The findings of the re-licensure survey, conducted 06/03/24 through 06/07/24, 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 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

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool

The facility put immediate plans of correction in place during the survey.

The findings of the first revisit to the re-licensure survey of 06/07/24, conducted  11/05/24 through 11/08/24, 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 second re-visit to the re-licensure survey of 06/07/24, conducted on 02/19/25 through 02/20/25, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Findings include, but are not limited to:

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

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing; and

OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool.

b. During the relicensure survey, conducted 06/03/24 through 06/07/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope, severity, and number of citations.

Refer to deficiencies in the report.

Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office if abuse could not immediately be ruled out, for 1 of 2 sampled residents (# 3) with injuries of unknown cause. Findings include, but are not limited to:

Resident 3 moved into the facility in 05/2021 with diagnoses including dementia.

Interviews with staff and review of the resident's clinical record were completed during the survey and identified the following:

* A "skin monitoring: Comprehensive CM shower review" form was completed on 05/20/24 indicating Resident 3 had a small skin tear on the right elbow; and

* A "skin monitoring: Comprehensive CM shower review" form was completed on 06/01/24 indicating Resident 3 had skin tears on the right forearm and left shin.

During an interview on 06/05/24, Staff 5 (Wellness Nurse) reported there were no incident reports completed for either of the above injuries. Staff 5 further stated she didn't know how the skin tears occurred and the resident would not be able to explain how they occurred.

These skin injuries represented injuries of unknown cause and required an immediate investigation to rule out suspected abuse and reporting to the local SPD office if abuse could not be ruled out.

There was no documented evidence the facility immediately investigated the injuries or reported the injuries of unknown cause to the local SPD office. At the request of the survey team, the facility reported the incidents to the local SPD office and confirmation was provided to the survey team prior to exit.

The need to ensure all injuries of unknown cause were immediately investigated to rule out suspected abuse or reported to the local SPD office if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause to rule-out abuse, document all required areas of an investigation, and report to the local SPD office if abuse could not immediately be ruled out, for 1 of 1 sampled resident (# 8) with an injury of unknown cause. This is a repeat citation. Findings include, but are not limited to:

Resident 8 moved into the facility in 07/2021 with diagnoses including Adenocarcinoma (type of cancer) and chronic kidney disease stage 3.

Interviews with staff and review of the resident's clinical record, including incident reports and observation notes were completed during the survey and identified the following:

An observation note dated 09/23/24 noted "Resident's lower R-lower lip [right lower lip] is still swollen and bruised with abrasion. Resident made no c/o pain or discomfort. No more bleeding or discharge noted."

The skin injury represented an injury of unknown cause and required an immediate investigation to rule out suspected abuse and reporting to the local SPD office if abuse could not be ruled out.

There was no documented evidence the facility immediately investigated the injury or reported the injury of unknown cause to the local SPD office. At the request of the survey team, the facility was asked to report the incident to the local SPD office. Confirmation was provided to the survey team on 11/08/24.

The need to ensure all injuries of unknown cause were immediately investigated to rule out suspected abuse or reported to the local SPD office if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 3 (AL Coordinator), Staff 24 (RN/Wellness Director) on 11/08/24 at approximately 9:48 am. They acknowledged the findings.

OAR 411-054-0028 (1-3)  C 231

Reporting and Investigating Abuse -Other Action

1. Actions taken to correct the rule violation is as follows:

Resident #8 Injury of Unknown Cause "skin injury" was reported to the local SOD office on 11/8/24.

2. To ensure that the system will be corrected so that this violation will NOT happen again:

a. All staff will be provided training on the following topics: Incident reporting, Investigating IR's, How to appropriately rule out abuse and neglect, implementing interventions on STO's, ensuring previous interventions and service planning were being followed to rule out abuse and neglect, as evidenced by when to report and when to notify local APS agency.

b. All incidents will be reviewed timely by the Wellness Director and the Executive Director. If abuse and neglect cannot be ruled out for injuries of unknown cause, then the community will follow the Abuse reporting guidelines for our local APS agency. IR's will be reviewed daily at clinical standup meetings.  The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan.

3. The plan will be reviewed on a daily-weekly basis with incident review in stand-up and quarterly basis.

4. The facility Administrator and/or designee will be responsible for ensuring the system is corrected and monitored.

3. Resident 3 moved into the facility in 05/2021 with diagnoses including dementia.

The quarterly evaluation dated 05/07/24 was reviewed, interviews were conducted, and the following was identified:

a. The quarterly evaluation was not accessible to staff.

b. The quarterly evaluation failed to accurately describe the resident's current status and condition in the following areas:

* Mental health status;

* Ambulation;

* Self directing of PRN medications;

* Use of laxative medications;

* Use of eye drops;

* Use of antidepressant medication;

* Toileting and incontinent care;

* Bathing;

* Activities;

* Weight loss or gain;

* Dietary needs including trouble swallowing or chewing;

* One-on-one meal assistance;

* Behavior expressions; and

* Transfers.

The need to ensure the quarterly evaluation was reflective of the resident's condition was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 resident (#4) who recently moved in, the quarterly evaluation was relevant to the needs and current condition of 2 of 3 residents (#s 2 and 3) whose quarterly evaluations were reviewed, and the most recent quarterly evaluation was available to staff for 3 of 3 residents (#s 2, 3, and 5). Findings include, but are not limited to:

1. Resident 4 moved into the facility in 05/2024 with diagnoses including bipolar disorder, depression, weakness, and dysphagia (difficulty swallowing).

The resident's move-in evaluation dated 04/30/24 was reviewed and lacked the following required elements:

* Eating routine;

* History of mental health treatment and non-drug interventions;

* Confusion and decision-making abilities;

* Personality;

* Personal hygiene;

* Transportation;

* Nutrition habits; and

* Recent losses.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 06/06/24. They acknowledged the findings, and no further information was provided.

2. Resident 2 moved into the facility in 06/2021 with diagnoses including type 2 diabetes and muscle weakness.

The quarterly evaluation dated 05/09/24 was reviewed, observations of the resident were made, and the following was identified:

a. The quarterly evaluation was not relevant to the needs and current condition of the resident in the following areas:

* Assistance with dining;

* Orientation;

* Communication;

* Behaviors and resistance to care; and

* How the resident expressed pain.

b. During an interview at 8:50 am on 06/06/24, Staff 2 (Wellness Director) confirmed the evaluation was not available to staff.

The need to ensure the quarterly evaluation was relevant to the resident was discussed with Staff 1 (ED) and Staff 2 on 06/06/24. They acknowledged the findings, and no further information was provided.

2. Resident 7 moved into the facility in 07/2020 with diagnoses including hemiplegia and hemiparesis of the dominant right side and moderate neurocognitive disorder with recurrent psychotic disturbance.

The quarterly evaluation, dated 10/31/24, was reviewed and interviews were conducted during the survey.

The quarterly evaluation failed to accurately describe the resident's current status and condition in the following areas:

* Mental status and ability to know one's own limits;

* Falls and fall interventions; and

* Behavior expressions including triggers and interventions to support the resident.

The need to ensure the quarterly evaluation was reflective of the resident's condition was discussed with Staff 1 (ED), Staff 3 (AL Coordinator), and Staff 24 (RN/Wellness Director) on 11/06/24 at 2:45 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure evaluations were relevant to the needs and current condition of 2 of 3 sampled residents (#s 6 and 7) whose quarterly or change of condition evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 moved into the facility in 01/2022 with diagnoses including Kennedy's disease (a progressive neuromuscular disorder) and history of cerebrovascular attack (stroke) with left sided hemiplegia.

The change of condition evaluation dated 10/21/24 was reviewed and observations of the resident were made. The evaluation was not relevant to the needs and current condition of the resident in the following areas:

*Recent visits to the emergency room;

*Activities of daily living including bowel management;  

*Ability to use key;

*Evacuation ability;

*Nutrition habits, fluid preferences and weight;

*History of weight loss;

*Customary routines related to eating;

*Eating ability including history of choking and difficulty swallowing and need for assistive devices including modified utensils;

*Risk for dehydration;

*Orientation plan and interventions;

*Pain expression and non-pharmaceutical interventions;

*Behavior expression including triggers and interventions; and

*Mobility including tilt in space wheelchair.

The need to ensure the change of condition evaluation was relevant to the resident was discussed with Staff 1 (ED) and Staff 3 (AL Coordinator) and Staff 24 (RN/Wellness Director) on 11/07/24 at 11:20 am. They acknowledged the findings, and no further information was provided.

OAR 411-054-0034 (1-6) Resident Move in and eval: Res Evaluation  C252

1. Action taken to correct the rule violation is as follows:

Resident #6 COC evaluation has been updated to reflect the following:

* Recent visits to the emergency room

* Activities of daily living including instructions for bowel management

* Ability to use a key

* Evacuation ability and plan

* Nutrition habits, fluid preferences and weight

* History of weight loss

* Customary routines related to eating

* Eating ability including history of choking and difficulty swallowing and need for assistive devices including modified utensils

* Risk for dehydration

* Orientation plan and interventions

* Pain expression and non-pharmaceutical interventions

* Behavior interventions

* Mobility including tilt and space wheelchair.

Resident # 7 Quarterly Evaluation has been updated to reflect the following:

* Mental Status and ability to know one's own limits

* Fall history and fall interventions

* Behavior expressions including triggers and interventions to support the resident

2. The system will be corrected so that this violation does not happen again by ensuring all evaluations are created to reflect the residents' current status prior to move-in, within 30 days and quarterly thereafter or with any significant COC per company policy and OR state rules. All evaluations will be reviewed and updated to reflect change via TSP, clinical care staff and administration, and resident participation to reflect every area thoroughly for all of the residents' care needs.

3. The area needing correction will be evaluated daily, weekly, monthly, quarterly to ensure accuracy and appropriateness.

4. Facility Administrator, Wellness Director, and Wellness Nurse will be responsible for completion and correct monitoring of this process.

3. Resident 5 was admitted to the facility in 02/2023 with diagnoses including dementia and history of cerebrovascular accident.

The resident's current service plan dated 04/28/24 and short term observation notes (STOs) from 02/28/24 to 06/01/24 were reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The service plan was not reflective of the resident's current needs and preferences or did not provide clear direction to staff in the following areas:

* Preferred activities;

* Meal preference for breakfast;

* Mobility regarding use of walker, tiring easily, use of wheelchair for long distances; and

* How the resident expressed pain.

The need to ensure the service plan was reflective of the resident's needs and preferences was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings, and no further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 3 sampled residents (#s 2, 3, and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 05/2021 with diagnoses including depression and dementia.  

Staff interviews were conducted during the survey and the current service plan dated 05/07/24 was reviewed.

Resident 3's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Number of staff needed to assist with showers, toileting, incontinent care, and transfers;

* One-on-one meal assistance including preference to eat in his/her apartment;

* Food and fluid preferences;

* Significant weight changes and interventions;

* Ambulation and use of assistive devices;

* Use of a communication device;

* Activities; and

* Instructions for emergency evacuation.

The need to ensure the service plan reflected the resident's current needs and provided clear instructions to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings.

2. Resident 2 moved into the facility in 06/2021 with diagnoses including type 2 diabetes and muscle weakness.

The resident's current service plan dated 05/09/24 and short term observation notes (STOs) from 03/03/24 to 06/03/24 were reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The service plan was not reflective of the resident's current needs and preferences or did not provide clear direction to staff in the following areas:

* Personal hygiene, including teeth-brushing;

* Communication status;

* Care refusals;

* Sleeping patterns;

* How the resident expressed pain; and

* Instructions for emergency evacuation.

The need to ensure the service plan was reflective of the resident's needs and preferences was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 06/06/24. They acknowledged the findings, and no further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 3 of 4 sampled residents (#s 6, 7, and 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 moved into the facility in 01/2022 with diagnoses including Kennedy's disease (a progressive neuromuscular disorder) and history of cerebrovascular attack (stroke) with left sided hemiplegia.

The resident's current service plan dated 10/21/24 and short term observation notes (STOs) from 08/30/24 through 11/04/24 were reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The service plan was not reflective of the resident's current needs and preferences or did not provide clear direction to staff in the following areas:

* Frequency of daytime wellness checks;

* Hearing aid care including where they were stored and how often batteries were changed;

* Bowel care;

* Evacuation assistance;

* Securing door to his/her apartment;

* Dining including assistance required from staff, assistive devices used for dining and how these would be cleaned,  

* Interventions for orientation, care refusal, and behaviors including anxiety;

* Expression of pain and non-pharmacological interventions; and

* Tilt-in-space motorized wheelchair, including instructions related to cleaning, charging, and assisting the resident with the head strap.

The need to ensure the service plan was reflective of the resident's needs and preferences was discussed with Staff 1 (ED) and Staff 3 (AL Coordinator) and Staff 24 (RN/Wellness Director) on 11/06/24 at 11:20 am. They acknowledged the findings, and no further information was provided.

2. Resident 7 moved into the facility in 07/2020 with diagnoses including hemiplegia and hemiparesis of the dominant right side, moderate neurocognitive disorder with recurrent psychotic disturbance.

The quarterly service plan dated 10/31/24 and available short term observation notes (STO's) were reviewed and interviews with staff were conducted.

Resident 7's service plan was not reflective of the resident's current needs and lacked clear direction to staff regarding the delivery of services in the following areas:

* Falls and fall interventions;

* Recent history of confusion and wandering; and

* Behavior expressions including triggers and interventions to support the resident.

The need to ensure the quarterly service plan was reflective of the resident's condition was discussed with Staff 1 (ED), Staff 3 (AL Coordinator), and Staff 24 (RN/Wellness Director) on 11/08/24 at 9:48 am. They acknowledged the findings.

3. Resident 8 moved into the facility in 07/2021 with diagnoses including adenocarcinoma (cancer) and chronic kidney disease stage 3.

Staff interviews were conducted during the survey and the current service plan dated 08/30/24 and available short term observation notes (STO's) were reviewed.

Resident 8's service plan was not reflective of the resident's current needs or lacked clear direction to staff regarding the delivery of services in the following areas:

* Number of staff needed to assist with incontinence care;

* Bowel care management including instructions for infection control;

* Significant weight changes and interventions, including frequency for meal tracking;

* Recent falls and fall interventions including removing the bathroom rug after showers;

* Aspiration precautions while eating;

* Grooming including instructions for standing while performing the task to increase endurance;

* Use of a wheelchair for ambulation; and

* Instructions for emergency evacuation, including one person assist with a wheelchair.

The need to ensure the service plan reflected the resident's current needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 3 (AL Coordinator), Staff 24 (RN/Wellness Director) and Staff 25 (VP of Wellness) on 11/06/24 at 2:45 pm. They acknowledged the findings.

OAR 411-054-0036 1-4) Service Plan General  C260

1 Actions taken to correct the rule violation as follows:

a. Resident # 6 SP has been updated to reflect the following:

* Frequency of daytime wellness check

* Hearing aid care including where they are stored and how often batteries are changed

* Bowel care instructions

* Evacuation assistance needed

* Securing the door in the apartment

* Dining including assistance required from staff, assistive devices used for dining and how these would be cleaned

* Interventions for orientation, care refusal, and behaviors including anxiety

* Expression of pain and no pharmacological interventions

* Information on the tilt and space motorized wheelchair, including instructions related to cleaning, charging, and assisting the resident with the head strap

Resident # 7 SP has been updated to reflect the following:

* Fall history and fall interventions

* Recent history of confusion and wandering

* Behavior expressions including triggers and interventions to support the resident

Resident # 8 SP has been updated to reflect the following:

* Number of staff needed to assist with incontinence care

* Bowel care management including instructions on infection control

* Significant weight changes and interventions, including frequency for meal tracking.

* Fall history and fall interventions including removing the bathroom rug after showers.

Aspiration precautions while eating

* Grooming including instructions for standing while performing the task to increase endurance

* Use of wheelchair for ambulation

* Instructions for emergency evacuations including one person assist with wheelchair.

2. The system will be corrected so that this violation does not happen again by ensuring that the SP is created to reflect the resident's current status prior to move-in, within 30 days, quarterly thereafter or with any significant COC per company policy and OR state rule. All updates to any SP will be signed and dated, leadership to provide observations to ensure SP's are being followed.  When a new evaluation is completed and a new SP is created there will be double checks by the Wellness Director and the Coordinator to verify that everything from the evaluation is carried over to the SP to reflect all of the resident's current needs before it is posted. All SP's will be reviewed and updated to reflect change via TSP, clinical care staff and administration input. The updates will be placed in the 24-hour book.

3. The area needing correction will be evaluated quarterly and PRN. Changes to SP will be reviewed daily in clinical standup meetings to ensure accuracy and appropriateness.

4. Facility administrator, and nursing will be responsible for completion and correct monitoring.

3. Resident 5 was admitted to the facility in 02/2023 with diagnoses including dementia and history of cerebrovascular accident (stroke), and was identified in the acuity interview as having a history of falls.

Observations of the resident were made, interviews with staff were conducted, review of the resident's 04/28/24 evaluation and service plan, 02/28/24 through 06/01/24 short term observations (STOs), progress notes, and incident reports were completed. The following was revealed:

a. The following short-term changes of condition lacked documentation of weekly progress noted to resolution:

* 05/13/24 - Fall with injury;

* 05/24/24 - Fall with injury;

* 05/24/24 - ER visit; and

* 06/01/24 - Fall.

b. There was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall, nor that they determined and documented resident-specific actions or interventions for each new fall.

The need to ensure actions and interventions for short-term changes of condition were monitored with weekly progress noted to resolution was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings, and no further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to evaluate, determine and document what actions or interventions were needed, communicate the interventions to staff, and monitor progress of the conditions to resolution for 3 of 3 sampled residents (#s 2, 3, and 5) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 05/2021 with diagnoses including dementia.

The resident's clinical record, including progress notes, dated 03/24/24 through 06/03/24, short term observation notes (STO's), and the current service plan dated 05/07/24 were reviewed, and interviews were conducted.

There was no documented evidence the facility evaluated, determined what resident-specific actions or interventions were needed, communicated the determined actions or interventions to staff, and documented weekly progress through resolution for the following short-term changes of condition:

* A "skin monitoring: Comprehensive CM shower review" form was completed on 05/20/24 indicating Resident 3 had a small skin tear on the right elbow; and

* A "skin monitoring: Comprehensive CM shower review" form was completed on 06/01/24 indicating Resident 3 had skin tears on the right forearm and left shin.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings.

2. Resident 2 moved into the facility in 06/2021 with diagnoses including type 2 diabetes and muscle weakness.

The resident's progress notes and short term observation notes (STOs) dated 03/03/24 to 06/03/24 were reviewed and the following was identified:

a. There was no documented evidence actions or interventions were communicated to staff on each shift for the following change of condition:

05/27/24 - "Open red area on ...left buttock."

b. There was no documented evidence the facility monitored with weekly progress noted to resolution the following short-term changes of condition:

04/27/24 - "[P]ain in groin area ...was red and appeared to be very irritated"; and

05/08/24 - "[P]urulent discharge [from groin area] ...there is also noted skin breakdown."

The need to ensure actions and interventions for short-term changes of condition were communicated to staff on each shift and the changes were monitored with weekly progress noted to resolution was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 06/06/24. They acknowledged the findings, and no further information was provided.

Based on interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed, communicate the interventions to staff, monitor the progress of the conditions at least weekly to resolution, and refer significant changes of condition to the facility RN for 3 of 4 sampled residents (#s 6, 7, and 9) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 moved into the facility in 02/2020 with diagnoses including hemiplegia and hemiparesis (loss of strength, stiffness, or paralysis) of the dominant right side and moderate neurocognitive disorder with recurrent psychotic disturbance.

The resident's clinical record, including progress notes, dated 08/05/24 through 11/03/24, short term observation notes (STO's), and the current service plan dated 10/31/24 were reviewed, and interviews with staff were conducted.

There was no documented evidence the facility evaluated, determined what resident-specific actions or interventions were needed, communicated the determined actions or interventions to staff, and documented weekly progress through resolution for the following short term changes of condition:

* 08/17/24 - Unwitnessed fall with abrasion to the right knee;

* 08/17/24 (second fall on the same day) - Unwitnessed fall with injury with abrasion to the right eyebrow and bruising on the right cheek;

* 08/22/24 - Behavior expression including confusion and visual hallucination;

* 10/09/24 - Verbal aggression toward staff;

* 10/13/24 - Increase in Lisinopril (medication for high blood pressure); and

* 10/29/24 - Verbal aggression toward staff.

There was no documented evidence the facility monitored previous fall interventions or behavior interventions for effectiveness.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, and communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution and interventions were reviewed for effectiveness was discussed with Staff 1 (ED), Staff 3 (AL Coordinator), and Staff 24 (RN/Wellness Director) on 11/08/24 at 9:48 am. They acknowledged the findings.

2. Resident 9 was admitted to the facility in 09/2024, with diagnoses including lung cancer and hypokalemia.

Review of Resident 9's progress notes, dated 08/05/24 through 11/05/24, indicated the resident experienced the following changes of condition, without documented evidence of new interventions being implemented, monitoring conducted, or progress noted, at least weekly, to resolution:

* 10/06/24- A progress note documented the resident stated "I have stomach pain". There was no further monitoring or charting on this incident;

* 10/08/24- A note documented "[Resident 9] has returned from hospital". There was no record of the resident being taken to the hospital, no description of the preceding event, and no instructions for staff regarding monitoring;

* 10/13/24- Care Manager found resident on the bathroom floor. The Incident Report described a "bruise on [his/her] left forearm about the size of a quarter, purple/green in color". There was no documented evidence of progress noted on this injury until 10/23/24;

* 11/02/24- Care Manager found resident sitting on the floor at the foot of (his/her) bed, with no apparent injuries reported.

The only fall interventions included in Resident 9's service plan were:

* "Ensure the call light is within reach and working";

* "Remind resident to use the call light"; and

* "Provide accompanied walks for the resident"

The service plan identified Resident 9 as "A high fall risk due to [his/her] decline in functional status". However, there was no documented evidence new interventions were added to the service plan following the falls, or the existing interventions were evaluated for effectiveness.

On 11/07/24 at 3:45 pm, the need to ensure the facility had a system for documenting changes of condition, implementing interventions when needed, and monitoring, at least weekly until resolved was reviewed with Staff 1 (ED), Staff 3 (AL Coordinator), and Staff 24 (RN/Wellness Director). They acknowledged the findings.

3. Resident 6 moved into the facility in 01/2022 with diagnoses including Kennedy's disease (a progressive neuromuscular disorder) and history of cerebrovascular attack (stroke) with left sided hemiplegia.

The resident's progress notes and short term observation notes (STOs) dated 08/30/24 through 11/04/24 were reviewed and the following was identified:

a. There was no documented evidence the facility determined and documented what action or intervention was needed for the resident, the documentation was resident specific, the actions or interventions were communicated to staff on each shift, and/or weekly progress was noted to resolution for the following short term changes of condition:

*08/30/24: Return from emergency room;

*10/21/24: New medications including PRN lorazepam (for anxiety), PRN morphine (for pain) and PRN oxygen (for shortness of breath);

*10/23/24: New treatment, nebulizer with albuterol (for shortness of breath);

*10/24/24: Diet change; and

*11/01/24: Resident report of choking incident.  

b. There was no documented evidence that the facility evaluated the resident, referred to the RN, documented the change and updated the service plan as needed for the following significant changes of condition:

*10/02/24: Severe weight loss; and

*11/02/24: Severe weight loss.

Refer to C 280.

The need to ensure actions and interventions for short-term changes of condition were resident specific, communicated to staff on each shift and the changes were monitored with weekly progress noted to resolution, and that significant changes of condition were evaluated and referred to the RN was discussed with Staff 1 (ED) and Staff 3 (AL Coordinator) and Staff 24 (RN/Wellness Director) on 11/07/24 at 11:20 am. They acknowledged the findings, and no further information was provided.

OAR 411-054-0040 (1-2)  C 270

Change of Condition and Monitoring

1. Action taken to correct this rule violation area as follows:

a. Resident #7 service planning interventions and effective new interventions will be documented and communicated each shift moving forward  in person, through staff memo via the AL care group texts, and 24-hour log. Documentation will be conducted and followed through until resolution. Evidence that new interventions have been proven effective through alert charting documentation until resolution documentation is recorded.

b. Resident # 9 SP has been updated with new interventions for high falls risk. Service planning interventions and effective new interventions will be documented and communicated each shift moving forward in person, through staff memo via the AL care group texts, and 24-hour log. Documentation will be conducted and followed through until resolution. Evidence that new interventions have been proven effective through alert charting documentation until resolution documentation is recorded.

2. To ensure that the system will be corrected so this violation will not happen again, the 24-hour log system will be in place and followed up on daily as follows:

1. Shift to shift communication log

2. Alert Charting Log

3. Significant COC log

4. Weekly RN monitoring

a. Med staff will start short-term monitoring/communication for any resident identified to have an acute change of condition, or falls.

b. Staff to be made aware of what to report to RN/WD per TSP that has been put into place, which will correlate with the residents COC. The TSP will have specific directions for staff and what to look for/monitor.

c. Staff will document and monitor until resident condition resolves, or they are back to baseline.

d.  RN will document effectiveness of interventions and resolve with a chart note when the resident is back to baseline.

e. 24-hour book/process will be reviewed daily during clinical standup for identification of possible COC that needs assessment by an RN.

3. System will be reviewed daily, weekly, monthly, and quarterly to ensure compliance is maintained.

4. The facility Administrator and RN will be responsible for ensuring the system has been corrected and monitored.

2. Resident 1 was admitted to the facility in 10/2020 with diagnoses including diabetes and hypertension.

Progress notes from Staff 5 (Wellness Nurse) on 05/28/24 noted "Resident was seen by HH nurse 5/27/24 for wound care ...Resident has stage 2 ulcer on R [right] buttock."

The new open wounds constituted a significant change in condition and an assessment by the facility RN was required.

In an interview on 06/06/24, Staff 5 indicated Resident 1 received wound care from home health. She was aware of Resident 1's pressure sore on his/her buttock but had not yet completed an RN assessment for the open wound.

The facility failed to ensure an RN assessment was completed for the open wounds 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), Staff 2 (Wellness Director) and Staff 3 (AL Coordinator) and Staff 5 on 06/06/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed timely by an RN with findings, resident status, and interventions documented for 2 of 2 sampled resident (#s 1 and 3) reviewed for significant changes of condition related to weight loss and a pressure ulcer. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 05/2021 with diagnoses including dementia.

The resident's clinical record, including the service plan, progress notes and observation notes were reviewed during the survey, and staff were interviewed.

a. Resident 3's weight records were reviewed and identified the following:

* 12/21/2023 - 131.4 pounds;

* 01/21/2024 - 131.0 pounds;

* 01/25/2024 - 132.3 pounds;

* 02/2024 - no weight recorded;

* 03/2024 - 81.4 pounds;

* 04/2024 - 80.8 pounds;

* 05/2024 - 93.4 pounds;

* 06/2024 - 133 pounds; and

* 06/06/2024 -134.9 pounds (taken during survey).  

During an interview on 06/06/24, Staff 7 (Lead Medication Care Manager AL) reported Resident 3 was weighed in a wheelchair due to changes in his/her ability to stand on the scale. Staff 7 confirmed this was the second time they used the wheelchair to weigh the resident, and previous weights were taken with him/her standing using a residential type scale in his/her apartment.

Resident 3's weight loss was initially triggered in 03/2024. From 12/2023 to 03/2024, Resident 3 had a weight loss of 50 pounds or 38.05 % of his/her body weight in three months. The severe weight loss indicated a significant change of condition and required an RN assessment.

From 04/2024 to 05/2024, Resident 3 had a weight gain of 12.6 pounds or 13.49% of his/her total body weight within one month. The severe weight gain constituted a significant change of condition and required an RN assessment.

Additionally, from 03/2024 to 06/2024 the resident had a weight gain of 51.6 pounds or 38.80 % of his/her body weight in three months. The severe weight gain indicated a significant change of condition and required an RN assessment.

b. On 03/18/24, progress notes indicated the resident was feeling weak and required two-person care for transfers. A HH PT referral was made and the resident began to receive PT services through 04/30/24, at which time s/he was discharged from services. The resident's level of care remained two-person care for showers, toileting, and transfers.

This constituted a significant change of condition which required an RN assessment.

During an interview on 06/05/24 with Staff 2 (Wellness Director) and Staff 5 (Wellness Nurse), an assessment for the significant weight changes and the increase in ADL care needs was requested. Staff 3 and 4 confirmed assessments were not completed.

The need to ensure all significant changes of condition were assessed timely by an RN with findings, resident status and interventions documented Staff 1 (ED), Staff 2, and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN with findings, resident status, and interventions documented for 1 of 3 sampled residents (#6) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 6 moved into the facility in 01/2022 with diagnoses including Kennedy's disease (a progressive neuromuscular disorder), dysphagia (difficulty swallowing) and history of cerebrovascular attack (stroke) with left sided hemiplegia.

The resident's clinical record, including weight records dated 03/01/24 through 11/04/24, service plan, short term observation notes and progress notes were reviewed and staff were interviewed. The following was identified:

The resident's baseline weight was consistently recorded as 216 pounds between 03/2024 and 05/2024.

Beginning 09/02/24, the resident's weight was recorded as follows:

*09/02/24 - 204 pounds;

*10/02/24 - 178.8 pounds; and

*11/02/24 - 154 pounds.

This constituted a severe weight loss of 25.2 pounds of 12.3% between 09/02/24 and 10/02/24, and an ongoing severe weight loss of an additional 24.4 pounds or 13.6% between 10/02/24 and 11/02/24. There was no documented evidence that an RN completed an assessment of either significant change of condition. During an interview on 11/05/24 at 1:45 pm, Staff 24 (RN/Wellness Director) confirmed there was no documented evidence that an RN had reviewed the weights or completed a significant change of condition assessment related to the resident's weight loss.

During interviews on 11/05/24, staff stated that the resident did not appear to be as hungry over the past few months. The resident picked up all meals from the dining hall and brought them back to his/her room, and the resident appeared to be eating less than 25% of the meals. In an interview with the resident on 11/05/24, s/he stated that s/he had been eating less of the food served by the facility as it was difficult to eat. Observations of the resident showed that s/he had difficulty lifting his/her head due to neck weakness and contractures in his/her left and right hands which would make cutting food difficult. His/her service plan, dated 10/21/24, did not include any information related to the resident's weight loss, need for assistive devices when eating or receiving assistance with cutting his/her food.  

On 11/05/24 at 2:30 pm, at the request of the survey team, the resident was re-weighed. Due to complications based on the size of the floor scale, the size of the resident's tilt-in-space wheelchair, and unclear documentation related to the weight of the resident's wheelchair, the MT had difficulty obtaining an accurate weight for the resident. At 4:00 pm on 11/05/24, the survey team requested assistance from Staff 24 and Staff 25 (VP of Wellness) to obtain an accurate weight for the resident. They recorded the resident's weight as 188.4 pounds, concluding that the previous weight recorded on 11/02/24 of 154 pounds had been documented in error. The weight of 188.4 continued to constitute a severe weight loss when compared to the resident's weight on 09/02/24 of 204 pounds. Staff 24 and Staff 25 acknowledged that the resident had experienced a severe weight loss which had not been assessed by an RN.

The need to ensure all significant changes of condition were assessed by an RN with findings, resident status and interventions documented was discussed with Staff 1 (ED) and Staff 3 (AL Coordinator) and Staff 24 on 11/07/24 at 11:20 am. They acknowledged the findings, and no further information was provided.

OAR 411-054-0045 (1) (a-f) (A) (C-F)

Resident Health Services   C280

1. Actions taken to correct this violation:

a. Resident #6 was re-weighed to obtain an accurate weight, and it was determined that the previous weight recorded was not accurate. The new weight was recorded. The new weight still constituted a sig weight loss therefore the RN created a COC evaluation to address the weight loss and to put interventions into place.

b. Residents' weights are taken monthly or as ordered by their PCP. Staff will record the weight that is shown on the scale. They will then compare this weight to the last weight. If there is a more than 3-pound difference the staff will re-weigh the resident for accuracy.  If there is still a more than 3-pound difference they will alert the RN of the change.

c. The RN will monitor the weight report weekly to verify there are no significant weight loss or weight gains recorded. If there is a 3% or more weight change the RN will investigate the cause of the weight change and verify the accuracy of the weight recorded. If the weight does not constitute a significant change, they will put an STO in place with specific guidelines/information on what to watch for, what to add or subtract from the resident's diet and what to report to the appropriate parties.  

d. If the weight change does constitute a significant COC, then the RN will complete a full evaluation of the resident's needs and contact the residents PCP to advise of resident's weight gain/loss and ask for recommendations.

The RN will then put the information on the amount of weigh gain or loss and the time frame into the SP.  They will also add interventions to avoid further weight gain or loss and what staff are to monitor and report. The RN will monitor this COC weekly until the resident is back to baseline.

2. System will be reviewed daily, weekly, monthly, and quarterly to ensure that we are in compliance.

3. The facility Administrator and RN/WD will be responsible for ensuring the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure coordination of appointments for on-site health services with outside service providers for 1 of 2 residents (#2) with outside service provider needs. Findings include, but are not limited to:

Resident 2 moved into the facility in 06/2021 with diagnoses including type 2 diabetes, dysphagia (difficulty swallowing), and muscle weakness.

The resident's progress notes and short term observation notes (STOs) dated 03/03/24 to 06/03/24 were reviewed and the following was identified:

a. A HH occupational therapy note dated 03/11/24 noted, "Care staff to call HH once new shower [chair] arrives to make sure no additional adjustments have to be made."

During an interview at 1:26 pm on 06/04/24, Staff 5 (Wellness Nurse) confirmed the facility had not attempted to coordinate an occupational therapy referral once the shower chair had been received.

b. A progress note dated 04/08/24 noted, "[r]esident has referral to speech pathology and physical therapy." There was no documented evidence the facility coordinated the therapy appointments for Resident 2.

The need to ensure the facility coordinated on-site health services with outside service providers was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 06/06/24. They acknowledged the findings, and no further information was provided.

Based on interview and record review, it was determined the facility failed to a safe medication and treatment administration system for 3 of 3 sampled residents (#s 2, 3, and 5) who received medication administration from facility staff. Findings include, but are not limited to:

Review of the 05/01/24 through 06/03/24 MARs for 3 of 3 sampled residents (#s 2, 3, and 5) who received medication administration from facility staff indicated the facility used non time-specific ranges for medication administration. The MAR included administration times of "AM - during time frame", "Noon - during time frame" or "PM - during time frame."

The facility's medication administration policy was requested and received on survey entrance. Review of the document revealed the facility lacked a policy for determining medication administration times not otherwise directed by the physician or other legally recognized practitioner. The document did not include information on how "AM - during time frame", "Noon - during time frame" or "PM - during time frame" was determined for each medication.

During an interview on 06/04/24 at 11:00 am, Staff 2 (Wellness Director) confirmed there was no policy for training Medication Aides to administer medications with the above time ranges.

The need to ensure a safe medication and treatment administration system was discussed with Staff 1 (ED) and Staff 2 on 06/06/24. They acknowledged the findings, and no further information was provided.

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

Resident 3 moved into the facility in 05/2021 with diagnoses including dementia and major depressive disorder.

Review of the resident's clinical record identified the following:

Resident 3 had an order for Lorazepam 1 mg tablet, take one tablet by mouth, twice daily, as needed for anxiety.

Resident 3's May 2024 MAR identified unlicensed staff administered 0.5 tabs (half of the prescribed dose) on five separate dates.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the physician or other legally recognized prescriber was notified when a resident refused to consent to a medication or treatment order for 1 of 2 sampled residents (#3) who had medications and treatments administered by the facility. Findings include, but are not limited to:

Resident 3 moved into the facility in 05/2021 with diagnoses including dementia. The resident's 05/01/24 to 06/04/24 MARs and progress notes were reviewed during the survey.

Staff documented the resident refused the following prescribed medications and treatment:

* Ensure on 15 occasions; and

* On 05/23/24, "resident refused 6:00 pm routine medications".

There was no documented evidence staff notified the prescriber of the above refusals.

The need to ensure the physician was notified if a resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a PRN psychotropic medication used to treat anxiety had documented non-pharmacological interventions attempted with ineffective results prior to administration of the medication for 1 of 1 sampled resident (#3) who was prescribed a PRN psychotropic medication. Findings include, but are not limited to:

Resident 3 moved into the facility in 05/2021 with diagnoses including major depressive disorder, anxiety, and dementia.

Review of the resident's 05/01/24 through 06/04/24 MARs and current physician orders identified the following:

* The resident was prescribed Lorazepam 1 mg tablet to be administered by mouth two times daily as needed for anxiety; and

* The medication was administered 29 times without documented non-pharmacological interventions attempted with ineffective results prior to administering the medication.

The need to ensure non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (AL Coordinator) on 06/06/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident, including sufficient staff to meet the fire safety evacuation standards, which put residents at risk for serious harm. Findings include, but are not limited to:

The facility was licensed as an Assisted Living Facility (ALF) with a capacity of 77 beds.

a. On 06/03/24 during the entrance conference, survey requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. The facility acuity-based staffing tool (ABST) for all residents was reviewed during the survey.

b. During the acuity interview on 06/03/24 and subsequent resident record reviews, the following care needs were identified:

* The facility had a census of 47 residents;

* Four residents required two-person transfers including three who required assistance with a mechanical lift or sliding board;

* One resident required one-person assistance with all transfers;

* One resident had medication administration times at 12:00 am;

* One resident was on hospice; and

* One resident needed one-on-one meal assistance.

c. The facility ABST was not accurately being used to determine the correct staffing minutes in multiple ADL areas for sampled Residents 2, 3, and 5 who required 1:1 meal assistance, two person ADL care needs, and/or had multiple falls with injuries. Survey also identified multiple unsampled resident ABSTs with high acuity that were not being used accurately to determine an appropriate staffing plan.

d. The staffing plan provided by the facility on 06/03/24 was as follows:

* Day shift - 3 Care Managers and 2 Med Care Managers;

* Evening shift - 3 Care Managers and 2 Med Care Managers; and

* Night shift - 2 Care Managers and 1 Med Care Manager.

Review of the staffing plan and employee time cards from 05/19/24 through 06/04/24 identified the following:

* The facility was not following the posted staffing plan on 11 shifts, including the night shift;

* On three occasions during the night shift the facility did not have a scheduled Med Care Manager and was using Med Care Managers who were scheduled to work in the memory care;

* Six of 11 shifts were during the night shift, leaving the facility short staffed and potentially unable to meet the evacuation needs of the residents.  

e. Observations and interviews conducted between 06/03/24 and 06/06/24 showed the following:

* Multiple residents needed full meal assistance in their apartments, two-person transfers, toileting, and/or bathing;

* During an interview on 06/06/24 at 8:43 am Staff 7 (Lead Medication Care Manager AL), 12 and 13 (Med Care Managers AL) all reported they had "delays waiting to provide care for two person transfers and ADL care on day and swing shift, multiple times per shift." They further stated, they "are aware of at least two residents who moved out and the lack of staff was a factor in their decision to leave." Staff 13 further reported "it is every day, countless times per shift where I am waiting for help for the other staff because we are spread too thin."

* During an interview on 06/06/24 at 9:58 am, Staff 13 reported "Sometimes [Staff 3] covers but sometimes it's no one." During the same interview, Staff 12 reported "They'll make us get off the cart and then we help out." Staff 13 further reported, "Then we don't have time to do the other things. We tried to tell them we can't get our tasks done but they said we're free after 10:00 [am]. That's not true. We still have to document, chart, call the pharmacy. There's a lot of other stuff to do that isn't just passing meds."

* During an interview on 06/04/24 Staff 22 (Maintenance Director) reported the facility was not relocating residents during fire drills. Documentation was requested for an alternate written fire safety plan to shelter in place from the Department or local fire jurisdiction but no additional information was provided.  Staff 22 confirmed the facility did not have evacuation equipment in the two stairwell exits to assist with the evacuation of the five residents who were bedfast or in wheelchairs.

* During an interview on 06/06/24 at 10:25 am, Resident 6 reported "I can tell you they're short-staffed. The other morning, I was having trouble breathing and I pushed my pendant. No one came. Then I pushed the emergency call button. No one showed up so I called on my phone and it went to voicemail. Finally, she [the Care Manager] came after about 30 minutes and she said she was sorry but she was the only one there."

f. Review of the call light report from 05/16/24 through 06/04/24 identified 141 call response times were in excess of 15 minutes through one hour and four minutes. The call light report also identified 11 residents who had been identified during survey as requiring two-person care, two-person transfers with a mechanical lift or a sliding board, had multiple falls with injuries, were on hospice, and/or had a dementia diagnosis who experienced excessive call light response times.

The facility's failure to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident contributed to excessive call light times, care needs not being met, and put residents at risk for serious harm.

An immediate plan of correction to address the insufficient staffing was requested from Staff 1 (ED) on 06/06/24 at 1:13 pm. The plan of correction was received and accepted by the survey team on 06/06/24 at 4:19 pm. The immediate risk was addressed; however the facility will need to evaluate the overall system failure associated with the licensing violation.

The facility's failure to ensure staff adequate in number to meet the scheduled and unscheduled needs of the residents was shared with Staff 1 on 06/06/24. She acknowledged the findings.

Refer to C 361.

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated with significant changes of condition, and addressed the amount of staff time needed to provide care for 3 of 3 sampled residents (#s 2, 3, and 5) and multiple unsampled residents to determine appropriate staffing levels for the facility, and to meet the 24-hour scheduled and unscheduled needs of residents. This put the residents at risk for potential harm and required an immediate plan of correction. Findings include, but are not limited to:

1. The facility's ABST was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director) on 06/04/24 at 12:50 pm, and showed total caregiving time for both floors at 547.27 hours per week. During the acuity interview on 06/03/24, 11 residents were identified as requiring two person care, two-person transfers with mechanical lift and/or sliding board, had multiple falls with injuries, were on hospice, and/or had a dementia diagnosis. Interviews with residents and staff indicated the facility was frequently short-staffed and residents had to wait up to an hour to have their care needs met, three of three sampled residents' ABSTs were not accurate of the amount of care time the residents needed, and review of the call light report from 05/26/24 to 06/04/24 indicated long call response time with potential for negative outcomes for residents requiring heavy care. Failure to use the facility ABST to determine appropriate staffing levels put residents at risk for potential harm and required an immediate plan of correction.

An immediate plan of correction was requested on 06/06/24, which included a request that the facility update the ABSTs of the 11 residents with heavy care needs. The plan of correction was received at 4:18 pm on 06/06/24 prior to survey exit, and the weekly caregiving time had increased to 626.68 hours per week, a difference of 79.41 hours per week. The immediate risk was addressed, however the facility will need to evaluate the overall system failure associated with the licensing violation.

2a. Resident 3 moved into the facility in 05/2021 with diagnoses including depression and dementia.  During the acuity interview on 06/03/24 staff reported the resident was administered an as needed psychotropic medication, required two staff to transfer, required full ADL care including one-on-one meal assistance in his/her apartment, had a recent decline, and was in process of transitioning onto palliative care.

Review of the facility's ABST for Resident 3 identified the facility failed to convert evaluated care needs into accurate staff hours used to generate the facility's staffing plan in the following areas:

* Time spent monitoring behavioral conditions or symptoms;

* Time spent monitoring physical conditions or symptoms;

* Time spent ensuring non-drug interventions for behaviors;

* Time spent cueing or redirecting due to cognitive impairment or dementia;

* Time spent supervising, cueing or supporting while eating;

* Time spent transferring in or out of bed or chair; and

* Additional care and services for two person care needs.

The resident was identified as having a recent sudden decline on 04/30/24 and was in the process of transitioning onto palliative care, which constituted a significant change of condition. The facility failed to update the resident's ABST.

b. Resident 2 moved into the facility in in 06/2021 with diagnoses including type 2 diabetes and muscle weakness.

During the acuity interview the resident was identified as requiring two staff and a mechanical lift for all transfers, was dependent on staff for ADL care, and had ongoing care refusals.

The resident's ABST, last updated 05/12/24, and current service plan dated 05/09/24 were reviewed and the following was identified:

The resident's ABST failed to capture adequate staff time for the following resident needs:

* Personal hygiene;

* Grooming;

* Monitoring behavioral symptoms or conditions;

* Monitoring physical symptoms or conditions; and

* Additional care and services for two-person care needs.

c. Resident 5 was admitted to the facility in 02/2023 with diagnoses including dementia and history of cerebrovascular accident (stroke). The resident's 04/28/24 service plan and ABST were reviewed.

The resident's ABST failed to capture staff time needed in the following care area:

* Bowel and bladder management.

An immediate plan of correction was discussed with Staff 1 (ED) and requested on 06/06/24 at 1:13 pm. The facility provided a plan of correction on 06/06/24 at 4:18 pm, prior to survey exit. The immediate risk was addressed, however the facility will need to evaluate the overall system failure associated with the licensing violation.

Refer to C 360.

Based on interview and record review, it was determined facility failed to ensure that direct care staff completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours of training on dementia care, for 2 of 3 long-term staff (#s 7 and 8) whose training records were reviewed. Findings include, but are not limited to:

Review of the facility's training records with Staff 4 (Business Office Manager) on 06/06/24 revealed the following:

* Staff 7 (Lead Medication Care Manager), hired 09/16/21, failed to have documented evidence of completing 12 hours of required in-service training, including six hours of training on dementia care, between 09/2022 and 09/2023; and

* Staff 8 (Care Manager), hired on 10/21/21, failed to have documented evidence of completing 12 hours of required in-service training, including six hours of training on dementia care, between 10/2022 and 10/2023.

The need to ensure staff completed and documented the required annual in-service training, which included six hours of approved dementia care training and was based on anniversary dates of hire, was reviewed with Staff 1 (ED) and Staff 4 on 06/06/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Fire drill records from 12/2023 through 05/2024 were reviewed with Staff 22 (Maintenance Director) on 06/04/24. Fire drill records lacked documentation of the following required elements:

* Escape route used;

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

* Evacuation time period needed;

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

The requirements for providing and documenting fire drills was discussed with Staff 22 on 06/04/24 and Staff 1 (ED) on 06/06/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire, and a written record of fire safety training was kept. Findings include, but are not limited to:

In an interview on 06/04/24, Staff 4 (Business Office Manager) was asked how the facility provided annual re-training on fire safety to residents in the Assisted Living Facility. He stated that training was done quarterly in the Town Hall meetings, however, acknowledged the facility did not currently have a process for documenting that training for all of the residents, including those not in attendance.

The need to ensure the residents were re-instructed at least annually on safety procedures and the re-instruction was documented, was discussed with Staff 1 (ED) on 06/06/24. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to submit a survey plan of correction which satisfied the Department, and to achieve and maintain substantial compliance with Oregon Administrative Rules for Residential Care and Assisted Living Facilities. Findings include but are not limited to:

Refer to C 231, C 252, C 260, C 270, and C 280.

OAR 411-054-0105 (2-4) Inspections and Investigations: Insp interval  C 455

Refer to C 231, C252,C260,C270 and C280

Based on observation and interview, it was determined the facility failed to ensure handrails were installed at one or both sides of resident-use corridors. Findings include, but are not limited to:

The interior of the building was toured on 06/03/24 at 11:00 am.

Approximately 20 feet of resident-use corridor lacked a handrail on either side to access two corner resident apartments (apartments 209 and 227) located on the second floor. In addition, the corridor on the second floor, located in between the elevator and resident-use life enrichment room, loft, a public restroom and the fitness center, lacked handrails on either side.

The need to ensure handrails were accessible to residents along corridors was discussed with Staff 1 (ED) and Staff 22 (Maintenance Director) on 06/05/24. They acknowledged the findings.

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

The facility's interior was toured on 06/03/24 at 11:00 am. The following issues were identified:

* Dark stains and streaks on hallway carpets located by elevators on the second and third floors and carpet in Room 212;

* Gouges on the walls in multiple public restrooms on the first and second floor; and

* The washing machine on the second floor resident-use laundry room had the lid removed with wires exposed. In an interview on 06/03/24, Staff 22 (Maintenance Director) confirmed the machine was not working, put the lid back on and would label as out of order.

The need to ensure the facility was clean and in good repair was discussed with Staff 1 (ED) on 06/05/24. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:

During observation of the facility on 06/03/24, a commercial type washing machine with automatic laundry detergent dispensers was located on the first floor. A sign was posted on the machine and directed staff to choose numbers one through six to determine what laundry detergent was used for the wash. The categories included: sheets, towels, blankets, new linen, colored clothes, and rewash. One of the laundry detergents hooked up to the washing machine included a chemical disinfectant.

In an interview on 06/03/24, Staff 23 (Care Manager AL) indicated staff were expected to wash all soiled linens and soiled clothing in the first floor laundry room. Staff 23 selected the washing cycle for soiled items depending on what items were being washed. "If I'm washing a blanket, I would select the blanket setting." Multiple additional staff were interviewed and confirmed that they used the same process when washing soiled items.

In an interview on 06/03/24, Staff 22 (Maintenance Director) confirmed the only two options to select that used the chemical disinfectant were the "sheets" and "towels" settings.  On 06/04/24 he also confirmed that all of the rinses for the commercial washing machine was cold water.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (ED) on 06/05/24. She acknowledged the findings.

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

During the survey, the facility was identified to have doors that exited into the facility's inner courtyard. The doors lacked a device to alert staff when residents entered the courtyard.

On 06/03/24, the exit doors were observed with Staff 22 (Maintenance Director). He confirmed there was no system to alert staff when residents exited the facility into the inner courtyard.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) on 06/05/24. She acknowledged the findings.