 06/25/24, progress notes, temporary service plans and incident reports dated 06/21/24 through 07/08/24 were completed.

The resident experienced multiple short-term changes without documented actions/interventions developed, monitoring of progress at least weekly until resolution and/or lacked resident-specific directions to staff as determined in the following areas:

* 06/21/24: New to facility;

* 06/27/24: Return from hospital for rectal bleeding;

* 06/30/24: Fall with  injury;

* 07/03/24: Right hand swelling with fluid filled blister; and

* 07/03/24: Increase in Lasix and Potassium medications.

The need to ensure short-term changes of condition had interventions and/or actions developed, documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff as determined was discussed with Staff 1 (ED) and Staff 9 (Resident Service Coordinator) on 07/08/24. They acknowledged the findings.  No further information was provided.

4. Resident 9 was admitted to the facility in 08/2021 with diagnoses including diabetes, heart failure, chronic bronchitis and neurogenic bladder.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 09/23/23, progress notes, incident report and temporary service plans dated 04/22/24 through 07/08/24 were completed.

The resident experienced short-term changes without documented monitoring of progress at least weekly until resolution and lacked resident-specific directions to staff  in the following areas:

* 05/14/24: Insulin order change; and

* 06/16/24: Incident with burn wounds to legs.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff  was discussed with Staff 1 (ED) and Staff 9 (Resident Service Coordinator) on 07/08/24. They acknowledged the findings.  No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure significant changes of condition were referred to the facility RN, actions and interventions were determined, communicated with staff and implemented, interventions were evaluated for effectiveness, determined additional interventions as indicated and monitored progress weekly through resolution for 3 of 4 sampled residents (#s 7, 8 and 9) with changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 02/2023 with diagnoses including diabetes and Asperger's syndrome.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 11/02/23 and progress notes dated 05/14/24 to 06/24/24 were completed.

a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Falls;

* Large bruise;

* Rash to thigh and groin;

* Hospital admit and ER visit; and

* Weight changes.

b. Review of the resident's weight records from May 2024 to June 2024, showed a 14-pound loss, which constituted a significant weight loss of 5.18%. Additionally, the resident experienced a 5.08% gain from 06/06/25 to 07/06/24. Staff 2 (RN) indicated she was not aware the resident had experienced a weight loss or gain. Staff 2 did not complete a significant change assessment for the weight loss or gain. Staff 2 indicated she would start an assessment for the change discovered on 07/06/24 as soon as possible. The weight change was noted two days prior to survey entrance.  

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/09/24. The staff acknowledged the findings.  

1.Residents 8: Resident 8 had multiple short term changes including falls, bruise, admit to ER etc that were not monitor weekly until resolution, the interventions put in place were not evaluated for effectiveness, nor implemented with proper clear resident specific directions for staff. Additionally resident 8 had a 5% drop in weight then a 5% gain that constitutes a sig change. Going forward short term changes will be monitored/documented on at least weekly in Aug Health until resolved, interventions put in place on investigations (Aug Health and paper form) will be discussed- evaluated for effectiveness and implemented with resident specific direction for the staff via TSP. Sig changes or perm changes will be added to the residents service agreement.  

      Resident 7: Resident 7 had multiple short term changes including      new to facility, return from hospital, fall with injury etc. that were not monitor weekly until resolution, the interventions put in place were not evaluated for effectiveness, nor implemented with proper clear resident specific directions for staff. Going forward short term changes will be monitored/documented on at least weekly in Aug Health until resolved, interventions put in place on investigations (Aug Health and paper form) will be discussed- evaluated for effectiveness and implemented with resident specific direction for the staff via TSP. Sig changes or perm changes will be added to the residents service agreement.  

       Resident 9: Resident 9 had multiple short term changes including insulin order change and burn with wound to legs that were not monitor weekly until resolution, the interventions put in place were not evaluated for effectiveness, nor implemented with proper clear resident specific directions for staff. Going forward short term changes will be monitored/documented on at least weekly in Aug Health until resolved, interventions put in place on investigations (Aug Health and paper form) will be discussed- evaluated for effectiveness and implemented with resident specific direction for the staff via TSP. Sig changes or perm changes will be added to the residents service agreement.  

2RN received instruction on the role of the RN with regards temp COC and sig COC and time to be completed. Daily clinical meetings will include going over that short term changes are being monitored/documented on at least weekly in Aug Health until resolved, that the interventions put in place on investigations (Aug Health and paper form) are discussed- evaluated for effectiveness and have been implemented with clear resident specific direction for the staff via TSP and that sig changes or perm changes are being added to the residents service agreement.  

3 Every am at clinical meeting.

4RN, RSD, RSC and Med Aids.      

2. Resident 11 was admitted to the facility in 09/2021 with diagnoses including anxiety.   

The resident's 09/30/24 service plan, 11/09/24 through 01/04/25 progress notes, temporary service plans and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:

* Cellulitis, red and weepy legs;

* Edema and scratches; and

* Antibiotic use.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 01/06/25. She acknowledged the findings.

3. Resident 12 was admitted to the facility in 10/2018 with diagnoses including visual impairment.   

The resident's 12/16/24 service plan, 11/08/24 through 12/19/24 progress notes, temporary service plans and physician communications were reviewed.

The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas:

* Loose pills on the floor;

* Diarrhea;

* Behaviors including aggression and agitation;

* Resistance to care;

* Weakness and legs "not working;" and

* Falls.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED) on 01/06/25. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced short-term changes of condition had resident-specific actions or interventions determined and documented, and residents' changes of condition were monitored consistent with evaluated needs with progress noted at least weekly to resolution for 3 of 4 sampled residents (#s 11, 12 and 14) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 14 was admitted to the facility in 10/2023 with diagnoses including neuropathy and glaucoma.   

The resident's 09/29/24 service plan, 10/31/24 through 01/06/25 progress notes, temporary service plans and physician communications were reviewed.

The resident experienced multiple short-term changes without resident-specific actions or interventions determined and documented, and  progress noted weekly until resolved in the following areas:  

* 09/29/24: Fall with head strike and left hip/groin pain, sent to ER and returned;

* 09/30/24: Family transported to ER for severe left hip and groin pain.  Returned from ER on 10/01/24 with determination of no fracture identified;

* 10/03/24: Increased confusion, decline in mobility, weakness, one to two person assist to sit him/her up and unable to stand to shower;

* 10/08/24: No longer able to ambulate, wheelchair use only;

* 10/14/24: Difficulty swallowing medications with order to crush all medications;

* 10/17/24 Discontinued pain medication hydrocodone;

* 11/13/24: Fall with left cheek laceration;

* 11/15/24: Red area coccyx;

* 10/20/24: Hospice admission;

* 12/17/24: Non-injury fall; and

* 01/06/24: Fall with abrasion to right elbow and bruising.

The need to ensure short-term changes of condition had resident-specific actions or interventions determined and documented progress noted weekly until resolution was discussed with Staff 1 (ED) and Staff 3 (RSD) on 01/06/25. They acknowledged the findings.

The RSD and RN will ensure that all TSPs, alerts (forms of short term monitoring) have resident specific interventions. A copy of the TSP will be in the care binder and the 24 hr book until resolve. Care staff will be reminded at shift change it is their responsibility to look at TSPs in the care binder. Interventions will be documented on per OAR and policy requirements weekly etc. At the end of the monitoring period the intervention will be resolved as succesful or not. If successful it will be added to the service agreement.

Resident 14 will have all successful interventions for documented incidents-short term monitoring on 9.29, 9.30, 10.1, 10.3, 10.8, 10.14, 10.17, 10.20, 11.13, 11.15, 12.17, and 1.06 added to her service agreement.

Resident 11 will have all successful interventions for documented changes in skin added to her service agreement.

Resident 12 will have all successful interventions for documented incidents-short term monitoring in regards to behaviors, weakness and loose stools added to her service agreement.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (# 3) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 08/2020 with diagnoses including polyneuropathy and prediabetes.

A review of the resident's clinical record between 11/14/23 and 02/13/24 identified the following:

* An order from Resident 3's primary care provider, dated 11/27/23 for referral to wound care for wound and cellulitis to right great toe;

* Resident 3 was first seen by the wound clinic on 11/30/23 with instructions for "[Patient] to wear post-op shoe to right foot.";

* Resident 3 was admitted to home health for wound care to right big toe on 12/13/23; and

* An observation note dated 12/18/23 entered by Staff 2 (RN) stated, "Wound assessed. Stage II wound 1 cm x 1 cm on [right] great toe. No drainage noted."

The right great toe wound stage two constituted a significant change in condition requiring a facility RN assessment.

There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment.

On 02/21/24, the surveyor observed Resident 3 had a post-op shoe donned to the right foot.

During a phone interview on 12/22/24 at 12:10 pm, Staff 2 confirmed an RN assessment had not been completed, and the wound care clinic and home health services were directing the care for Resident 3's toe wound. She confirmed that Resident 3 had a non-removable dressing placed by home health and was unable to observe the wound this week.

The need to ensure the RN at minimum assessed all residents with a significant change of condition was reviewed with Staff 1 (ED) Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

1.RN was hired around the same time the resident entered the community. RN had no prior LTC knowledge. RN was not given proper training. ED then left in Nov. RN will be provided with the training, guidance, support, forms and follow up to effectively do her job duties.  

2.RN will have the needed training, support, paperwork and follow up to do her job with confidence.  

3.Weekly

4.Resident Services Director and Executive Director.  

Resident 3: RN assessment will be done and COC. As well as proper weekly documentation on toe (skins report).  

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 1 of 1 sampled residents (#8) who experienced significant weight loss. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 02/2023 with diagnoses including diabetes and Asperger's syndrome.   

Weight records, dated May 2024 through July 2024 and progress notes, dated 05/14/24 to 06/24/24, indicated the resident experienced the following:

* A 14-pound weight loss between 05/2024 and 06/2024, which constituted a 5.18% significant loss in a month.

The resident's weight increased 5.07% between June and July 2024. A significant change of condition was started after Staff 2 (RN) was made aware of the resident's gain.

Progress notes, temporary service plans, and physician communications dated 05/14/24 to 07/09/24 indicated the resident was independent with meals. The resident was provided regular textures and could make his/her needs known. The resident had ongoing processing delays with some confusion that was not at his/her baseline. The physician suspected possible TIAs (mini strokes).

Observations of the resident between 07/08/24 and 07/09/24 showed the resident in and out of his/her apartment. The resident could take himself/herself to the dining room and back up to his/her apartment. The resident's lower legs and feet were noted to have edema (excess fluid collection). The resident was observed to eat 100% of food and fluids provided at meals and snacks.

Interviews with staff and the resident on 07/08/24 and 07/09/24, showed the following:

Resident 8 indicated s/he received plenty to eat and drink. The resident had food and fluids in the apartment as well as the food provided by the facility. The resident indicated s/he sometimes ate in the dining room and sometimes in his/her apartment. The resident expressed no concern regarding the care s/he received or his/her meals.

Staff 23 (MT) indicated the resident had a recent change and was not quite himself/herself. The resident could still do many of his/her ADLs independently, but the resident was "off." Staff 23 stated the resident ate meals without assistance both in the dining room and in his/her apartment and could make his/her needs known. The resident had ongoing edema that was treated with a diuretic (medication to remove the excess fluid).

Staff 2 (RN) indicated the resident could eat on his/her own and had good intake. The resident ate in his/her apartment as well as in the dining room. Staff 2 was unaware of the resident's weight fluctuations over the last few months. Staff 2 further indicated the resident currently had significant edema, which was a chronic issue. Staff 2 did not complete a significant change of assessment of the weight changes prior to the surveyor request for information.

No RN assessment could be located for the significant weight loss.

The facility failed to ensure an RN assessment was completed for the resident's weight loss, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/09/24. The staff acknowledged the findings.  

1.Resident 8: Resident 8 had a 5% weight loss followed by a 5% gain in weight over a two month period indicating a sig weight change. No RN assessment for weight loss was done, nor a change in resident status and interventions, clear resident specific instructions for staff were not implemented based on that RN assessment. Going forward short term changes will be monitored/documented on at least weekly in Aug Health until resolved, interventions put in place on investigations (Aug Health and paper form) will be discussed- evaluated for effectiveness and implemented with resident specific direction for the staff via TSP. Sig changes or perm changes will be communicate with and then assessed by the RN, added to the residents service agreement.

2.Going forward short term changes will be monitored/documented on at least weekly in Aug Health until resolved, interventions put in place on investigations (Aug Health and paper form) will be discussed- evaluated for effectiveness and implemented with resident specific direction for the staff via TSP. Sig changes or perm changes will be communicate with and then assessed by the RN, added to the residents service agreement.

3.Daily Clinicals, Monthly weight submissions

RN, RSD, RSC and ED.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 2 of 3 sampled residents (#s 11 and 14) who experienced significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 09/2021 with diagnoses including arthritis.   

Observations of the resident, interviews with staff, review of the service plan, dated 09/30/24 and 11/09/24 through 01/04/2025 progress notes, physician communications, and 11/07/24 through 01/06/25 weight records were completed.

The resident required partial assistance with some of his/her ADLs. The resident was independent with intake and able to eat and drink without staff assistance. The resident was alert and oriented and could make needs known and direct his/her own care.

Multiple observations of the resident on 01/06/25 showed the resident in his/her wheelchair primarily in his/her apartment. The resident ate lunch in his/her apartment and was independent after delivery. The resident was noted to have a few snack items in his/her kitchen. The resident's lower legs had significant edema to both sides, with wraps in place.

Weight records for 11/2024 through 01/2025 showed the following:

* A 13.3-pound weight loss between 11/07/24 and 12/07/24, which constituted an 8.43% loss in one month.

* A 19.7-pound weight gain between 12/07/24 and 01/06/25, which constituted a 13.65% weight gain in one month.

A current weight was obtained for the resident on 01/06/25 which showed the above noted 13.65% gain in one month.

In an interview on 01/06/25, the resident indicated s/he received plenty to eat and drink. The resident had no concerns with the amount of food s/he received. The resident indicated s/he had some items in his/her kitchen, utilized outside food delivery as well as online shopping when the resident wanted or needed anything. The resident stated his/her legs were frequently swollen and s/he should get them elevated more often.

In an interview on 01/06/25, Staff 1 (ED) indicated she could not locate any information on a reweigh of the resident or a significant change assessment related to his/her weight. Staff 1 stated there were problems with one of the scales recently and it was replaced. The resident eats well and has chronic swelling to his/her legs.

The facility RN was out of the facility and was not interviewed regarding the resident's weight changes.

The facility failed to ensure an RN assessment was completed for the weight loss and gain which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED) on 01/06/25. She acknowledged the findings.

2. Resident 14 was admitted to the facility in 10/2023 with diagnoses including neuropathy and glaucoma.

During the acuity interview on 01/06/25, Staff 3 (RSD) reported the resident had a significant decline in 10/2024, and was now improving, although continued to be "heavy care" for ADLs.

Observations of Resident 1 during survey revealed he/she was assisted with transfers, toileting and ambulation using a walker.  

Interviews with staff and review of the resident's 09/29/24 service plan, temporary service plans, and 08/23/24 through 01/06/25 progress notes, were completed.

The service plan dated 09/29/24, indicated the resident was independent with transfers, toileting and ambulation using a walker, and was independent with dressing, grooming and basic hygiene.

The progress notes revealed a fall on 09/29/24 which resulted in a left hip injury with resultant severe left hip and groin pain. On 10/03/24 the resident was identified as having increased confusion, increased assistance of  one to two staff for bed mobility and transfers. On 10/08/24 the resident was unable to ambulate and used a wheelchair exclusively for mobility. On 10/20/24 Resident 14 was placed on hospice services.  

During an interview with Staff 29 (CG) on 01/06/25, she reported that Resident 14 was independent in most areas prior to the 09/29/24  fall. She stated the resident became very confused, painful, and required two person assist for transfers and full assist for all ADLs, including meal assistance.  Staff 29 stated the resident had since improved some although continued to require full staff assistance for all ADL's and assist with transfers and ambulation using the walker for safety.  

During an interview with Staff 1 (ED) on 01/06/25, she reported an RN assessment had been not been completed for Resident 14's significant change of condition.

The need to ensure an RN assessment was completed for significant changes of condition which included resident status and interventions made as a result of the assessment was discussed with Staff 1, and Staff 3 on 01/06/25. No further documentation was provided and staff acknowledged the findings.

RSD and RN will ensure that any sig change of condition along with any interventions is documented in a timely manor per policy and OAR. 24 hour book and care binder will be check regularly to ensure nothing is overlooked.

The community has for some time used multiple scales. Some scales were found to be inaccurate so all weights will be done on the upstairs wheelchair scale going forward to help with discrepencies.

Resident 11 has been reweighed and scale descrepency documented in her chart.

Resident 14 is back at baseline with the occassional need for assistance. This will be updated in her service agreement.   

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 (# 2) 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.

Resident 2 was admitted to facility in 09/2016 with diagnoses including osteoarthrtis and diabetes.

1. During the acuity interview on 02/20/24, Resident 2 was identified to be administered insulin injections by non-licensed staff.

Resident 2's MARs, reviewed from 02/01/24 - 02/20/24, revealed insulin had been given by Staff 10, 18 and 19 (MTs) on several occasions.

Review of Resident 2's delegation documentation on 02/21/24 revealed there was no documented delegation completed for Staff 10, 18 and 19.

In an interview on 02/22/24 at 3:30 pm, Staff 2 (RN) stated she had completed the initial delegation for Staff 10, 18, and 19. No additional documentation was available during the survey.

2. Review of Resident 2's delegation documentation during the survey revealed the following:

The initial delegation for Staff 4 (RSM), 21 (MT), and 22 (MT), completed on 10/11/23 lacked the following:

* Rationale for subsequent reassessment of client;

* Rationale for subsequent re-delegation and time frame for unlicensed staff; and

* Unlicensed Staff #s 4, 21, and 22 were not re-delegated within 60 days of their initial delegation.

In an interview on 02/22/24 at 3:30 pm, Staff 2 (RN) stated she was aware she was behind in her re-delegation.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 3 (RSM) and Staff 17 (Regional Director) on 02/22/24. They stated Staff 10, 18 and 19 would not give insulin until the re-delegation was completed.

1.RN hired with no prior LTC knowledge and not given the proper training. Then the ED left in Nov. RN will get the proper training, support, follow up, and forms to be able to complete her job as needed.  

2.RN to get the training, support, follow up and forms needed to do her job effectively.  

3.Weekly

4.Resident Services Director and Executive Director.     

Resident 2: Residents insulin will be gone over, staff delegated properly and follow up by RSD, RSC and RN to ensure accuracy.  

2. Resident 1 was admitted to the facility in 10/2022 with diagnoses including diabetes and anxiety.

The resident and staff were interviewed, and Resident 1's medical chart including the MAR, dated 02/01/24 through 02/20/24, and an "Outside Agency Documentation" form dated 01/23/24 were reviewed. The following recommendation was made:  

* "Do daily am glucose checks" relating to "out of control A1C [a test to measure average sugar levels]."

On 02/21/24 at 11:14 am, Resident 1 confirmed talking to the physician about the facility doing his/her glucose checks as s/he "just can't poke myself." The resident also confirmed that staff had not been checking his/her glucose levels.

During an interview on 02/21/24 at 11:55 am, Staff 3 (Resident Services Manager) confirmed the facility was not checking Resident 1's glucose as the resident self administered his/her oral diabetic medications.

The need to ensure staff were informed of new interventions and the service plan was updated as needed after on-site health services were provided was discussed with with Staff 1 (ED), Staff 3, and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided for 2 of 2 sampled residents (#s 1 and 3) who received on-site health services. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2020 with diagnoses including polyneuropathy and prediabetes.

The "Outside Agency Documentation" forms dated 11/30/23 through 02/12/24, were reviewed and revealed the following recommendations:  

* 11/30/23 - "[Patient] to wear post-op shoe to right foot.";

* 12/12/23 - "Wear Velcrow shoe [at] all times when out of bed. [Non weightbearing right] foot except for transfers. Cover the [right] foot when in shower - can use glove and coban/tape to cover and make waterproof.";

* 12/15/23 - "If dressing falls off - replace with clean, dry dressing of choice to keep dry until next Home Health visit.";

* 12/19/23 - "Please offer pain medication, elevate foot and report any [signs/symptoms] of infection, including redness, pain, odor, purulent drainage and/or fever. Please keep wound clean and dry.";

* 12/26/23 - "Please cover wound with bag to keep dry with showering. Important to keep wound clean and dry. Please report any [signs/symptoms] of infection including increased reddness, purulent drainage, increased pain, and/or fever.";

* 01/12/24 - "Monitor bandage for soiled, wet, or dirty. Rewrap toe if this is found."; and

* 01/20/24 - "[Resident 3] is to still be wearing [his/her] surgical shoe until otherwise stated by wound care clinic."

Resident 3 was observed to be wearing post-op shoe to right foot on 02/21/24 and 02/22/24.

There was no documented evidence the facility updated the resident's service plan as necessary after being informed of the new interventions.  

The need to ensure staff were informed of new interventions and the service plan was updated as necessary after on-site health services were provided was discussed with with Staff 1 (ED) and Staff 3 (Resident Services Manager). They acknowledged the findings.

1.Service plans will be updated in accordance with the OAR's and be made available to staff at all times. A TSP binder has been made for care staff. TSPs with interventions will be place in the care TSP binder and in the 24 hr binder for med aids. Staff trained on the importance of, how to use and document interventions according to OAR's. August Health will be used according to company policy but due to the lacking section for interventions on investigations, the community will also keep on file a paper investigation form with the OR state compliant sections including interventions.

2.Will discuss daily in clinical meeting.  

3.Daily

4.Nursing department and Executive Director.  

Resident 3: Recommendations will be reviewed and added to service plan as well as staff informed of changes via tsp and shift report.  

Resident 1: Community will check glucose per Drs orders.      

4/22/24

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility on 01/2024 with diagnoses including recurrent urinary tract infections.

The resident's 02/01/24 through 02/20/24 MAR and signed physician's orders, dated 01/25/24 were reviewed on 02/20/24. The following was identified:

* Resident 6 had a physician order to receive doxycycline 100 mg (for infection) two times daily.

There was no documented evidence the medication was administered twice daily between 02/01/24 and 02/20/24 as prescribed.

In a 02/20/24 interview with Staff (MT), she confirmed the order to administer doxycycline 100 mg two times daily to Resident 6 was not followed as prescribed.  

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 10/2022 with diagnoses including diabetes and anxiety.

The resident's MAR, dated 02/01/24 through 02/20/24, and physician's orders were reviewed and the following was identified:  

* On 01/23/24, the physician signed an order for the facility to "Do daily am glucose checks" relating to "out of control A1C [a test to measure average sugar levels]."

On 02/21/24 at 11:14 am, Resident 1 confirmed talking to the physician about the facility doing his/her glucose checks and reported that staff had not been checking his/her glucose levels.

During an interview on 02/21/24 at 11:55 am, Staff 3 (Resident Services Manager) confirmed the facility was not checking Resident 1's glucose as the resident self administered his/her oral diabetic medications. He also confirmed the physician was not contacted for clarification of the signed order.  

The need to ensure physician orders were carried out as prescribed was discussed with with Staff 1 (ED), Staff 3, and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

1.The nursing dept will have daily clinical meetings and go over all orders for the past 24 hours for accuracy.  

2.Nursing department will implement and carry out daily clinical meetings in which all orders for the previous 24 hours will be gone over for accuracy.  

3.Daily

4.RSD, RCC and Med Aids.  

Resident 6: Residents medication orders will be gone thru for accuracy in the MAR and reviewed by RN, RSD, RSC for proper entry.  

Resident 1: Residents medication orders will be gone thru for accuracy in the MAR and reviewed by RN, RSD, RSC for proper entry.

3. Resident 1 was admitted to the facility in 10/2022 with diagnoses including diabetes.

During the acuity interview on 02/20/24, the resident was identified to manage his/her own medications.

Resident 1's facility medical record and 02/01/24 through 02/20/24 MAR revealed the following:

The resident self-administered the following medications:

* Glipizide (for high blood sugar); and

* Metformin (for diabetes).

On 02/20/24, the quarterly evaluation to assure the ability to safely self-administer medications and the physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications were requested from Staff 3 (Resident Services Manager). On 02/20/24 at 3:34 pm, Staff 3 confirmed there was no quarterly evaluation or physician's order for Resident 1 to self-administer his/her medications.

On 02/21/24 at 11:14 am, Resident 1 verified s/he self-administered the above mentioned medications.

The need to complete self-administration evaluations quarterly and have a physician's order of approval was discussed with Staff 1 (ED), Staff 3, and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 06/2023 with diagnoses including hypertension.

During the acuity interview on 02/20/24, the resident was identified to manage his/her own medications.

During an interview on 02/21/24 at 10:04 am, Resident 4 stated s/he managed his/her own medications.

A review of Resident 4's clinical record revealed there was no documented evidence the facility evaluated Resident 5's ability to safely self-administer the medications.

The lack of evaluation of the resident's ability to self-administer medications was reviewed with Staff 1 (ED) and Staff 3 (Resident Services Manager) on 02/22/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications, for 3 of 3 sampled residents (#s 1, 2 and 4) who administered their own medications or had medications kept in their unit. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2016 with diagnoses including keratosis and psoriasis.

Review of Resident 2's MAR dated 02/01/24 through 02/20/24 and current physician's orders  indicated Resident 2 was self administering the following medications:

* Betameth cream (for keretosis);

* Hydrocortisone cream (for itch);

* Nystatin powder (for skin care); and

* Albuterol inhaler (for wheezing).

A self-medication evaluation to determine the resident's ability to safely self administer medications was completed on 07/21/2021. There were no quarterly evaluations completed. There was no physician's order for Resident 2 to self-administer his/her own medications.

The need to complete evaluations of a resident's ability to self administer medications at least quarterly and have a physician's order to self-administer and was discussed with Staff 1 (ED), and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

1.All residents in the community who self med administer have been identified and assessed. Binder for nursing department made with all needed assessments and instruction for future reference on what to do with each provided.

2.Residents living in the community already who self med have been identified and assessment done. Going forward new residents will be assessed at move in. Binder containing all needed assessments according to OAR's and company policy provided to the nursing dept along with instruction for reference.  

3.Quarterly

4.RN and Resident Services Director.

Resident 2: Self med assessment will be done and updated quarterly. Drs order for self administration will be obtained.  

Resident 4: Resident will be evaluated to administer Resident 5's medications. It will be updated quarterly. Drs order will be obtained.  

Resident 1: Self med assessment will be done and updated quarterly. Drs order for self administration will be obtained.  

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who chose to self-administer their medications was evaluated at least quarterly to ensure their ability to safely self-administer, for 1 of 1 sampled residents (#8) who administered their own medications. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 02/2023 with diagnoses including diabetes and Asperger's syndrome.   

During the acuity interview on 07/08/24, the resident was identified to manage his/her own medications.

During an interview on 07/09/24 at 11:40 am, Resident 8 stated s/he managed his/her own medications.

A review of the resident's record showed not current evaluation of the resident to safely self-administer their own medications. The last evaluation was dated 07/21/21.

The need to ensure an evaluation of the resident's ability to safely self-administer medications, was done at least quarterly was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/09/24. They acknowledged the findings.

1. Resident 10 had a self medication administration assessment done but it had not been updated this quarter. She was missing her quarterly assessment. Resident 10 has had her quarterly self administration assessment redone, her name was added to the self administered list and it will continue to be done on time. A nursing assessment tracker has been developed for the RN to keep track of when each residents assessments are due. A binder was also made containing all assessments needed and laid out in order for easy use.

2.A nursing assessment tracker has been developed for the RN to keep track of when each residents assessments are due. A binder was also made containing all assessments needed and laid out in order for easy use.

3.Quarterly or if COC.

4.RN, RSD and ED.

Based on observation, interview, and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed for assistive devices with potentially restraining qualities for 1 of 1 sampled resident (# 2) who had a supportive device. Findings include, but are not limited to:

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

During the entrance conference on 02/20/24, Resident 2 was identified as having bilateral siderails on his/her bed.

Observations of the resident and the resident's room showed the quarter length siderails were on the bed and in the up position.  The devices were used for bed mobility and/or to minimize falls from bed and were devices with restraining qualities.

Review of Resident 2's record revealed there was no documented evidence an assessment of the siderails had been completed by an RN, PT or OT. There was no documented evidence that Resident 2's siderails were assessed quarterly.

In an interview on 02/21/24 at 01:00 pm, Staff 3 (Resident Care Manager) stated no assessment had been completed for Resident 2's siderails.

The lack of an assessment for the resident's siderails was discussed with Staff 1 (ED) and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

1.All residents currently living in the community with assistive devices have been identified and assessed. Nursing dept. provided with a binder containing all needed assessments and instruction for reference. RN given training on how, when, why etc assessments are to be completed.  

2.Nursing dept and RN given the guidance, documentation, and support to complete needed assessments, quarterly follow up.

3.Quarterly

4.RN, RSD and ED.

Resident 2: An evaluation for assistive devices with restraining qualities will be done by RN, PT or OT and updated according to OARs going forward.

2. Resident 10 was admitted to the facility in 10/2017 with diagnoses including multiple sclerosis and diabetes.   

Observations of the resident, interviews with staff, and review of the resident's service plan dated 06/06/23 showed the resident had half side rails on each side of the bed, at the head of the bed. The resident was able to transfer himself/herself but would sometimes request assistance from staff. The resident indicated s/he used the rails to position in bed and to balance at the edge when transferring.

Review of the resident's record showed no documented assessment or evaluation of the side rails since 06/15/2022.

The need to complete an assessment and the required components for the use of devices with restraining qualities at least quarterly was discussed with Staff 1 (ED) and Staff 2 (RN) on 07/09/24. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, document other less restrictive alternatives were evaluated prior to the use of the device, instruct caregivers on the correct use and precautions related to the use of the device, and include the use of the supportive device on the service plan for 2 of 2 sampled residents (#s 7 and 10) who used a supportive device with restraining qualities. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 06/2024 with diagnoses including congestive heart failure.

On 07/09/24, a hospital bed was observed to have bilateral, third-length siderails. Both siderails were in the up position and were securely fastened to the bed.

Resident 7 reported that the side rails were placed because she had multiple falls from rolling off his/her bed prior to admission to the facility. She stated they did not prevent her from getting out of bed.

Review of Resident 7's service plan dated, 06/25/24, revealed there was no documentation of the use of supportive devices with restraining qualities included in the resident service plan.

During an interview on 07/09/24 at approximately 2:00 pm, Staff 1 (ED) verified there was no documented evidence an assessment of the device with restraining qualities had been completed.

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and documentation of their use was included in the resident service plan was discussed with Staff 1. She acknowledged the findings.

1.Resident 7 has had her assistive device assessment done-orders received. Her bed was brought in on a weekend on 6/29/24 via family without community knowledge. Staff have been advised any time any type of new device-bed-wheelchair etc arrive in the community to advise management immediately and document in care binder/August Health so that the proper paperwork can be put in place.

Resident 10 has had her assistive device quarterly assessment done/along with orders on file in her chart.

2.A nursing assessment tracker has been developed for the RN to keep track of when each residents assessments are due. A binder was also made containing all assessments needed and laid out in order for easy use. Morning clinical meetings and the whiteboard for new information should also communicate these changes as they occur so that things are not overlooked.

3.Daily in clinicals and this coming staff meeting.

4.RN, RSD, and ED.

Based on observation, interview, and record review, it was determined the facility failed to ensure devices with restraining qualities were assessed at by an RN, OT or PT to determine safety of the device, the risks vs benefits for the resident and if the least restrictive option was utilized for 1 of 1 sampled resident (# 12) who had a siderail. This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 01/06/25, Resident 12 was identified to have a device with potentially restraining qualities related to use of a siderail on his/her bed.

Resident 12 was admitted to the facility in 10/2018 with diagnoses including visual impairment.   

Observations of the resident, interviews with staff, and review of the resident's service plan dated 12/16/24 showed the resident had a half siderail on the right side at the head of the bed.

Review of the resident's record showed no documented assessment, completed by an RN, PT or OT, for the use of the siderail. The resident's service plan did not provide information to staff related to the device, safety/maintenance items to watch for or how to use the device with the resident.  

The need for a PT, RN or OT to complete an assessment of any device with restraining qualities, was discussed with Staff 1 (ED) on 01/06/25. She acknowledged the findings.

RSD and RN will keep a log and track who has a device and its needed update date. Care staff will document in the care binder if they see any new devices in apartments

It was found that since this community as a whole is very independent -very low aquity, most residents still drive, travel, own other houses etc. Often times residents bring in devices and do not tell us. We do not go into everyones apartment every day due to the independent nature of the residents here (they come and go) plus the new HCBS rule (if we are not told we can enter we cannot). As such, in an effort to not miss anything, a notice will be sent out to current residents advising them that if any device is brought into the community to please let nursing know.

Resident 12s apartment contains two devices. A pole and a side rail. The pole assessment was done properly and put in chart. The side rail was missed. Have gone over with RSD and RN that each device in the apartment needs to have its own assessment. Assessment will be completed and put in chart.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in to the facility and failed to have an accurate number of minutes for each resident to ensure the staffing plan developed met the 24 hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:

The facility's ABST was reviewed on 02/21/24 and revealed the following:

* Resident 6 was added to the ABST 22 days after admitting to the facility;

* Two unsampled residents who were reflected in the ABST no longer lived at the facility; and

* Two unsampled residents who currently lived at the facility were not entered into the ABST.

The need to ensure the ABST was updated before a resident moved into the facility and was accurate for the staffing plan to meet the 24 hour scheduled and unscheduled needs of residents was discussed with Staff 1 (ED), Staff 3 (Resident Services Manager) and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

1.Community has been working on ABST with state as no prior system was established. Service Plan Team will input ABST at the same time as initial Service Plan-Contract is done to ensure it is completed in a timely manor.

2.Service Plan Team will complete ABST with the initial service plan and contract prior to move in.

3.Quarterly

4.RN, RSD and ED.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 8, 10, and 12) completed pre-service orientation training prior to beginning their job responsibilities and 2 of 4 kitchen staff (#s 14 and 15) who prepared and served food had an active food handler's certificate. Findings include, but are not limited to:

The facility's training records were reviewed with Staff 7 (Business Office Manager) on 02/21/24. The following was noted:

a. Staff 8 (Concierge) hired 09/25/23, Staff 10 (MT) hired 10/05/23, and Staff 12 (CG) hired 09/25/23, lacked documented evidence pre-service Infectious Disease Prevention was completed prior to providing care to residents.

b. Staff 8, Staff 10, and Staff 12 lacked documented evidence of a written job description.

c. Staff 10 and Staff 12 lacked documented evidence all pre-service dementia care training topics were provided prior to providing care to residents.

d. Staff 14 (Cook) lacked documented evidence of a food handler's certificate (FHC). Staff 15's (Cook) FHC expired on 09/22/20.

The need to ensure staff completed all required pre-service orientation training prior to beginning job duties and kitchen staff who prepared and served food had an active food handler's certificate was discussed with Staff 1 (ED) and Staff 7 on 02/21/24. They acknowledged the findings.

1.All current staff have been assigned the needed OR state compliant training to be done in a timely manner. Home office provided with the OR state training requirements. Training tracker established to monitor staff progress. Newly hired staff get one week of training time prior to starting on the floor to complete all needed training pre and 30 day to help avoid gaps in training.  

2.New hires will have one week prior to starting on the floor to do all needed training. Reminders will be given as due dates approach for CEUs etc.  

3.Upon hire and as due.

4.BOD, RSD and ED.  

Staff 8: Will do preservice dementia and infection control as well as have a written job description.

Staff 10: Will do preservice dementia and infection control as well as have a written job description.

Staff 12: Will do preservice dementia and infection control as well as have a written job description.

Staff 14: Will obtain food handlers.

Staff 15: Will obtain food handlers.

Based on interview and record review, it was determined the facility failed to ensure an approved HCBS (Home and Community Based Services) course had been completed prior to providing direct care to residents for 2 of 2 newly hired staff (#s 23 and 26), and 1 of 2 long term staff (# 11) had not completed an approved HCBS course by 03/31/24. This is a repeat citation. Findings include, but are not limited to:

The facility's training records were reviewed with Staff 7 (Business Office Manager) on 07/09/24. The following was noted:

* Staff 23 (MT), hired 04/10/24, and Staff 26 (CG/Dishwasher), hired 04/11/24, lacked documented evidence an approved HCBS course was completed prior to providing care to residents.

* Staff 11 (CG), hired 08/25/06, lacked documented evidence an approved HCBS course was completed by 03/31/24.

The need to ensure pre-service orientation training included an approved HCBS course, and for all facility staff to have taken an approved HCBS course by 03/31/24 was reviewed with Staff 1 (ED) and Staff 7 on 07/09/24. They acknowledged the findings.

1.Staff members 23, 26 and 11 have completed their training. Currently I give 2 weeks of at home paid computer based training so that it is completed prior to coming in. Employees are no longer allowed to start any type of work without paper copy of training completion turned in to the facility. Also a tracker for each employee had been developed and was not being used. This tracker is now required and will be inspected biweekly to ensure no oversight.

2.Systems put in placed will be used and looked at biweekly.

3.Biweekly

4.BOD and ED

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 10 and 12) had verification of demonstrated satisfactory performance in any duty they were assigned within thirty days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 7 (Business Office Manager) on 02/21/24. The following was identified:

There was no documented evidence Staff 10 (MT) and Staff 12 (CG), hired on 10/05/23 and 09/25/23 respectively, demonstrated competency within 30 days of hire in one or more of the following areas:

* Providing assistance with ADLs;

* Identification, documentation, and reporting changes of condition;

* Other duties as applicable (medications and treatments); and

* Abdominal thrust training.

On 02/21/24 at 1:47 pm, Staff 1 (ED) and Staff 7 confirmed Staff 10 would not be passing medications or providing treatments to residents until she had documented evidence of the above training.

The need to ensure documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 and Staff 7 on 02/21/24. They acknowledged the findings.

1.All current staff have been assigned the needed OR state compliant training to be done in a timely manner. Home office provided with the OR state training requirements. Training tracker established to monitor staff progress. Newly hired staff get one week of training time prior to starting on the floor to complete all needed training pre and 30 day to help avoid gaps in training.   

2.New hires will have one week prior to starting on the floor to do all needed training. Reminders will be given as due dates approach for CEUs etc.  

3.Upon hire and as due.

4.BOD, RSD and ED.  

Staff 10: Will have the needed 30 day training completed.  

Staff 12: Will have the needed 30 day training completed.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 23 and 26) completed all required competency demonstration training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 07/09/24 with Staff 7 (Business Office Manager).  

Staff 23 (MT), hired on 04/10/24, and Staff 26 (CG/Dishwasher), hired on 04/11/24, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:

*Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* First Aid and abdominal thrust training.

The requirement to have documented demonstrated competency in all assigned job duties prior to working independently with residents was reviewed with Staff 1 (ED) on 07/09/24. She acknowledged the findings.

1.Staff members 23 and 26  are cross trained. They now have both care giver and med aid orientation and all 30 day competencies done. Tracker form will be used and inspected biweekly to ensure nothing has been overlooked.

2.Systems put in placed will be used and inspected biweekly.

3.Biweekly

4.BOD and ED

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 long term direct care staff (#9) completed a minimum of 12 hours of in-service training annually including six hours on dementia care, 2 of 2 long term direct care staff (#s 9 and 13) and 1 of 1 long term non-care staff (#16) completed the annual Infectious Disease Training. Findings include, but are not limited to:

Review of the facility's training records with Staff 7 (Business Office Manager) on 02/21/24 revealed the following:

1. Staff 9 (MT) hired 06/09/20 did not have documented evidence of 12 hours of annual in-service training related to provision of care in CBC including six hours of dementia care.

2. Staff 9, Staff 13 (CG) hired 12/18/18, and Staff 16 (Dishwasher) hired 10/08/18, did not have documented evidence of annual Infectious Disease Training.

The need to ensure all staff had a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including dementia care topics and that long term staff completed Infectious Disease Training was discussed with Staff 1 (ED) and Staff 7 on 02/21/24. They acknowledged the findings.

1.All current staff have been assigned the needed OR state compliant training to be done in a timely manner. Home office provided with the OR state training requirements. Training tracker established to monitor staff progress. Newly hired staff get one week of training time prior to starting on the floor to complete all needed training pre and 30 day to help avoid gaps in training. Reminders given as items are due, CEUs approaching etc.  

2.Training tracker, reminders as deadlines approach.  

3.Upon hire and as needed.  

4.BOD, RSD and ED.  

Staff 9: Will have the needed 12 hours of annual CEUs including 6 hours of dementia and infectious dieses.   

Based on interview and record review, it was determined the facility failed to have a system to ensure all care staff completed 12 hours of annual in-service training, including at least six hours of dementia care and one hour of infectious disease training. This is a repeat citation. Findings include, but are not limited to:

During an interview on 07/09/24 with Staff 1 (ED) and Staff 7 (Business Office Manager), it was reported by Staff 1 that the facility had developed a tracking form for annual training. There was no documented evidence the tracking form had been initiated and no evidence annual in-service training for staff had been accounted for.   

The facility had no system to ensure all care staff completed the required annual training.

The need to ensure and document long-term direct care staff completed the required number of hours of annual in-service training was discussed with Staff 1 and Staff 7 on 06/27/24. They acknowledged the findings.

1. Staff identified have completed all required annual training. BOM will inspect training tracker form biweekly to ensure that the system is being followed for completion of required annual training for all staff.

2.Check BODs work biweekly to ensure they are following the systems put in place.

3.Biweekly.

4.BOD and ED

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted every other month and included all required components and fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to:

Facility fire drill records dated 08/2023 through 02/2024 were reviewed with Staff  6 (Maintenance Director) on 02/21/24. The facility lacked documented evidence unannounced fire drills were conducted every other month and included the following components:

* Date and time of the fire drill;

* Location of simulated fire;

* Escape route used;

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

* Evacuation time period needed;

* Staff members on duty and participating; and

* Number of occupants evacuated.

In addition, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.

The need to ensure unannounced fire drills were conducted every other month and included all required components and fire and life safety instruction was provided to staff on alternate months of fire drills, was discussed with Staff 1 (ED) on 02/22/24. She acknowledged the findings.

1.New maintenance director trained on state regulations. Provided with binder that contains daily, weekly, monthly etc tasks and forms with instruction for reference.

2.Maintenance director will conduct fire drills in accordance with OAR's. Binder made for quick reference and containing all material needed to be OAR compliant.

3.Monthly

4.Maintenance Director and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code on alternate shifts and all required components were documented. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records, reviewed between 04/2024 and 06/2024, showed documentation was lacking in the following areas:

* The escape route used;

* Problems encountered;

* Evidence of alternate routes used;

* Evacuation time-period needed; and

* The number of occupants evacuated.

The need to ensure all required components were addressed and documented for each fire drill and were conducted on alternating shifts, was discussed with Staff 1 (ED) on 07/9/24. The staff acknowledged the findings.

1.Companies fire drill form does not comply with the state requirements. Community will develop their own form that is state compliant and use this form in accordance with state regulations for fire drills.

2.Develop our own form for fire drill documentation that complies with state regulations. Use that form going forward.

3.Monthly.

4.ED, BOD and DM.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to:

On 02/21/24, fire and life safety records were reviewed with Staff 1 (ED) and the following was identified:

There was no documented evidence residents were instructed in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and re-instructed at least annually.

On 02/22/24, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and re-instructed at least annually as required by the Oregon Fire Code was discussed with Staff 1. She acknowledged the findings.

1.All current residents in community have now had a fire safety assessment. Going forward the nursing dept to assess at move in and review yearly.

2.To be done at move in by nursing dept. Binder provided with all needed forms and instructions for reference.

3.Quarterly

4.RN and RSD.

Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year. Findings include, but are not limited to:

During an interview with Witness 1 (Ombudsman) on 02/20/24 at 2:00 pm, there was expressed concern related to emergency preparedness specifically a power outage during the previous month.  

Staff 1 (ED) was requested to provide documentation of emergency preparedness drills conducted at the facility over the previous 12 months on 02/20/24 at 4:30 pm. Staff 1 confirmed the facility had not conducted drills for the emergency preparedness plan at least twice a year.  

The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year was reviewed with Staff 1, Staff 3 (Resident Services Manager), and Staff 17 (Regional Director) on 02/22/24. They acknowledged the findings.

1.Emergency Drills to be held in accordance with state regulations.

2.New maintenance director trained on when drills are needed and why. Maintenance director provided with a binder containing all the needed forms layed out as daily weekly monthly etc, also containing detailed instruction for how to conduct-refer back to.

3.Quarterly

4.Maintenance Director and Executive Director.

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 C 252, C 260, C 262, C 270, C 280, C 325, C 340, C 370, C 372, C 374 and C 420.

1.Get all the above items done in a timely manor available for staff and state.

2.Staff to help double check each others work to ensure it is done correctly and on time.

3.Daily, Biweekly etc depending on the violation.

4.RN, RSD, BOD, DM and ED.

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 C260, C 270, C280, C340.

All tags will be cleared and properly addressed. RSD-RN will ensure that going forward policy and OAR are followed.  

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

The interior of the facility was toured on 02/20/24.

a. The following was found to be in need of repair:

* Double doors and door frames in the first floor activity room, door to the Lifestyle Director's office, exit door and door frame to the smoking area and doors to units 112 and 120 had chipped paint, rust spots and gouges; and

* Walls outside of units 110, 120, and behind the sink in the first floor activity room had chipped paint and gouges.

b. The following was found to be in need of cleaning:

* Carpets throughout the common areas of the facility and in unit 117 had black and brown spots.

The areas in need of cleaning and repair were toured with Staff 6 (Maintenance Director) on 02/21/24 at 09:42 and reviewed with Staff 1 (ED) on 02/22/24. They acknowledged the findings.

1.Maintenance director provided with binder that contains logs for regular carpet cleaning. All door frames will be painted and then maintained as damage occurs.

2.Complete and log carpet cleaning in binder. Maintain and paint door frames as damage occurs.

3.Weekly

4.Maintenance Director and Executive Director.